Abstract
BACKGROUND
The effectiveness of balloon guide catheter (BGC) use has not been prospectively studied and its added value for improving reperfusion in acute ischemic stroke (AIS) treatment has ...only been reported in studies in which no contact aspiration was combined with the stent retriever (CA + SR).
OBJECTIVE
To compare the reperfusion results and clinical outcomes with and without BGC use when a combined CA + SR strategy is employed in first line to treat AIS.
METHODS
From January 2016 to April 2019, data from the ETIS registry (Endovascular Treatment in Ischemic Stroke) were reviewed. We included patients having undergone endovascular treatment with a combined CA + SR strategy and use or not of a BGC according to the operator's discretion. We compared BGC and nonBGC populations with matching and inverse probability of treatment weighting propensity scores. Primary outcome was the final near-complete/complete revascularization (mTICI2c/3) rate. Secondary outcomes included clinical outcomes and safety considerations.
RESULTS
Among 607 included patients, BGC was used in 32.9% (n = 200), and 190 matched pairs could be found. We found no significant difference in final mTICI2c/3 between patients with and without BGC (60.1% in BGC group compared to 62.7% in nonBGC group (matched RR, 0.92; 95%CI, 0.80 to 1.14)), first-pass mTICI2c/3 (35.1% vs 37.3%, matched RR, 0.94; 95%CI, 0.68 to 1.30), clinical outcome (matched RR of 1.12 (95%CI, 0.85 to 1.47) for favorable outcome.
CONCLUSION
The reperfusion and clinical results with and without BGC use are not significantly different when combined CA + SR are used as a first-line strategy for large vessel occlusion in the setting of AIS.
Graphical Abstract
Graphical Abstract
Despite successful recanalization with mechanical thrombectomy (MT) for acute anterior ischemic stroke (AAIS), the number of passes may impact clinical outcome.We analyzed the impact of more than ...three MT passes (>3) in a trial that evaluated contact aspiration (CA) versus stent retriever (SR) as the first-line technique in AAIS.
We included patients with mTICI 2b/3 recanalization after MT for isolated intracranial occlusions. The primary outcome was the percentage of patients with a 90-day modified Rankin Scale (mRS)≤2. Secondary outcomes included overall distribution of 90-day mRS, parenchymal hematoma on 24 hours' brain imaging (PH), and 90-day mortality.
Among the 281 patients included and even after adjustment on time to recanalization, significantly more patients with >3 passes had PH than patients with ≤3 passes in multivariate analysis (adjusted OR, 3.62; 95% CI, 1.55 to 8.44). When the analyses were stratified according to CA vs. SR, patients with >3 passes had a stronger risk of PH than patients with ≤3 passes, only in the SR first-line-treated group (adjusted OR, 9.24; 95% CI, 2.65 to 32.13) and not in the CA first-line-treated group (adjusted RR, 1.73; 95% CI, 0.57 to 5.19). A negative association of borderline significance (P=0.07) between >3 passes and favorable outcome was observed only in SR first-line-treated patients (adjusted OR, 0.33; 95% CI, 0.09 to 1.11).
After three passes of SR and unlike for three passes of CA, there is an increased risk of PH and a trend toward a worse clinical outcome.
•The “white” compared to “Red-Black” visual aspect of the thrombus at the moment of withdrawal with mechanical thrombectomy (MT) for acute ischemic stroke (AIS) was related to atypical etiologies ...like infective endocarditis.•The susceptibility vessel sign (SVS) and the two-layered SVS (TL-SVS) could help predict outcome and cardio-embolic etiology of AIS.•The SVS on MRI at the acute phase of AIS provides a good prediction accuracy to anticipate the macroscopic visual aspect of the thrombus after MT.•In the presence of a SVS+ thrombus it is highly likely that this is a not a white, “atypical” thrombus.
The “white” compared to “Red-Black” visual aspect of the thrombus at withdrawal with mechanical thrombectomy (MT) for acute ischemic stroke (AIS) was related to atypical etiologies like infective endocarditis. The susceptibility vessel sign (SVS) and the two-layered SVS (TL-SVS) could help predict outcome and cardio-embolic etiology of AIS. We aim to evaluate the diagnostic performance of the SVS and TLSVS to predict the visual aspect of the thrombus.
We included patients treated by MT and screened with MRI for the SVS and the TL-SVS for whom thrombus photograph was available. Photographs underwent a double-blind evaluation by neuroradiologists who classified the thrombus as “White” or “Red-Black”. Logistic regression assessed the association of Red-Black thrombus and age, sex, baseline National Institutes of Health Stroke Scale, occlusion site, the IVr-tPA administration, SVS and TL-SVS. We calculated the diagnostic performances of the SVS to predict a Red-Black type thrombus.
Between May 2017 and July 2018, 139 patients were included in the study. On multivariate analysis, only SVS was an independent predictor for Red-Black thrombus (Odd ratio 8.31, 95%CI2.30 to 32, p value<0.001). Concerning SVS diagnostic performances, the specificity was 0.58 (95%CI0.28 to 0.85), the sensitivity was 0.87 (95%CI0.80 to 0.93), the negative predictive value was 0.30 (95% 0.13 to 0.53), the positive predictive value was 0.96 (95%CI0.90 to 0.99) and accuracy was 0.85 (95%CI0.78 to 0.90).
The SVS on MRI provides a good prediction accuracy to anticipate the macroscopic visual aspect of the thrombus after MT for AIS.
Cerebral aspergillosis is associated with a significant morbidity and mortality rate. The imaging data present different patterns and no full consensus exists on typical imaging characteristics of ...the cerebral lesions. We reviewed MRI findings in 21 patients with cerebral aspergillosis and correlated them to the immune status of the patients and to neuropathological findings when tissue was available. The lesions were characterized by their number, topography, and MRI signal. Dissemination to the brain resulted from direct spread from paranasal sinuses in 8 patients, 6 of them being immunocompetent. Hematogenous dissemination was observed in 13 patients, all were immunosuppressed. In this later group we identified a total of 329 parenchymal abscesses involving the whole brain with a predilection for the corticomedullary junction. More than half the patients had a corpus callosum lesion. Hemorrhagic lesions accounted for 13% and contrast enhancement was observed in 61% of the lesions. Patients with hematogenous dissemination were younger (p = 0.003), had more intracranial lesions (p = 0.0004) and had a higher 12-week mortality rate (p = 0.046) than patients with direct spread from paranasal sinuses. Analysis of 12 aneurysms allowed us to highlight two distinct situations. In case of direct spread from the paranasal sinuses, aneurysms are saccular and located on the proximal artery portions, while the hematogenous dissemination in immunocompromised patients is more frequently associated with distal and fusiform aneurysms. MRI is the exam of choice for cerebral aspergillosis. Number and type of lesions are different according to the mode of dissemination of the infection.
The relationship between stroke topography (ie, the regions damaged by the infarct) and functional outcome can aid clinicians in their decision-making at the acute and later stages. However, the side ...(left or right) of the stroke may also influence the identification of clinically relevant regions. We sought to determine which brain regions are associated with good functional outcome at 3 months in patients with left-sided and right-sided stroke treated by endovascular treatment using the diffusion-weighted imaging-Alberta Stroke Program Early CT Score (DWI-ASPECTS).
Patients with ischaemic stroke (n = 405) were included from the ASTER trial and Pitié-Salpêtrière registry. Blinded readers rated ASPECTS on day 1 DWI. Stepwise logistic regression analyses were performed to identify the regions related to 3-month outcome in left (n = 190) and right (n = 215) sided strokes with the modified Rankin scale (0-2) as a binary independent variable and with the 10 regions-of-interest of the DWI-ASPECTS as independent variables.
Median National Institute of Health Stroke Scale (NIHSS) at baseline was 17 (IQR: 12-20), median age was 70 years (IQR: 58-80) and median day-one NIHSS 9 (IQR: 4-18). Not all brain regions have the same weight in predicting good outcome at 3 months; moreover, these regions depend on the affected hemisphere. In left-sided strokes, the multivariate analysis revealed that preservation of the caudate nucleus, the internal capsule and the cortical M5 region were independent predictors of good outcome. In right-sided strokes, the cortical M3 and M6 regions were found to be clinically relevant.
Cortical non-motors areas related to outcome differed between left-sided and right-sided strokes. This difference might reflect the specialisation of the dominant and non-dominant hemispheres for language and attention, respectively. These results may influence decision-making at the acute and later stages.
NCT02523261.
Introduction
Stent-assisted coiling is an established treatment option for intracranial aneurysms, particularly, wide neck aneurysms with complex anatomy. The purpose of the present study was to ...assess the safety and efficacy of LEO+ stents in the treatment of intracranial aneurysms.
Materials and Methods
A prospective, observational, multicenter study including 12 centers was performed on patients with ruptured, unruptured, and recanalized intracranial aneurysms treated with LEO+ stents. The primary efficacy endpoint was the rate of complete aneurysmal occlusion at 18 months post-procedure, and the primary safety endpoint was the morbidity and mortality at 18 months post-procedure.
Results
From March 2015 to June 2017, 176 patients were enrolled (mean age of 54.8 ± 11.5 years; 65.9% women). The aneurysms were located mainly in the anterior communicating artery (29.2%) and the middle cerebral artery (28.6%). They were mostly saccular (94%), with a mean dome size of 5.3 ± 2.6 mm and a mean aspect ratio of 1.2 ± 1.0. In total, 3% of the aneurysms were treated in the acute phase of rupture. Complete/nearly complete aneurysmal occlusion and major recanalization were observed in 89% (
n
= 146/164) and 1.8% (
n
= 3/164) of patients at 18-month follow-up, respectively. The LEO+ related mortality rate was 0.6% (
n
= 1/170), the morbidity rate was 4.1% (
n
= 7/170), and these patients were mRS 0–2 at 18 months.
Conclusion
Our results reflecting the use of LEO+ stents in real-world conditions confirm the efficacy and safety of LEO+ stents in the management of complex intracranial aneurysms.
In the Aspiration vs. Stent Retriever for Successful Revascularization (ASTER) trial, which evaluated contact aspiration (CA) versus stent retriever (SR) use as first-line technique, the impact of ...the susceptibility vessel sign (SVS) on magnetic resonance imaging (MRI) was studied to determine its influence on trial results.
We included patients having undergone CA or SR for M1 or M2 occlusions, who were screened by MRI with T2
gradient recalled echo. Occlusions were classified as SVS (+) or SVS (-) in each randomization arm. Modified thrombolysis in cerebral infarction (mTICI) 2b, 2c, or 3 revascularization rates were recorded and clinical outcomes assessed by the overall distribution of modified Rankin scale (mRS) at 90 days.
Among the 202 patients included, 143 patients were SVS (+) (70.8%; 95% confidence interval CI, 64.5% to 77.1%). Overall, there was no difference in angiographic and clinical outcomes according to SVS status. However, compared to SR, CA achieved a lower mTICI 2c/3 rate in SVS (+) patients (risk ratio RR for CA vs. SR, 0.60; 95% CI, 0.51 to 0.71) but not in SVS (-) (RR, 1.11; 95% CI, 0.69 to 1.77;
for interaction=0.018). A significant heterogeneity in favor of superiority of first-line SR strategy in SVS (+) patients was also found regarding the overall mRS distribution (common odds ratio for CA vs. SR, 0.40 vs. 1.32; 95% CI, 0.21 to 0.74 in SVS (+) vs. 95% CI, 0.51 to 3.35 in SVS (-);
for interaction=0.038).
As a first line strategy, SR achieved higher recanalization rates and a more favourable clinical outcome at 3 months compared to CA when MRI shows SVS within the thrombus.
Background:
Technical improvements in devices, changes in angiographic grading scales and various confounding factors have made difficult the detection of the temporal evolution of angiographic and ...clinical results after endovascular treatment (EVT) for acute ischemic Stroke (AIS). We analyzed this evolution in time using the Endovascular Treatment in Ischemic Stroke (ETIS) registry.
Materials and Methods:
We analyzed the efficacy outcomes of EVT performed from January 2015 to January 2022, and modelized the temporal trends using mixed logistic regression models, further adjusted for age, intravenous thrombolysis prior to EVT, general anesthesia, occlusion site, balloon catheter use and the type of first-line EVT strategy. We assessed heterogeneity in temporal trends according to occlusion site, balloon catheter use, cardio embolic etiology, age (<80 years vs ⩾80 years) and first-line EVT strategy.
Results:
Among 6104 patients treated from 2015 to 2021, the rates of successful reperfusion (71.1%–89.6%) and of complete first pass effect (FPE) (4.6%–28.9%) increase, whereas the rates of patients with >3 EVT device passes (43.1%–17.5%) and favorable outcome (35.8%–28.9%) decrease significantly over time. A significant heterogeneity in temporal trends in successful reperfusion according to the first-line EVT strategy was found (p-het = 0.018). The temporal trend of increasing successful reperfusion rate was only significant in patients treated with contact aspiration in first-line (adjusted overall effect p = 0.010).
Conclusion:
In this 7-year-old large registry of ischemic stroke cases treated with EVT, we observed a significant increase with time in the rate of recanalization whereas there was a tendency toward a decrease in the rate of favorable outcome over the same period.
The CLinical Assessment of WEB device in Ruptured aneurYSms (CLARYS) study has shown that the endovascular treatment of ruptured bifurcation aneurysms with the Woven EndoBridge (WEB) is safe and ...effective and provides protection against rebleeding at 1 month and 1 year. The 12-month angiographic follow-up is an important endpoint of the study.
The CLARYS study is a prospective multicenter study conducted in 13 European centers. The study enrolled 60 patients with 60 ruptured aneurysms of the anterior and posterior circulation. The study was conducted with an independent assessment of safety outcomes and imaging.
Sixty patients with 60 ruptured bifurcation aneurysms to be treated with the WEB were included. Fifty-three aneurysms (88.3%) had a broad base with a dome to neck ratio <2 (mean 1.6). Of these, 46 patients were evaluated by an independent core laboratory with follow-up imaging performed at 12 months or before eventual retreatment. At 1 year, 19/46 aneurysms (41.3%) were completely occluded (Raymond-Roy grade I), 21/46 (45.7%) had a residual neck and 6/46 (13.0%) had residual aneurysm filling. Adequate occlusion was reported in 40/46 (87%) aneurysms. Six patients underwent target aneurysm retreatment.
The CLARYS study has previously shown that the use of the WEB in the endovascular treatment of ruptured bifurcation aneurysms provides effective protection against rebleeding with a good safety profile. The angiographic occlusion rates at 1 year reported here are comparable to those already seen in previous multicenter studies which primarily included unruptured aneurysms.
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