Flow Diverters (FD) are a new emerging therapy for intracranial aneurysms. Initial reports focused on the treatment of proximally located aneurysms. We report our experience with FDs in the treatment ...of aneurysms at and beyond the circle of Willis.
We treated 30 aneurysms at and beyond the circle of Willis with FDs (silk and pipeline). Aneurysms were treated with FDs alone in 73.3% (22/30) and with FDs and coils in 23.3% (7/30). One procedure was converted in parent vessel occlusion.
Thirty aneurysms (21/30, 70.0% saccular; 7/30, 23.3% fusiform; 2/30, 6.7% blister-like; sizes 1.2-19.6, mean 6.8 mm) were treated in 26 patients (17 women, 9 men; mean age, 49 years) during 27 procedures. Access site complication was noted in 3.7% (1/27). Reversible neurological complications were noted in 7.4% (2/27), permanent neurological complication in 3.7% (1/27). There was no mortality. No aneurysms bled or rebled after treatment. Aneurysms treated with FDs alone were significantly smaller than those treated with FDs and coils (5.7 and 10.0 mm, respectively; P=0.0174). Immediate angiographic occlusion was achieved in 18.2% (4/22) with FDs alone, in 0.0% (0/7) with FDs and coils. Twenty-four aneurysms (80.0%) had been followed (mean, 13 months). Fifteen of 19 aneurysms (78.9%) treated with FDs against 4 of 4 of aneurysms (100%) treated with FDs and coils were occluded. There was no angiographic recurrence of initially totally occluded aneurysms.
Aneurysms at and beyond the circle of Willis are amenable to selective treatment with FDs.
Neutrophil Extracellular Traps (NETs) are DNA extracellular networks decorated with histones and granular proteins produced by activated neutrophils. NETs have been identified as major triggers and ...structural factors of thrombosis. A recent study designated extracellular DNA threads from NETs as a potential therapeutic target for improving tissue-type plasminogen activator (tPA)-induced thrombolysis in acute coronary syndrome. The aim of this study was to assess the presence of NETs in thrombi retrieved during endovascular therapy in patients with acute ischemic stroke (AIS) and their impact on tPA-induced thrombolysis.
We analyzed thrombi from 108 AIS patients treated with endovascular therapy. Thrombi were characterized by hematoxylin/eosin staining, immunostaining, and ex vivo enzymatic assay. Additionally, we assessed ex vivo the impact of deoxyribonuclease 1 (DNAse 1) on thrombolysis of AIS thrombi.
Histological analysis revealed that NETs contributed to the composition of all AIS thrombi especially in their outer layers. Quantitative measurement of thrombus NETs content was not associated with clinical outcome or AIS pathogenesis but correlated significantly with endovascular therapy procedure length and device number of passes. Ex vivo, recombinant DNAse 1 accelerated tPA-induced thrombolysis, whereas DNAse 1 alone was ineffective.
This study suggests that thrombus NETs content may be responsible for reperfusion resistance, including mechanical or pharmacological approaches with intravenous tPA, irrespectively of their etiology. The efficacy of a strategy involving an administration of DNAse 1 in addition to tPA should be explored in the setting of AIS.
URL: http://www.clinicaltrials.gov. Unique identifier: NCT02907736.
Intravenous thrombolysis (IVT) followed by mechanical thrombectomy (MT) is recommended to treat acute ischemic stroke (AIS) with a large vessel occlusion (LVO). Most hospitals do not have on-site MT ...facilities, and most patients need to be transferred secondarily after IVT (drip and ship), which may have an effect on the neurologic outcome.
To compare the functional independence at 3 months between patients treated under the drip-and-ship paradigm and those treated on site (mothership).
This study used a prospectively gathered registry of patients with AIS to select patients admitted through the Saint-Antoine and Tenon (drip and ship) or the Fondation Rothschild (mothership) hospitals from January 1, 2013, through April 30, 2016. The study included patients older than 18 years treated with bridging therapy for AIS with LVO of the anterior circulation. Among the 159 patients who received MT at the mothership, 100 had been transferred after IVT from the drip-and-ship hospitals and 59 had received IVT on site.
The main outcome was 3-month functional independence (modified Rankin scale score ≤2). Both groups were compared using a multivariate linear model, including variables that were significantly different in the 2 groups.
During the study period, 497 patients were hospitalized at the drip-and-ship and mothership hospitals for an AIS eligible to reperfusion therapy; 11 patients had a basilar artery occlusion and were excluded, leaving 100 patients in the drip-and-ship group (mean age, 73 years; age range, 60-81 years; 57 men 57.0%) and 59 in the mothership group (mean age, 70 years; age range, 58-82 years; 29 men 49.2%). The proportion of patients with a favorable neurologic outcome at 3 months was similar in both groups (drip and ship, 61 61.0%; mothership, 30 50.8%; P = .26), even after adjusting the analysis for the baseline National Institutes of Health Stroke Scale score, diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score, and general anesthesia (P = .82). Patients had less severe conditions in the drip-and-ship group (median baseline National Institutes of Health Stroke Scale score, 15 vs 17 P = .03; median diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score, 7.5 vs 7 P = .05). Process times were longer in the drip-and-ship group (onset-to-needle time, 150 vs 135 minutes; onset-to-puncture time, 248 vs 189 minutes; and onset-to-recanalization time, 297 vs 240 minutes; P < .001). Both groups were similar in terms of substantial recanalization (Thrombolysis in Cerebral Ischemia scores 2B to 3; drip and ship, 84 84.0%; mothership, 47 79.7%; P = .49) and symptomatic hemorrhagic transformation (drip and ship, 2 2.0%; mothership, 2 3.4%; P = .63).
This study found that patients treated under the drip-and-ship paradigm also benefit from bridging therapy, with no statistically significant difference compared with those treated directly in a comprehensive stroke center.
Modern endovascular thrombectomy (MET), using stent retrievers or large-bore distal aspiration catheters in stroke patients with acute basilar artery occlusion (BAO), is routinely performed to date. ...However, more than 35% of BAO patients treated with MET die within 90 days despite high recanalization rates. The purpose of this study is to investigate the parameters associated with 90-day mortality in patients with BAO after MET.
We analyzed 117 consecutive BAO patients included in the Endovascular Treatment in Ischemic Stroke prospective clinical registry of consecutive acute ischemic stroke patients treated with MET (60 patients 51.3% treated with a stent retriever as first-line technique) between March 2010 and April 2017. Successful recanalization was defined as modified thrombolysis In cerebral infarction scores 2b-3 at the end of MET, and mortality was defined as modified Rankin Scale 6 at 90 days. Associations of baseline characteristics (patient and treatment characteristics) and intermediate outcomes (recanalization, complications) with 90-day mortality were investigated in univariate and multivariate analyses.
Overall successful recanalization rate was 79.5, and 41.9% (95% CI 32.8-51.0%) of patients died within 90 days after MET. Patients with successful recanalization had a lower mortality rate (32.9 vs. 74.4%; p < 0.001). Failure of successful recanalization was an independent predictor of mortality (OR 5.1; 95% CI 1.34-19.33). In multivariate analysis, age ≥60 years (OR 6.37; 95% CI 1.74-23.31), admission National Institute of Health Stroke Scale (NIHSS) ≥13 (OR 4.62; 95% CI 1.42-15.03), lower posterior circulation-Alberta Stroke Program Early CT Score (pc-ASPECTS; OR 1.71; 95% CI 1.19-2.44), use of antithrombotic medication prior to stroke onset (OR 3.38; 95% CI 1.03-11.08), absence of intravenous thrombolysis (OR 3.36; 95% CI 1.12-10.03), and angioplasty/stenting of the basilar artery (OR 4.71; 95% CI 1.34-16.54) were independent predictors for mortality after MET.
Failure of successful recanalization was a strong predictor for mortality. In the setting of recanalization, age, admission NIHSS, pc-ASPECTS, absence of intravenous thrombolysis, and angioplasty/stenting of the basilar artery were also independent predictors for mortality after MET of BAO patients.
Advances in deep learning can be applied to acute stroke imaging to build powerful and explainable prediction models that could supersede traditionally used biomarkers. We aimed to evaluate the ...performance and interpretability of a deep learning model based on convolutional neural networks (CNN) in predicting long-term functional outcome with diffusion-weighted imaging (DWI) acquired at day 1 post-stroke. Ischemic stroke patients (n = 322) were included from the ASTER and INSULINFARCT trials as well as the Pitié-Salpêtrière registry. We trained a CNN to predict long-term functional outcome assessed at 3 months with the modified Rankin Scale (dichotomized as good mRS ≤ 2 vs. poor mRS ≥ 3) and compared its performance to two logistic regression models using lesion volume and ASPECTS. The CNN contained an attention mechanism, which allowed to visualize the areas of the brain that drove prediction. The deep learning model yielded a significantly higher area under the curve (0.83 95%CI 0.78–0.87) than lesion volume (0.78 0.73–0.83) and ASPECTS (0.77 0.71–0.83) (p < 0.05). Setting all classifiers to the specificity as the deep learning model (i.e., 0.87 0.82–0.92), the CNN yielded a significantly higher sensitivity (0.67 0.59–0.73) than lesion volume (0.48 0.40–0.56) and ASPECTS (0.50 0.41–0.58) (p = 0.002). The attention mechanism revealed that the network learned to naturally attend to the lesion to predict outcome.
Central vein disease (CVD) is a well-known complication of central venous cannulations, indwelling dialysis catheters, and arteriovenous grafts. Brachiocephalic vein (BCV) stenosis or thrombotic ...occlusion can occur in dialysis patients, and the presence of an ipsilateral arteriovenous fistula can cause cerebral venous hypertension due to retrograde flow in the ipsilateral jugular vein. A 53-year-old man receiving hemodialysis (left brachiocephalic hemodialysis fistula) presented with impaired consciousness and seizures related to status epilepticus due to left temporal multifocal hemorrhages. Brain computed tomography and angiogram showed left cortical vein congestion without intracranial arteriovenous shunt. Complementary left brachial angiogram showed a left BCV stenosis and jugular and cerebral high-flow venous reflux with cortical venous reflux from the hemodialysis fistula. The left arm shunt resulted in severe cerebral venous hypertension due to ipsilateral stenosis of the BCV. BCV angioplasty immediately resolved the cerebral reflux. Patients with hemodialysis fistulas are at a higher risk of developing these intracerebral hemorrhage complications.
Observational studies described associations between higher systolic blood pressure (SBP) values and intracranial hemorrhages (ICHs) and worse outcomes after successful reperfusion by endovascular ...therapy (EVT). However, the BP-TARGET trial BP-Target in Acute Ischemic Stroke to Reduce Hemorrhage after EVT found that an intensive SBP target did not reduce ICH rates after successful EVT. The presence of contrast enhancement (CE) immediately after reperfusion is also associated with higher odds of ICH and worse outcomes. Our research question was to investigate the effect of 2 SBP strategies after reperfusion on ICH rates and functional outcomes according to the presence of CE in the BP-TARGET trial. We hypothesized that patients with CE could benefit from an intensive SBP control.
We included BP-TARGET patients in whom a brain flat panel was performed immediately after reperfusion. We described CE as present or absent, ICH consisted of any radiographic ICH 24 hours after EVT, and unfavorable outcome consisted of a modified Rankin Scale score between 3 and 6 at 3 months.
Among the 324 patients randomized in BP-TARGET, 164 were included in this analysis, of whom 113 (68.9%) presented CE after reperfusion. The 24-hour mean SBP was significantly lower in the intensive SBP group compared with the standard group (129.7 vs 138.3 mm Hg,
< 0.001). Patients with CE and randomized in the intensive and standard SBP group had increased ICH rates: aOR = 11.26, 95% CI 4.59-27.63, and aOR = 4.08, 95% CI 1.75-9.50, respectively. However, the test of heterogeneity did not reach the significant level (aOR = 2.76, 95% CI 0.80 to 9.48,
= 0.11). Patients with CE and randomized in the intensive SBP group had also higher odds of unfavorable outcomes (aOR = 2.91, 95% CI 1.24-6.82), but this association was not significant in the standard SBP group (aOR = 1.89, 95% CI 0.85-4.23). No significant heterogeneity was found between the 2 groups (aOR, 1.54, 95% CI 0.48 to 4.97,
= 0.47).
Altogether, patients with CE and randomized in the intensive SBP group did not have lower rates of ICH or improved outcomes compared with the standard SBP group, as CE was associated with higher odds of ICH in both groups, without significant heterogeneity.
NCT03160677.
This study provides Class IV evidence that for adults with contrast-enhancing lesions after successful EVT of an AIS, intensive blood pressure management did not significantly increase the risk of ICH.
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