Systemic tolerance of intravenous milrinone administration for cerebral vasospasm secondary to non-traumatic subarachnoid hemorrhage

PURPOSE

Delayed cerebral ischemia (DCI) is a severe subarachnoid hemorrhage (SAH) complication, closely related to cerebral vasospasm (CVS). CVS treatment frequently comprises intravenous milrinone, an inotropic and vasodilatory drug. Our objective is to describe milrinone's hemodynamic, respiratory and renal effects when administrated as treatment for CVS.

METHODS

Retrospective single-center observational study of patients receiving intravenous milrinone for CVS with systemic hemodynamics, oxygenation, renal disorders monitoring. We described these parameters' evolution before and after milrinone initiation (day - 1, baseline, day 1 and day 2), studied treatment cessation causes and assessed neurological outcome at 3-6 months.

RESULTS

Ninety-one patients were included. Milrinone initiation led to cardiac output increase (4.5 L/min [3.4-5.2] at baseline vs 6.6 L/min [5.2-7.7] at day 2, p < 0.001), Mean Arterial Pressure decrease (101 mmHg [94-110] at baseline vs 95 mmHg [85-102] at day 2, p = 0.001) norepinephrine treatment requirement increase (32% of patients before milrinone start vs 58% at day 1, p = 0.002) and slight PaO2/FiO2 ratio deterioration (401 [333-406] at baseline vs 348 [307-357] at day 2, p = 0.016). Milrinone was interrupted in 8% of patients. 55% had a favorable outcome.

CONCLUSION

Intravenous milrinone for CVS treatment seems associated with significant impact on systemic hemodynamics leading sometimes to treatment discontinuation.

Evaluation of mechanical thrombectomy in acute ischemic stroke related to a distal arterial occlusion: A randomized controlled trial

RATIONALE

Mechanical thrombectomy (MT) associated with the best medical treatment (BMT) has recently shown efficacy for the management of acute ischemic stroke (AIS) secondary to a large vessel occlusion. However, evidence is lacking regarding the benefit of MT for more distal occlusions.

AIM

To evaluate the efficacy in terms of good clinical outcome at 3 months of MT associated with the BMT over the BMT alone in AIS related to a distal occlusion.

METHODS

The DISCOUNT trial is a multicenter open-label randomized controlled trial involving French University hospitals. Adult patients (⩾18 years) with an AIS involving the anterior or posterior circulation secondary to a distal vessel occlusion within 6 h of symptom onset or within 24 h if no hyperintense signal on fluid attenuation inversion recovery acquisition will be randomized 1:1 to receive either MT associated with the BMT (experimental group) or BMT alone (control group). The number of patients to be included is 488.

STUDY OUTCOMES

The primary outcome is the rate of good clinical outcome at 3 months defined as a modified Rankin scale (mRS) ⩽2 and evaluated by an independent assessor blinded to the intervention arm. Secondary outcomes include recanalization of the occluded vessel within 48 h, angiographic reperfusion in the experimental group, 3-month excellent clinical outcome (mRS ⩽ 1), all adverse events, and death. A cost utility analysis will estimate the incremental cost per quality-adjusted life year (QALY) gained.

DISCUSSION

If positive, this study will open new insights in the management of AISs.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05030142 registered on 1 September 2021.

Longitudinal radiological follow-up of individual level non-ischemic cerebral enhancing lesions following endovascular aneurysm treatment

BACKGROUND

Non-ischemic cerebral enhancing (NICE) lesions following aneurysm endovascular therapy are exceptionally rare, with unknown longitudinal evolution.

OBJECTIVE

To evaluate the radiological behavior of individual NICE lesions over time.

METHODS

Patients included in a retrospective national multicentric inception cohort were analyzed. NICE lesions were defined, using MRI, as delayed onset punctate, nodular, or annular foci enhancements with peri-lesion edema, distributed in the vascular territory of the aneurysm treatment, with no other confounding disease. Lesion burden and the longitudinal behavior of individual lesions were assessed.

RESULTS

Twenty-two patients were included, with a median initial lesion burden of 36 (IQR 17-54) on the first MRI scan. Of the 22 patients with at least one follow-up MRI scan, 16 (73%) had new lesions occurring mainly within the first 200 weeks after the date of the procedure. The median number of new lesions per MRI was 6 (IQR 2-16). Among the same 22 patients, 7 (32%) had recurrent lesions. The median persistent enhancement of a NICE lesion was 13 weeks (IQR 6-30). No factor was predictive of early regression of enhancement activity with lesion regression kinetics mainly being patient-dependent.

CONCLUSIONS

The behavior of individual NICE lesions was found to be highly variable with an overall patient-dependent regression velocity.

Early ischemic recurrence in acute spontaneous cervical artery dissection

BACKGROUND AND PURPOSE

Early ischemic recurrence (EIR) following the diagnosis of acute spontaneous cervical artery dissection (CeAD) has been little investigated. We aimed to determine the prevalence and determinants on admission of EIR in a large single-center retrospective cohort study of patients with CeAD.

METHODS

EIR was defined as any ipsilateral clinical or radiological cerebral ischemia or intracranial artery occlusion, not present on admission and occurring within 2 weeks. CeAD location, degree of stenosis, circle of Willis support, presence of intraluminal thrombus, intracranial extension, and intracranial embolism were analyzed on initial imaging by 2 independent observers. Uni- and multivariate logistic regression was used to determine their association with EIR.

RESULTS

Two hundred thirty-three consecutive patients with 286 CeAD were included. EIR was observed in 21 patients (9%,95%CI=5-13%) with a median time from diagnosis of 1.5 days (range:0.1-14.0 days). No EIR was observed in CeAD without ischemic presentation or with less than 70% stenosis. In the remaining cases, poor circle of Willis (OR=8.5, CI95%=2.0-35.4, p = 0.003), CeAD extending to other intracranial arteries than just V4 (OR=6.8, CI95%=1.4-32.6, p = 0.017), cervical artery occlusion (OR=9.5, CI95%=1.2- 39.0, p = 0.031), and cervical intraluminal thrombus (OR=17.5, CI95%=3.0-101.7, p = 0.001) were independently associated with EIR.

CONCLUSIONS

Our results suggests that EIR is more frequent than previously reported, and that its risk might be stratified on admission with a standard workup. In particular, the presence of a poor circle of Willis, intracranial extension (other than just V4), cervical occlusion, or cervical intraluminal thrombus are associated with high risk of EIR, for which specific management should be further evaluated.

Blood Flow Velocity: a Decision Tool for Stenting Indication in Venous Pulsatile Tinnitus

BACKGROUND AND PURPOSE

Lateral sinus stenosis is the most common cause of venous pulsatile tinnitus (VPT). Stenting is an effective treatment after demonstration of a trans-stenotic pressure gradient; however, pressure measurement has many technical limitations. In 2018, a study showed that a combined approach with intravascular velocity measurement could be effective in identifying most appropriate candidates for stenting. The aim of the present study was to evaluate a new strategy using this biomarker for the indication of stenting even without a significant pressure gradient.

MATERIAL AND METHODS

Consecutive patients with disabling VPT were included from 2016 to 2019 and analyzed retrospectively. Intrasinusal pressures were measured and blood flow velocities (with a dual-sensor guidewire) were used for the indication of stenting independent of the pressure gradient. We evaluated the clinical outcome after stenting based on this new biomarker.

RESULTS

A total of 41 patients were treated according to this strategy. At last follow-up (mean = 30.2 months), 32/33 patients (97%) treated by stenting showed complete resolution or a significant decrease in VPT intensity. The use of velocity as the threshold for indicating stenting identified 8 patients (24%) missed by the pressure gradient. Their clinical outcome after stenting was excellent and no complications occurred.

CONCLUSION

Measurement of sinus blood flow velocity provides a hemodynamic explanation of disease and may be a better tool than pressure gradient for the indication of stenting in VPT.

Clinical features and maternal and fetal outcomes in women with Guillain-Barré syndrome in pregnancy

BACKGROUND

Guillain-Barre syndrome (GBS) is an acute inflammatory polyradiculoneuropathy rarely observed during pregnancy.

METHODS

In this retrospective study, we analyzed the characteristics of pregnant women with GBS (pGBS) diagnosed in French University Hospitals in the 2002-2022 period and compared them with a reference group of same-age non-pregnant women with GBS (npGBS) identified in the same institutions & timeframe.

RESULTS

We identified 16 pGBS cases. Median age was 31 years (28-36), and GBS developed in the 1st, 2nd, and 3rd trimester in 31%, 31% and 38% of cases respectively. A previous infection was identified in six cases (37%), GBS was demyelinating in nine cases (56%), and four patients (25%) needed respiratory assistance. Fifteen patients (94%) were treated with intravenous immunoglobulins, and neurological recovery was complete in all cases (100%). Unscheduled caesarean section was needed in five cases (31%), and two fetuses (12.5%) died because of cytomegalovirus (CMV) infection (1 case) and HELLP (Hemolysis, Elevated Liver enzymes and Low Platelets) syndrome (1 case). In comparison with a reference group of 18 npGBS women with a median age of 30 years (27-33), pGBS patients more frequently had CMV infection (31% vs 11%), had a prolonged delay between GBS onset and hospital admission (delay > 7 days: 57% vs 12%), more often needed ICU admission (56% vs 33%) and respiratory assistance (25% vs 11%), and more often presented with treatment-related fluctuations (37% vs 0%).

CONCLUSIONS

This study shows GBS during pregnancy is a severe maternal condition with significant fetal mortality.

Glycoprotein IIb/IIIa inhibitors for the neurointerventionalist

Antiplatelet therapies are commonly used in neurointerventional procedures. However, specific guidelines for their use in these settings is lacking and it can often be difficult to balance the potential risks and benefits of these medications. Considering the continued growth and adoption of neurointerventional procedures, it is crucial to understand the properties of these agents in order to use them safely. Large-scale clinical trials are still needed to clarify many of these aspects for this emerging field. However, the existing literature already provides insight into which antiplatelet drugs are of benefit to the neurointerventionalist as well as their associated risks of ischemic and hemorrhagic complications. Hence, this review focuses on the applications of GPIIb/IIIA inhibitors to neurointerventional procedures.

Distribution of symptomatic cerebral vasospasm following subarachnoid hemorrhage assessed using cone-beam CT angiography

BACKGROUND AND PURPOSE

Cone-beam CT angiography (CB-CTA) provides a three-dimensional spatial resolution which is, so far, unmatched in clinical practice compared with other conventional techniques such as two-dimensional digital subtracted angiography. We aimed to assess the distribution of symptomatic cerebral vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) using CB-CTA.

METHODS

30 consecutive patients with aSAH undergoing vasospasm percutaneous balloon angioplasty (PBA) were recruited and underwent CB-CTA in this single-center prospective cohort series. Intracranial arteries were systematically analyzed by two independent observers from the large trunks to the distal cortical branches and perforators using a high-resolution reconstruction protocol. Intermediate and severe cerebral vasospasm was defined as 30-50% and >50% narrowing in the diameter of the vessel, respectively.

RESULTS

35 arterial cervical artery territories were analyzed, of which 80% were associated with clinical or radiological signs of delayed cerebral ischemia. The median spatial resolution was 150 µm (range 100-250 µm). Intermediate or severe vasospasm was observed in the proximal (86%, 95% CI 74% to 97%), middle (89%, 95% CI 78% to 99%), and distal (60%, 95% CI 44% to 76%) segments of the large trunks, as well as the cortical branches (11%, 95% CI 1% to 22%). No vasospasm was observed in basal ganglia or cortical perforators, or in arteries smaller than 900 µm. Vasospasm was more severe in middle or distal segments compared with proximal segments in 43% (95% CI 26% to 59%) of cases.

CONCLUSIONS

Our study demonstrated that symptomatic cerebral vasospasm following aSAH did not involve arteries smaller than 900 µm, and frequently predominated in middle or distal segments. These results offer new insights into the potential management options for vasospasm using PBA.

Results of watchful waiting of unruptured intracranial aneurysms in a Western patient population: a single-center cohort

BACKGROUND

The natural history of unruptured intracranial aneurysms (UIAs) in Western populations is still debated, especially for those <7 mm. Reporting data of a large single-center cohort managed with watchful waiting is therefore interesting.

METHODS

From January 2011 to June 2019, 662 UIAs were followed up by yearly MR angiography. Morphologically stable UIAs were managed conservatively while unstable UIAs were offered treatment. The patients' clinical and radiological data were analyzed retrospectively.

RESULTS

UIAs were ≤4 mm in 60%, 4.1-7.0 mm in 33%, and >7 mm in 7%. They were located on the anterior circulation in 90% of cases. The mean follow-up duration was 51.32 months for a total of 2831 aneurysm-years. During follow-up, 37 UIAs (5.5%) were treated because of an increase in size, and 8 UIAs were treated because of patient decision. Three aneurysms ruptured during follow-up for an annual risk of rupture of 0.1% (95% CI 0% to 0.24%). No risk factors for rupture were identified. The three ruptured cases made an excellent recovery. During follow-up, annual mortality from unrelated causes was 0.8% (95% CI 0.51% to 1.18%).

CONCLUSIONS

This single-center cohort evaluated our watchful waiting policy applied in two-thirds of all incidental UIAs. Morphological change of UIAs during follow-up led to treatment in 5.5% of cases. With such a management paradigm, we found a low rupture rate in these selected UIAs and the mortality was unrelated to aneurysms.

Computed tomography angiography for quantification of cerebral vasospasm following aneurysmal subarachnoid hemorrhage

PURPOSE

The purpose of this study was to assess the accuracy of computed tomography angiography (CTA) for quantification of cerebral vasospasm following aneurysmal subarachnoid hemorrhage in proximal and middle segments of intracranial arteries.

MATERIALS AND METHODS

Twenty consecutive patients (7 men, 13 women; mean age, 47 ± 7 [SD] years; age range: 27-78 years) with aneurysmal subarachnoid hemorrhage who underwent CTA and digital subtracted angiography (DSA) with a 6-hour window at baseline and during vasospasm period were included. Twelve artery segments were analyzed in each patient. Vasospasm was blindly quantified on CTA and digital subtracted angiography (DSA) by two independent readers with discordance > 10% resolved by open data consensus. Inter-reader and inter-test correlations with DSA as reference, and causes of discordant readings were analyzed. The best sensitivity and specificity of CTA for determination of vasospasm ≥ 50% on DSA was determined using receiver operating curve analysis.

RESULTS

Two-hundred-and-ten arterial segments were analyzed after exclusion of 30 segments with missing data or metallic artifacts. An inter-reader discordance >10% was observed in 82 segments (82/210; 39% [95% CI: 32-46]). Inter-test discordances >10% were observed respectively in 115 segments (115/210; 55% [95% CI: 49-62]) with the junior reader and in 73 segments (73/210; 35% [95% CI: 29-42]) with the senior reader. They were related to reader error in 55 (55/210; 26% [95% CI: 20-32]) with the junior reader and 13 (13/210; 6% [95% CI: 3-9]) with the senior reader, as well systematic biases in 8 (8/210; 4% [95% CI: 1-6]), and intrinsic limitation in 52 (52/210; 25% [95% CI: 19-31]). Best sensitivity and specificity of CTA were observed for a threshold value of 30% (sensitivity = 88% [95% CI: 78-97%]; specificity = 84% [95% CI: 77-90%]; area under curve = 0.92 [95% CI: 0.86-0.97]). On a patient basis, sensitivity was 100% (specificity = 60% [95% CI: 38-81%]; area under curve = 0.97 [95% CI: 89-100%] for this same threshold.

CONCLUSION

Our study shows a moderate accuracy of CTA for the quantification of cerebral vasospasm, mostly related to challenging interpretation and intrinsic limitations. CTA may rule-out angiographic vasospasm ≥ 50% when no segment has vasospasm over than 30%.

Transarterial embolization of dural arteriovenous fistulas of the lateral sinuses with stent-assisted sinus protection

BACKGROUND

The balloon-assisted sinus protection technique has been described as a sinus-preserving technique during transarterial embolization (TAE) of dural arteriovenous fistulas (DAVFs). However, some serious complications of this technique have been documented.

OBJECTIVE

To describe our preliminary experience with a new technique called stent-assisted sinus protection (SSP).

METHODS

We performed a retrospective analysis of seven consecutive patients with type I or IIa DAVFs of the lateral sinus treated by TAE with a closed-cell stent temporarily deployed in the sinus.

RESULTS

Of the seven patients, four had type I DAVF, and three had type IIa DAVF. The patency of all involved sinuses and their tributaries (including the inferior anastomotic vein and the superior petrosal sinus) was preserved. At the end of the procedure, all stents were successfully retrieved with embolic particles trapped in their meshes. No procedural complications were noted. Clinical follow-up was satisfactory, with complete resolution or significant reduction of pulsatile tinnitus.

CONCLUSIONS

SSP appears to be feasible and probably safe. However, larger studies are needed to confirm these preliminary results.

Intensive therapies of delayed cerebral ischemia after subarachnoid hemorrhage: a propensity-matched comparison of different center-driven strategies

BACKGROUND

Intensive therapies of delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH) have still controversial and unproven benefit. We aimed to compare the overall efficacy of two different center-driven strategies for the treatment of DCI respectively with and without vasospasm angioplasty.

METHODS

Two hundred consecutive patients with aSAH were enrolled in each of two northern European centers. In an interventional center, vasospasm angioplasty was indicated as first line rather than rescue treatment of DCI using distal percutaneous balloon angioplasty technique combined with intravenous milrinone. In non-interventional center, induced hypertension was the only intensive therapy of DCI. Radiological DCI (new cerebral infarcts not visible on immediate post-treatment imaging), death at 1 month, and favorable outcome at 6 months (modified Rankin scale score ≤ 2) were retrospectively analyzed by independent observers and compared between two centers before and after propensity score (PS) matching for baseline characteristics.

RESULTS

Baseline characteristics only differed between centers for age and rate of smokers and patients with chronic high blood pressure. In the interventional center, vasospasm angioplasty was performed in 38% of patients with median time from bleeding of 8 days (Q1 = 6.5;Q3 = 10). There was no significant difference of incidence of radiological DCI (9% vs.14%, P = 0.11), death (8% vs. 9%, P = 0.4), and favorable outcome 74% vs. 72% (P = 0.4) between interventional and non-interventional centers before and after PS matching.

CONCLUSIONS

Our results suggest either that there is no benefit, or might be minimal, of one between two different center-driven strategies for intensive treatment of DCI. Despite potential lack of power or unknown confounders in our study, these results question the use of such intensive therapies in daily practice without further optimization and validation.

Non-ischemic cerebral enhancing lesions after intracranial aneurysm endovascular repair: a retrospective French national registry

BACKGROUND

Non-ischemic cerebral enhancing (NICE) lesions are exceptionally rare following aneurysm endovascular therapy (EVT).

OBJECTIVE

To investigate the presenting features and longitudinal follow-up of patients with NICE lesions following aneurysm EVT.

METHODS

Patients included in a retrospective national multicentre inception cohort were analysed. NICE lesions were defined, using MRI, as delayed onset punctate, nodular or annular foci enhancements with peri-lesion edema, distributed in the vascular territory of the aneurysm EVT, with no other confounding disease.

RESULTS

From a pool of 58 815 aneurysm endovascular treatment procedures during the study sampling period (2006-2019), 21/37 centres identified 31 patients with 32 aneurysms of the anterior circulation who developed NICE lesions (mean age 45±10 years). Mean delay to diagnosis was 5±9 months, with onset occurring a month or less after the index EVT procedure in 10 out of 31 patients (32%). NICE lesions were symptomatic at time of onset in 23 of 31 patients (74%). After a mean follow-up of 25±26 months, 25 patients (81%) were asymptomatic or minimally symptomatic without disability (modified Rankin Scale (mRS) score 0-1) at last follow-up while 4 (13%) presented with mild disability (mRS score 2). Clinical follow-up data were unavailable for two patients. Follow-up MRI (available in 27 patients; mean time interval after onset of 22±22 months) demonstrated persistent enhancement in 71% of cases.

CONCLUSIONS

The clinical spectrum of NICE lesions following aneurysm EVT therapy spans a wide range of neurological symptoms. Clinical course is most commonly benign, although persistent long-term enhancement is frequent.

Endovascular treatment of infectious intracranial aneurysms complicating infective endocarditis: a series of 31 patients with 55 aneurysms

PURPOSE

Endovascular treatment (EVT) has become a major option in management of infectious intracranial aneurysms (IIAs) complicating infective endocarditis. We report a retrospective, single-center series of consecutive patients with IIAs treated by EVT.

METHODS

Patients were included from January 2009 to July 2020. IIAs were diagnosed on DSA. Each patient underwent a neurological assessment before and after EVT and was followed up by imaging within 15 days of EVT. Safety was assessed on the evolution of NIHSS score. A minor stroke was defined as a worsening of NIHSS < 4 points. Efficacy was defined as the absence of hemorrhagic event during cardiac surgery and the exclusion of the IIA on control imaging.

RESULTS

Sixty-two IIAs (30 ruptured) were diagnosed in 31 patients. Fifty-six IIAs were diagnosed on the first DSA and 6 on the early control exploration. EVT was achieved in 55 IIAs by parent artery occlusion with glue in 52 distal IIAs and coils in 3 proximal IIAs. IIAs were located in 90.9% of cases on a fourth-division branch of a cerebral artery. The neurological examination remained unchanged in 29 patients (93.5%), and 2 patients suffered minor stroke. EVT was performed before cardiac surgery in 20/22 patients. All treated IIAs were excluded on follow-up imaging. No hemorrhage was observed during cardiac surgery or in the aftermath. Seven (11.3%) unruptured IIAs were not embolized.

CONCLUSION

EVT of IIAs by occlusion of the parent artery is effective in preventing rupture and carries no significant neurological risk.

Navigability of a long sheath in the lateral dural sinuses facilitated by the pilot balloon technique: technical note

Dural sinus stenting is an increasingly recognized intervention for the treatment of lateral sinus stenosis. This procedure can be challenging in tortuous anatomy and in the presence of intraluminal septa because of poor trackability and crossability of long sheath commonly used for stenting. We report a technique using a pilot angioplasty balloon positioned at the distal end of the long sheath that improves its navigability in dural sinuses and facilitated the intervention.

Venous sinus stenting after repair of skull base spontaneous cerebrospinal fluid leaks: A single-center retrospective cohort series with case-control analysis

BACKGROUND

Management of idiopathic intracranial hypertension (IIH) is recommended after surgical repair of spontaneous cerebrospinal fluid leaks (sCSF-leaks) of the skull base for prevention of recurrence.

PURPOSE

To assess the feasibility of venous sinus stenting, a treatment commonly used for the treatment of IIH associated with intracranial venous sinus stenosis (VSS), after sCSF-leaks closure.

MATERIALS AND METHODS

A single-center cohort series of consecutive patients who underwent sCSF-leak closure was retrospectively analyzed. Stenting was considered either for leak recurrence or in prophylactic manner after repair in patients with VSS as confirmed by cerebral venous imaging. Leak recurrence, need for new repair or adjunctive treatment of IIH, meningitis, and stenting complications were determined at the last follow-up. Cases who had prophylactic stenting were compared to historical controls before stenting option.

RESULTS

Twenty-two patients had intracranial venous stenting after sCSF-leak closure. Their median age was 58 years (Q1=45; Q3=68), BMI=31 kg.m^-2 (Q1=27; Q3=36), and female rate=85%. The overall rate of successful repair after stenting was 95% (95% CI = 87-100%) at a median follow-up of 2.4 years (Q1=1.2; Q3=3.3). Adjunctive treatment for IIH was needed in 4 patients (4/22, 18%) including 2 patients without leak recurrence. No meningitis, permanent morbidity or mortality was observed after stenting. Compared to 18 controls, cases had significantly less recurrence (P = 0.03), and a trend for less adjunctive treatment for IIH (P = 0.06).

CONCLUSIONS

Our study suggests that stenting might be a valid option for prevention of sCSF-leak recurrences after repair in patients with intracranial venous sinus stenosis.

Intracranial venous sinus stenting for the treatment of lateral sinus stenoses: An analysis of 200 patients

PURPOSE

The purpose of this study was to analyze the long-term efficacy and safety of intracranial venous sinus stenting in a large cohort of patients with any type of presentation of primary lateral venous sinus stenosis (VSS).

MATERIALS AND METHODS

A retrospective cohort study was performed including patients treated by venous sinus stenting for symptomatic VSS from 2012 to 2019. Successful primary resolution of symptoms without adjunctive treatment or recurrence, and complications after stenting were analyzed at the last follow-up time point.

RESULTS

Two-hundred patients were included. There were 14 men and 186 women with a mean age of 39±14 (SD) years (age range: 13-75 years). Presenting symptoms included venous pulsatile tinnitus in 168 patients (168/200; 84%), idiopathic intracranial hypertension in 100 patients (100/200; 50%) and/or spontaneous cerebrospinal fluid leak in 35 patients (35/200; 17%). The overall rate of successful primary resolution of any typical presenting symptoms was 79% (95% CI: 73-85%). This rate ranged from 74% to 93% depending on the symptom with no significant difference between patients with and those without idiopathic intracranial hypertension (P=0.08). Recurrence rate was 10% (95% CI: 6-14%). No death or permanent morbidity were observed during a median follow-up of 2.2 years (Q1, Q3: 1.4, 3.3; range: 1-7.7 years).

CONCLUSION

Our study shows that venous sinus stenting has a low morbidity and high success rate at long-term follow-up for the treatment of idiopathic intracranial hypertension, venous pulsatile tinnitus or spontaneous cerebrospinal fluid leak associated with VSS. The excellent safety suggests considering this treatment as first-line treatment when medical management is ineffective or poorly tolerated.

Results of transvenous embolization of intracranial dural arteriovenous fistula: a consecutive series of 136 patients with 142 fistulas

OBJECTIVE

Intracranial dural arteriovenous fistula (DAVF) is mainly treated with an endovascular approach. Two major treatment advances include transvenous embolization (TVE) with coils in 1989 and, more recently, transarterial embolization with Onyx. The aim of this study was to present a large monocentric series of patients with DAVF treated with TVE. This series reports more than 20 years of experience and describes the evolution of the medical management of these patients, as well as current indications for this treatment at the authors' center.

METHODS

Consecutive patients treated for intracranial DAVFs with TVE from 1995 to 2018 were included. Clinical and imaging data were systematically collected. Univariate and multivariate analyses were performed to identify factors that were significantly associated with adverse clinical course or complications.

RESULTS

In this study of 136 patients with 142 DAVFs treated with TVE, the occlusion rate was 90%. The median length of follow-up was 11 months. The rate of permanent complications was 5.1%, and the procedure-related mortality rate was 1.5%. Procedure-related mortality was associated with extension of thrombosis that was observed early in our experience. The introduction of a postoperative anticoagulation regimen has drastically decreased the occurrence of this complication. Other minor complications included cochleovestibular syndrome after embolization of lateral sinus DAVF and oculomotor nerve damage after embolization of cavernous sinus DAVF.

CONCLUSIONS

TVE allows efficient occlusion of DAVF. It remains a valid option for DAVF located on a sinus that does not participate in normal venous drainage of the brain.

Embolization of Internal Carotid Artery Branches in Juvenile Nasopharyngeal Angiofibroma

OBJECTIVE

Preoperative embolization of juvenile nasopharyngeal angiofibroma (JNA) is usually performed by the occlusion of branches of the external carotid artery (ECA). However, a significant proportion of JNAs also receive blood from the internal carotid artery (ICA). The objective of this study was to report on the feasibility and clinical impact of superselective embolization of ICA branches in complex cases of JNA.

METHODS

This was a single-center retrospective study of all patients operated on for JNA between 2000 and 2018. The patients treated with embolization of branches of the ICA were identified. The results in terms of complications, intraoperative blood loss, and rate of residual disease were analyzed and compared to those of a control group of patients treated only with embolization of ECA branches and matched by age, stage, angiographic pattern, surgical approach, and previous surgery.

RESULTS

Ninety-two patients were included. Embolization of branches of the ICA was attempted in 14 cases of advanced or recurrent tumors and was ultimately possible in nine cases. There were no complications after embolization. The mean intraoperative blood loss was 1428 mL. Residual disease was found in three cases (33%). There was no significant difference compared with the control group (mean intraoperative blood loss = 1355 mL, residual disease = 4 (44%); all P > .05).

CONCLUSION

In this retrospective study, we report the feasibility of superselective embolization of ICA branches in selected cases of JNA. There was no observed benefit of this technique in terms of intraoperative bleeding or decreased risk of residual disease.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E775-E780, 2021.

Delayed Cerebral Infarction is Systematically Associated with a Cerebral Vasospasm of Large Intracranial Arteries

BACKGROUND

Whether delayed cerebral infarction (DCIn) after aneurysmal subarachnoid hemorrhage (aSAH) is driven by large artery vasospasm is still controversial.

OBJECTIVE

To study the association between DCIn and vasospasm by using quantitative assessment of vasospasm up to distal arteries with time and territorial-based correlation.

METHODS

Clinical and imaging data of 392 patients with aSAH treated at our center between 2012 and 2017 were reviewed. DCIn was defined as any cerebral infarction occurring within 3 to 21 d after ictus and not related to other specific cause. In patients with DCIn, vasospasm was assessed within 24 h around DCIn for each cerebral artery up to the end of the 2nd segments. DCIn and vasospasm analyses were blinded.

RESULTS

DCIn was found in 11% of patients (inter-rater k = 0.90, computed tomography (CT)-scan = 100%, follow-up MRI = 91%). Vasospasm was quantified in 258 artery territories including 66 with and 192 without DCIn (DSA = 93%, computed tomography angiography = 7%). Vasospasm was more severe in DCIn than in non-DCIn territories (60% [55-69] vs 20% [0-50], P < .001). Vasospasm was associated with DCIn in a "dose-dependent" manner (P for trend = .022). Every DCIn territory had a vasospasm ≥ 50%, including 39% only of distal artery segments. Only 9% of non-DCIn territories had vasospasm ≥ vasospasm in DCIn territories.

CONCLUSION

The necessary association between severe vasospasm and DCIn in our study brings additional arguments in favor of large artery vasospasm (especially of distal segments) as a major determinant of DCIn and a potential therapeutic target.

Aneurysms of the communicating segment of the internal carotid artery with posterior communicating artery agenesis are associated with perforator infarction after embolization

BACKGROUND

While anatomic features associated with the risk of posterior communicating artery (PcoA) occlusion after embolization of aneurysms of the PcoA segment of the internal carotid artery (ICA) are well known, the link between perforator origin and perforator infarction has only been reported following neurosurgical clipping. The aim of this study was to determine the origin of anterior thalamic perforators and correlate it with risk of perforator infarction after embolization of PcoA segment aneurysms.

METHODS

One-hundred-and-ninety consecutive patients treated for PcoA segment aneurysms between 2017 and 2019 were included. PcoA and anterior thalamic perforator origin anatomy was assessed with computed tomography (CT) angiography, digital subtracted angiography, and high-resolution three-dimensional rotational cone-beam CT angiography (CBCT-A) by two independent interventional neuroradiologists. The presence of perforator infarction after embolization was ascertained from the patient's notes and follow-up imaging.

RESULTS

CBCT-A was superior in demonstrating the origin of perforators (P<0.001). The prevalence of perforator origin was estimated at 86% (95% CI 81%-92%) for PcoA, 8% (95% CI 4%-13%) for aneurysm wall, and 5% (95% CI 2%-9%) for ICA. The aneurysm wall origin was exclusively associated with PcoA agenesis, as well as higher risk of perforator infarction after aneurysm coiling compared with other variants (OR=14, 95% CI 2-88, P=0.006).

CONCLUSIONS

Our study suggests that anterior thalamic perforators may arise from aneurysm wall when there is no PcoA. Anatomic association between PcoA agenesis and perforator arising from ICA could underlie such findings, and careful consideration is essential before aneurysm repair to anticipate the risk of thalamic infarction in such cases.

Effect of emergent carotid stenting during endovascular therapy for acute anterior circulation stroke patients with tandem occlusion: A multicenter, randomized, clinical trial (TITAN) protocol

Background and hypothesis

There is no consensus on the optimal endovascular management of the extracranial internal carotid artery steno-occlusive lesion in patients with acute ischemic stroke due to tandem occlusion. We hypothesized that intracranial mechanical thrombectomy plus emergent internal carotid artery stenting (and at least one antiplatelet therapy) is superior to intracranial mechanical thrombectomy alone in patients with acute tandem occlusion.

Study design

TITAN is an investigator-initiated, multicenter, prospective, randomized, open-label, blinded-endpoint (PROBE) study. Eligibility requires a diagnosis of acute ischemic stroke, pre-stroke modified Rankin Scale (mRS)≤2 (no upper age limit), National Institutes of Health Stroke Scale (NIHSS)≥6, Alberta Stroke Program Early Computed Tomography Score (ASPECTS)≥6, and tandem occlusion on the initial catheter angiogram. Tandem occlusion is defined as large vessel occlusion (intracranial internal carotid artery , M1 and/or M2 segment) and extracranial severe internal carotid artery stenosis ≥90% (NASCET) or complete occlusion. Patients are randomized in two balanced parallel groups (1:1) to receive either intracranial mechanical thrombectomy plus internal carotid artery stenting (and at least one antiplatelet therapy) or intracranial mechanical thrombectomy alone within 8 h of stroke onset. Up to 432 patients are randomized after tandem occlusion confirmation on angiogram.

Study outcomes

The primary outcome measure is complete reperfusion rate at the end of endovascular procedure, assessed as a modified Thrombolysis in Cerebral Infarction (mTICI) 3, and ≥4 point decrease in NIHSS at 24 h. Secondary outcomes include infarct growth, recurrent clinical ischemic event in the ipsilateral carotid territory, type and dose of antiplatelet therapy used, mRS at 90 (±15) days and 12 (±1) months. Safety outcomes are procedural complications, stent patency, intracerebral hemorrhage, and death. Economics analysis includes health-related quality of life, and costs utility comparison, especially with the need or not of endarterectomy.

Discussion

TITAN is the first randomized trial directly comparing two types of treatment in patients with acute ischemic stroke due to anterior circulation tandem occlusion, and especially assessing the safety and efficacy of emergent internal carotid artery stenting associated with at least one antiplatelet therapy in the acute phase of stroke reperfusion.

Trial registration

ClinicalTrials.gov NCT03978988

Impact of Antiplatelet Therapy During Endovascular Therapy for Tandem Occlusions

Background and Purpose—

Antiplatelet agents could be used in the setting of endovascular therapy for tandem occlusions to reduce the risk of de novo intracranial embolic migration, reocclusion of the extracranial internal carotid artery lesion, or in-stent thrombosis in case of carotid stent placement but have to be balanced with the intracerebral hemorrhagic transformation risk. In this study, we aim to investigate the impact of acute antiplatelet therapy administration on outcomes during endovascular therapy for anterior circulation tandem occlusions.

Methods—

This is a retrospective analysis of a collaborative pooled analysis of 11 prospective databases from the multicenter observational TITAN registry (Thrombectomy in Tandem Lesions). Patients were divided into groups based on the number of antiplatelet administered during endovascular therapy. The primary outcome was favorable outcome, defined as a modified Rankin Scale score of 0 to 2 at 90 days.

Results—

This study included a total of 369 patients; 145 (39.3%) did not receive any antiplatelet agent and 224 (60.7%) received at least 1 antiplatelet agent during the procedure. Rate of favorable outcome was nonsignificantly higher in patients treated with antiplatelet therapy (58.3%) compared with those treated without antiplatelet (46.0%; adjusted odds ratio, 1.38 [95% CI, 0.78–2.43]; P =0.26). Rate of 90-day mortality was significantly lower in patients treated with antiplatelet therapy (11.2% versus 18.7%; adjusted odds ratio, 0.47 [95% CI, 0.22–0.98]; P =0.042), without increasing the risk of any intracerebral hemorrhage. Successful reperfusion (modified Thrombolysis in Cerebral Ischemia score 2b-3) rate was significantly better in the antiplatelet therapy group (83.9% versus 71.0%; adjusted odds ratio, 1.89 [95% CI, 1.01–3.64]; P =0.045).

Conclusions—

Administration of antiplatelet therapy during endovascular therapy for anterior circulation tandem occlusions was safe and was associated with a lower 90-day mortality. Optimal antiplatelet therapy remains to be assessed, especially when emergent carotid artery stenting is performed. Further randomized controlled trials are needed.

A 10% blood pressure drop from baseline during mechanical thrombectomy for stroke is strongly associated with worse neurological outcomes

Background

Mechanical thrombectomy (MT) for acute ischemic stroke can be performed under local anesthesia, with or without conscious sedation (CS), or under general anesthesia (GA). The hemodynamic consequence of anesthetic drugs may explain why GA may be associated with worse outcomes. We evaluated the association between hypotension duration during MT and the 90 day functional outcome under both anesthetic regimens.

Methods

Patients were included in this retrospective study if they had an ischemic stroke treated by MT under GA or CS. The main exposure variable was the time below 90% of the reference value of arterial pressure measured before MT. The primary outcome was poor functional outcome defined as a 90 day modified Rankin Score ≥3.

Results

371 patients were included in the study. GA was performed in 42%. A linear association between the duration of arterial hypotension and outcome was observed. The odds ratio for poor functional outcome of 10 min under 90% of the baseline mean arterial pressure was 1.13 (95% CI 1.06 to 1.21) without adjustment and 1.11 (95% CI 1.02 to 1.21) after adjustment for confounding factors. The functional outcome was poorer for patients treated under GA compared with CS, but the association with the depth of hypotension remained similar under both conditions.

Conclusion

In this study, we observed a linear association between the duration of hypotension during MT and the functional outcome at 90 days. An aggressive and personalized strategy for the treatment of hypotension should be considered. Further trials should be conducted to address this question.

Stent Placement for Disabling Pulsatile Tinnitus Caused by a Lateral Sinus Stenosis: A Retrospective Study

BACKGROUND

Lateral sinus stenosis is a little-known cause for pulsatile tinnitus (PT). In several small series, stenting has been described as an effective treatment for disabling PT linked with this type of stenosis.

OBJECTIVES

To describe the clinical, radiological, and manometric characteristics of patients treated for disabling PT by lateral sinus stenosis. Assessment of the efficacy of stenting for this indication.

METHODS

Retrospective study of patients treated for isolated PT by stenting of a lateral sinus stenosis in our institution, between 2009 and 2015.

RESULTS

Fourteen patients were included in our study. All of them were women. The median age at the onset of symptoms was 39.0 (21.0) years. The median body mass index was 28.5 (7.0) kg/m 2 . Stenting of the lateral sinus led to the disappearance of PT without recurrence in 13 patients. In one patient, stenting did not modify the noise. In this case, another cause of PT was diagnosed after stent placement.

CONCLUSION

Lateral sinus stenosis is a curable cause of venous PT. Other causes of PT must be ruled out before an endovascular treatment is undertaken, due to the frequent asymptomatic nature of Pacchioni granulations in the lateral sinus. Treatment by stenting is effective in all cases, provided that stenosis underlies the PT.

Effect of extracranial lesion severity on outcome of endovascular thrombectomy in patients with anterior circulation tandem occlusion: analysis of the TITAN registry

Introduction

Endovascular treatment (EVT) for tandem occlusion (TO) of the anterior circulation is complex but effective. The effect of extracranial internal carotid artery (EICA) lesion severity on the outcomes of EVT is unknown. In this study we investigated the effect of EICA lesion severity on the outcomes of tandem occlusion EVT.

Methods

A multicenter retrospective TITAN (Thrombectomy In TANdem lesions) study that included 18 international endovascular capable centers was performed. Patients who received EVT for atherosclerotic TO with or without EICA lesion intervention were included. Patients were divided into two groups based on the EICA lesion severity (high-grade stenosis (≥90% North American Symptomatic Carotid Endarterectomy Trial) vs complete occlusion). Outcome measures included the 90-day clinical outcome (modified Rankin Scale score (mRS)), angiographic reperfusion (modified Thrombolysis In Cerebral Ischemia (mTICI) at the end of the procedure), procedural complications, and intracranial hemorrhage at 24 hours follow-up.

Results

A total of 305 patients were included in the study, of whom 135 had complete EICA occlusion and 170 had severe EICA stenosis. The EICA occlusion group had shorter mean onset-to-groin time (259±120 min vs 305±202 min; p=0.037), more patients with diabetes, and fewer with hyperlipidemia. With respect to the outcome, mTICI 2b–3 reperfusion was lower in the EICA occlusion group (70% vs 81%; p=0.03). The favorable outcome (90-day mRS 0–2), intracerebral hemorrhage and procedural complications were similar in both groups.

Conclusion

Atherosclerotic occlusion of the EICA in acute tandem strokes was associated with a lower rate of mTICI 2b–3 reperfusion but similar functional and safety outcomes when compared with high-grade EICA stenosis.

Head or Neck First? Speed and Rates of Reperfusion in Thrombectomy for Tandem Large Vessel Occlusion Strokes

Background

We aim to evaluate the speed and rates of reperfusion in tandem large vessel occlusion acute stroke patients undergoing upfront cervical lesion treatment (Neck-First: angioplasty and/or stent before thrombectomy) as compared to direct intracranial occlusion therapy (Head-First) in a large international multicenter cohort.

Methods

The Thrombectomy In TANdem Lesions (TITAN) collaboration pooled individual data of prospectively collected thrombectomy international databases for all consecutive anterior circulation tandem patients who underwent emergent thrombectomy. The co-primary outcome measures were rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b/3) and time from groin puncture to successful reperfusion.

Results

In total, 289 patients with tandem atherosclerotic etiology were included in the analysis (182 Neck-First and 107 Head-First patients). Except for differences in the Alberta Stroke Program Early CT Score (ASPECTS; median 8 [range 7-10] Neck-First vs. 7 [range 6-8] Head-First; p < 0.001) and cervical internal carotid artery (ICA) lesion severity (complete occlusion in 35% of the Neck-First vs. 57% of the Head-First patients; p < 0.001), patient characteristics were well balanced. After adjustments, there was no difference in successful reperfusion rates between the study groups (odds ratio associated with Neck-First: 1.18 [95% confidence interval, 0.60-2.17]). The time to successful reperfusion from groin puncture was significantly shorter in the Head-First group after adjustments (median 56 min [range 39-90] vs. 70 [range 50-102]; p = 0.001). No significant differences in the rates of full reperfusion, symptomatic hemorrhage, 90-day independence, or mortality were observed. Sensitivity analysis excluding patients with complete cervical ICA occlusion yielded similar results.

Conclusions

The upfront approach of the intracranial lesion in patients with tandem large vessel occlusion strokes leads to similar reperfusion rates but faster reperfusion as compared to initial cervical revascularization followed by mechanical thrombectomy. Controlled studies are warranted.

Long term follow-up of endovascular management of spinal cord arteriovenous malformations with emphasis on particle embolization

Objective

To determine long term safety and efficacy of endovascular treatment of spinal cord arteriovenous malformations (AVMs), with calibrated particle embolization as a firstline approach.

Methods

We reviewed clinical and imaging data of consecutive patients who underwent endovascular treatment for both nidal and fistulous type spinal cord AVMs in our center, from 1990 to 2015. Outcome at the last follow-up was assessed by an independent observer.

Results

Embolization of spinal cord AVMs was performed in 61 patients, including 46 (75%) with particles (exclusively in 29 patients), 30 (49%) with cyanoacrylate, and 6 (10%) with combined surgical treatments. Particle embolizations were iterative in 33 patients (median number of sessions 5 (range 3–6)). Neurological deterioration after treatment occurred in 5 patients (cyanoacrylate=4, surgery=1, particles=0; P<0.001). At a median follow-up of 6 years (range 3–13 years), angiographic cure was obtained in 11/61 (18%) patients (nidal type=6/53 (11%), fistulous type=5/8 (63%)). In progressive forms, neurological improvement occurred in 16/28 (57%) patients, stabilized in 9/28 (31%), and worsened in 3/28 (12%). In hemorrhagic forms, the rebleeding rate was 4/14 patient years without standard treatment, 0/322 patient years in partial iterative treatment, and 0/15 patient years in angiographically cured lesions (P=0.001).

Conclusion

Our study suggests that particle embolization as a firstline therapy to treat spinal cord AVMs is safe and offers long term efficacy, especially for those with small, distal, and multiple shunts. Partial occlusion of the AVM may be sufficient to prevent rebleeding, without the potential risks of complete occlusion. Particle calibration and injection technique, ‘one by one’, are critical to safety. Cyanoacrylate embolization or surgery remains necessary if particle embolization fails to occlude large shunts.

Prevalence and treatment of spontaneous intracranial artery dissections in patients with acute stroke due to intracranial large vessel occlusion

OBJECTIVE

To identify the prevalence and therapeutic consequences of spontaneous intracranial artery dissection (IAD) at the acute phase of ischemic stroke.

METHODS

We reviewed clinical and imaging data of consecutive patients attending our center for mechanical thrombectomy (MT) between January 2012 and November 2017. IAD was defined according to published criteria and our own angiographic criteria (no clot following MT, and normalization of the vessel caliber after stenting).

RESULTS

IAD was retrospectively diagnosed in 13/391 (3%) patients (inter-rater agreement κ=0.885, P<0.001). It was an extending of extracranial dissection in 7/13 (54%) patients. A total of 21 recanalization approaches (with or without IV tissue plasminogen activator) were analyzed in 13 patients. A medical approach was used in 7/21 (33%), MT in 7/21 (33%) (stent retriever=6, thromboaspiration=1), and permanent stenting in 7/21 (33%). A rescue recanalization was necessary after 8/14 (57%) approaches without stenting. Stenting was associated with a best rate of recanalization (P=0.001) and with a trend towards a lower rate of ischemic recurrence (P=0.057). Stenting of a circulating false lumen failed to recanalize the artery in two patients. At the last follow-up, no patient had developed a subarachnoid hemorrhage due to the dissection. The outcome at 3 months was favorable in 8/13 (62%) patients. One patient died at 3 weeks owing to a severe cerebellar infarction.

CONCLUSION

IAD is a rare diagnosis that should be systematically considered in patients with intracranial large vessel occlusion, especially in patients with extracranial artery dissection and when MT does not retrieve any clot. Stenting of IAD as first-line approach should be assessed in further studies.

Stenting of the Lateral Sinus in Idiopathic Intracranial Hypertension According to the Type of Stenosis

BACKGROUND

Over the past decade, stenting of lateral sinus stenosis has been used to treat idiopathic intracranial hypertension. Two types of stenoses have been identified: extrinsic and intrinsic.

OBJECTIVE

The aim of this study was to report the results of our use of this procedure to treat patients with extrinsic or intrinsic stenoses in idiopathic intracranial hypertension.

METHODS

We retrospectively studied clinical, radiological, and manometric data from patients with idiopathic intracranial hypertension who were treated at our institution between January 2009 and January 2015 by stenting of the lateral sinus.

RESULTS

Data were studied from 19 women and 2 men. Average body mass index was 29 kg/m 2 , and the median age at stenting was 33 years. Patients with extrinsic stenoses were younger than those with intrinsic stenoses. Transstenotic gradients measured with patients under general anesthesia were lower than those measured with patients under local anesthesia. In all cases, stenting was effective for papilledema and pulsatile tinnitus. Seventeen patients reporting headaches found that they disappeared completely after stenting. Two complications without long-term effects were reported.

CONCLUSION

Irrespective of the type of stenosis, stenting of lateral sinus stenoses is an effective treatment for intracranial hypertension symptoms. At our institution, this treatment has replaced draining of cerebrospinal fluid when treatment with acetazolamide has proved to be ineffective.

3D digital subtracted CT angiography to evaluate the venous anatomy in extra-axial tumors invading the major dural venous sinuses

Background Investigation of the venous system surrounding a tumor that is invading a dural sinus is of great use for guiding the surgical excision. Non-invasive imaging is often inadequate since enhancement of the tumor causes it to blend with the contrast of the venous vascular structures. Conventional two-dimensional angiography is also often insufficient. Objective The objective of this study was to report regarding the potential of three-dimensional digital subtracted computed tomography angiography (3D DS-CTA) as a technique to preoperatively explore these tumors. Methods We retrospectively studied the radiological and surgical features of patients explored with 3D DS-CTA for a tumor invading a major dural sinus. Results Three patients were included in this study, one hemangiopericytoma and two meningiomas. 3D DS-CTA allows for accurate assessment of the patency of the sinus, the location of the secondary intra- and trans-osseous venous outlets, and surgical guidance by neuronavigation. Conclusion 3D DS-CTA could be a promising guiding and diagnostic tool for the pre- and intraoperative treatment of vascular tumors invading the dural sinuses, for which the venous morbidity and mortality is substantial.

Tentorial meningioma supplied by a marginal tentorial artery arising from the superior cerebellar artery: Anatomic and technical considerations

Background and importance The marginal tentorial artery runs over the free edge of the tentorium. Different origins have been described, always involving branches of the carotid artery. We report the superior cerebellar artery as an unknown origin of this artery. We developed our strategy in a case of a tentorial meningioma mainly supplied by this artery. Clinical presentation A 53-year-old man was admitted in our institution for the surgical treatment of a large tentorial and petroclival meningioma. A 2D conventional angiogram was insufficient to detect the tumoral blush. A 3D digital subtraction angiogram (DSA) of the vertebral artery highlighted a blush arising from a marginal tentorial artery fed by the superior cerebellar artery. Selective embolization of this branch led to significant devascularization of the tumor. A total tumor resection was performed 24 h after embolization without complication. The dural medial tentorial artery of the superior cerebellar artery is relatively unknown and courses at the inferior surface of the tentorium. We report the first case in which the marginal tentorial artery arises from this artery. Major bleeding may result from its section or its avulsion from the superior cerebellar artery during surgery; its preoperative diagnosis is thus essential. In this case, a 3D-DSA with dual volume visualization was more sensitive than a 2D conventional angiogram to detect such an anatomic variant. Conclusion The marginal tentorial artery may originate from the superior cerebellar artery. The recognition of this anatomic variant may be essential to avoid hemorrhagic complications during surgery of hypervascular tumors of the tentorium.

Abstract TMP105: Endovascular Treatment of Severe and Refractory Cerebral Vasospasm Following Aneurysmal Subarachnoid Hemorrhage Improves Outcome: A Systematic Review and Meta-analysis of Different Treatment Options Evaluated Since 2006 for Cerebral Vasospasm

Introduction: To report clinical outcome of aneurysmal subarachnoid hemorrhage (aSAH) patients exposed to cerebral vasospasm (CVS) targeted treatments in a systematic review and meta-analysis and compare the efficacy of endovascular and non-endovascular treatments in severe / refractory vasospasm patients.

Methods: The literature was searched using PubMed, EMBASE, and The Cochrane Library database. Eligibility criteria were (1) Rated clinical outcome; (2) at least 10 patients; (3) aSAH; (4) study published in English or French (January 2006 - October 2014); and (5) methodological quality score > 10, according to STROBE criteria. Endpoint included unfavorable outcome rate, defined as mRS 3-6, GOS 1-3 or GOSE 1-4 at latest follow-up. Analyses included stratification per route of administration (oral, i.v., intra-arterial or cisternoventricular) and per study inclusion criteria (severe, CVS, refractory CVS or high risk for CVS). Univariate and multivariate subgroup analyses were performed to identify interventions associated with a better outcome.

Results: Sixty-two studies, including 26 randomized controlled trials, were included (8976 patients). Overall 2490 patients had unfavorable outcome including death (random-effect weighted average: 33.7%, 99%CI, 28.1-39.7%; Q-value: 806.0, I 2 =92.7%). Clinical outcome was significantly better in severe or refractory patients for whom, on top of best medical treatment, endovascular intervention was performed (RR=0.76, IC95% [0.66-0.89], p <0.00001) whereas other route of administration didn’t show significant differences. RR of unfavorable outcome was significantly lower, vs control groups, in patients treated with Cilostazol (RR=0.46 (IC99% [0.25-0.85], P = 0.001, Q value 1.5, I 2 = 0).

Conclusion: In case of CVS following aSAH, endovascular treatment in severe / refractory vasospasm patients. including intra-arterial injection of pharmacological agents or balloon angioplasty, improves outcome as compared to other route of administration.

The Capillary Index Score before thrombectomy: an angiographic correlate of favorable outcome

BACKGROUND AND PURPOSE

The angiography based Capillary Index Score (CIS) has recently emerged as a potential surrogate marker of cerebral perfusion before intra-arterial thrombolysis. We assessed the prevalence of a favorable CIS (f-CIS) and its relationship with clinical outcome in patients treated by mechanical thrombectomy (MT).

METHODS

Data from consecutive patients treated by MT from acute middle cerebral artery (MCA) occlusion were retrospectively analyzed. CIS was calculated from a pre-intervention cerebral angiogram. Association with favorable clinical outcome (modified Rankin Scale score ≤2) at 3 months was assessed in multivariate analysis.

RESULTS

146 patients were included in the study. f-CIS was observed in 106/146 (72%) patients with an acceptable inter-rater agreement (κ=0.73, p<0.001). It was associated with a lower pretreatment National Institutes of Health Stroke Scale (NIHSS) score (p=0.014), an isolated M1/M2 occlusion without internal carotid occlusion (p=0.042), and an Alberta Stroke Program Early CT Score (ASPECTS) >4 (p=0.004). In binary regression, a favorable outcome was independently associated with f-CIS (OR (-95% CI, +95% CI)=3.8 (1.3 to 10.9), p=0.013), as well as NIHSS (p=0.007), ASPECTS (p=0.005), isolated M1/M2 occlusion (p=0.013), and age (p=0.032). The positive predictive value of f-CIS for a favorable outcome was 67%.

CONCLUSIONS

f-CIS was strongly associated with a favorable outcome after MT of acute MCA occlusion. As an easy surrogate marker of cerebral perfusion, it may be a useful-albeit not sufficient-diagnostic test to select patients just before an MT or to manage them after recanalization.

Epidemiology, pathophysiology, diagnosis, and management of intracranial artery dissection

Spontaneous intracranial artery dissection is an uncommon and probably underdiagnosed cause of stroke that is defined by the occurrence of a haematoma in the wall of an intracranial artery. Patients can present with headache, ischaemic stroke, subarachnoid haemorrhage, or symptoms associated with mass effect, mostly on the brainstem. Although intracranial artery dissection is less common than cervical artery dissection in adults of European ethnic origin, intracranial artery dissection is reportedly more common in children and in Asian populations. Risk factors and mechanisms are poorly understood, and diagnosis is challenging because characteristic imaging features can be difficult to detect in view of the small size of intracranial arteries. Therefore, multimodal follow-up imaging is often needed to confirm the diagnosis. Treatment of intracranial artery dissections is empirical in the absence of data from randomised controlled trials. Most patients with subarachnoid haemorrhage undergo surgical or endovascular treatment to prevent rebleeding, whereas patients with intracranial artery dissection and cerebral ischaemia are treated with antithrombotics. Prognosis seems worse in patients with subarachnoid haemorrhage than in those without.

Mechanisms of Unexplained Neurological Deterioration After Intravenous Thrombolysis

Background and Purpose—

Unstable clinical course characterizes the first 24 hours after thrombolysis for anterior circulation stroke, including early neurological deterioration (END), a secondary complication consistently predictive of poor outcome. Apart from straightforward causes, such as intracerebral hemorrhage and malignant edema, the mechanism of END remains unclear in the majority of cases (END unexplained ). Based on the core/penumbra model, we tested the hypothesis that END unexplained is caused by infarct growth beyond the initial penumbra and assessed the associated vascular patterns.

Methods—

From our database of consecutive thrombolyzed patients (n=309), we identified 10 END unexplained cases who had undergone both admission and 24-hour MRI. Diffusion-weighted imaging lesion growth both within and beyond the acute penumbra (T max >6 seconds) was mapped voxelwise. These 10 cases were compared with 30 no-END controls extracted from the database blinded to 24-hour diffusion-weighted imaging to individually match cases (3/case) according to 4 previously identified clinical and imaging variables.

Results—

As predicted, lesion growth beyond initial penumbra was present in 9 of 10 END unexplained patients (substantial in 8) and its volume was significantly larger in cases than controls (2 P =0.047). All END unexplained cases had proximal arterial occlusion initially, of which only 2 had recanalized at 24 hours.

Conclusions—

In this exploratory study, most instances of END unexplained were related to diffusion-weighted imaging growth beyond acute penumbra. Consistent presence of proximal occlusion at admission and lack of recanalization at 24 hours in most cases suggest that hemodynamic factors played a key role, via for instance systemic instability/collateral failure or secondary thromboembolic processes. Preventing END after tissue-type plasminogen activator using, eg, early antithrombotics may therefore be feasible.

Unexplained Early Neurological Deterioration After Intravenous Thrombolysis

Background and Purpose—

Early neurological deterioration (END) after anterior circulation stroke is a serious clinical event strongly associated with poor outcome. Regarding specifically END occurring within 24 hours of intravenous recombinant tissue-type plasminogen activator, apart from definite causes such as symptomatic intracranial hemorrhage and malignant edema whose incidence, predictors, and clinical management are well established, little is known about END without clear mechanism (END unexplained ).

Methods—

We analyzed 309 consecutive patients thrombolysed intravenously ≤4.5 hours from onset of anterior circulation stroke. END unexplained was defined as a ≥4-point deterioration on 24-hour National Institutes of Health Stroke Scale, without definite mechanism on concomitant imaging. END unexplained and no-END patients were compared for pretreatment clinical and imaging (including magnetic resonance diffusion and diffusion/perfusion mismatch volumes) data and 24-hour post-treatment clinical (including blood pressure and glycemic changes) and imaging (24-hour recanalization) data, using univariate logistic regression. Exploratory multivariate analysis was also performed after variable reduction, with bootstrap analysis for internal validation.

Results—

Among 33 END patients, 23 (7% of whole sample) had END unexplained . END unexplained was associated with poor 3-month outcome ( P <0.01). In univariate analysis, admission predictors of END unexplained included no prior use of antiplatelets ( P =0.02), lower National Institutes of Health Stroke Scale score ( P <0.01), higher glycemia ( P =0.03), larger mismatch volume ( P =0.03), and proximal occlusion ( P =0.01), with consistent results from the multivariate analysis. Among factors recorded during the first 24 hours, only no recanalization was associated with END unexplained in multivariate analysis ( P =0.02).

Conclusions—

END unexplained affected 7% of patients and accounted for most cases of END. Several predictors and associated factors were identified, with important implications regarding underlying mechanisms and potential prevention of this ominous event.

3T MRI improves the detection of transmantle sign in type 2 focal cortical dysplasia

PURPOSE

Type 2 focal cortical dysplasia (FCD2) is one of the main causes of refractory partial epilepsy, but often remains overlooked by MRI. This study aimed to elucidate whether 3T MRI offers better detection and characterization of FCD2 than 1.5T, using similar coils and acquisition time.

METHODS

Two independent readers reviewed the 1.5T and 3T MR images of 25 patients with histologically proven FCD2. For both magnetic fields, the ability to detect a lesion was analyzed. We compared the identification of each of the five criteria typical of FCD2 (cortical thickening, blurring, cortical signal changes, subcortical signal changes, and "transmantle" sign) and artifacts, using a four-point scale (0-3). Interobserver reliability for lesion detection was calculated.

KEY FINDINGS

Seventeen lesions (68%) were detected at 3T, two of which were overlooked at 1.5T. Interobserver reliability was better at 3T (κ = 1) than at 1.5T (κ = 0.83). The transmantle sign was more clearly identified at 3T than 1.5T (mean visualization score: 1.72 vs. 0.56; p = 0.002).

SIGNIFICANCE

The use of 3T MRI in patients suspected of type 2 FCD improves the detection rate and the lesion characterization owing to the transmantle sign being more clearly seen at 3T. This point is of interest, since this feature is considered as an MR signature of FCD2.