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Patients with pre-stroke disability, defined as a modified Rankin Scale (mRS) ≥3, were excluded from most trials of endovascular thrombectomy (EVT) for acute stroke. We sought to evaluate the prognostic factors associated with favorable outcome in stroke patients with known disability undergoing EVT, and the impact of successful reperfusion.Consecutive acute stroke patients with pre-stroke disability, undergoing EVT, were retrospectively collected between 2016 to 2019 from a Canadian cohort and a multicenter French cohort (Endovascular Treatment in Ischemic Stroke registry-ETIS). Favorable outcome was defined as an mRS equal to pre-stroke mRS. Patients achieving successful reperfusion (defined as a modified Thrombolysis in Cerebral Infarction score of 2b/3) were compared with patients without successful reperfusion to determine if successful EVT was associated with better functional outcomes.Among 6220 patients treated with EVT, 280 (4.5%) patients with a pre-stroke mRS ≥3 were included. Sixty-one patients (21.8%) had a favorable outcome and 146 (52.1%) died at 3 months. Patients with successful reperfusion had a higher proportion of favorable 90-day mRS (27.6% versus 19.6%, p = 0.025) and a lower mortality (48.3% versus 69.6%, p = 0.008) than patients without successful reperfusion. After adjusting for baseline prognostic factors, successful reperfusion defined by TICI ≥2b was associated with favorable functional outcome (OR 3.16 CI95% [1.11-11.5]; p 0.048).In patients with pre-stroke disability, successful reperfusion is associated with a greater proportion of favorable outcome and lower mortality.

Background and purpose Recent clinical trials demonstrated the benefit of thrombectomy beyond 6 h based on the automated measurement of infarct volume exclusively with the RAPID software. We aimed to compare eight tools commonly used for the measurement of infarct volume and see whether they would lead to similar thrombectomy decisions based on the Diffusion-weighted-imaging or computerized-tomography-perfusion Assessment with clinical mismatch in the triage of Wake-up and late-presenting strokes undergoing Neurointervention with Trevo (DAWN) trial imaging inclusion criteria. Materials and Methods The diffusion-weighted-imaging (DWI) infarct volume of 36 patients was measured with 3 automated tools (including RAPID) and 5 non-automated tools. The agreement for the measurements of DWI infarct volume and the resulting thrombectomy decisions were assessed with intraclass correlation coefficient (ICC) and Fleiss’ Kappa (K) statistics. Results The correlation for the measurement of DWI infarct volume between all 9 tools was excellent (ICC > 0.8). After dichotomization, agreement was substantial for any of the cut-points used in DAWN trial. Discrepancies involving at least one of the tools for thrombectomy decisions based on DAWN criteria occurred in one third of cases. Compared with RAPID, the use of any other tool for treatment decision based on DAWN criteria would have led to contradictory decisions in 6% to 19% of cases. Conclusion There are several currently available tools for the measurement of DWI infarct volume with excellent correlation. Despite the high agreement demonstrated in our study, frequent discrepancies between measurements in some dichotomized configurations led to frequent diverging thrombectomy decisions when applying DAWN criteria.

Background Hemorrhagic transformation (HT) is a complication of stroke [1] that can occur spontaneously or after treatment. We aimed to assess the interrater and intrarater reliability of HT diagnosis. Methods Studies assessing the reliability of the European Cooperative Acute Stroke Study (ECASS) classification [2] of HT or of the presence (yes/no) of HT were systematically reviewed. Eighteen raters independently examined 30 post-thrombectomy [3] computed tomography scans selected from the Aspiration versus Stentriever (ASTER) trial [4] . They were asked whether there was HT (yes/no), what the ECASS classification of the particular scan (0/HI1/HI2/PH1/PH2) was, and whether they would prescribe an antiplatelet agent if it was otherwise indicated. Agreement [5] was measured with Fleiss’ and Cohen's kappa statistics. Results The systematic review yielded 4 studies involving few (≤ 3) raters with heterogeneous results. In our 18-rater study, agreement for the presence of HT was moderate (κ=0.55, 95%CI [0.41–0.68]). Agreement for ECASS classification was only fair for all 5 categories, but agreement improved to substantial (k = 0.72, 95%CI [0.69-0.75]) after dichotomizing ECASS into 0/HI1/HI2/PH1 versus PH2. The interrater agreement for the decision to reintroduce antiplatelet therapy was moderate for all raters, but substantial among vascular neurologists (κ=0.70 [0.57–0.84]). Conclusion The ECASS classification may involve too many categories and the diagnosis of HT may not be easily replicable, except in the presence of a large parenchymal hematoma. Clinical Trial Registration URL: http://www.clinicaltrials.gov Unique identifier: NCT02523261 .

Introduction Les malformations durales pediatriques sont rares et ne sont pas comparables aux shunts decrits dans la population adulte. Trois differentes entites pathologiques sont reconnues : les malformations des sinus duraux, les fistules durales de type infantile et les fistules durales de type adulte. L’objectif de ce travail est de presenter notre experience dans la prise en charge des patients porteurs de ces shunts arterioveineux en analysant leur presentation clinique, les techniques therapeutiques ainsi que les resultats cliniques et radiologiques. Materiel et methode Tous les patients pediatriques ( Resultats Vingt-six patients (12 M/14 F, âge moyen : 3,8 ans) ont ete pris en charge dont 11 patients (7 M/4 F ; âge moyen : 13 mois) presentant des malformations des sinus duraux, 4 patientes (4 F ; âge moyen : 4,6 ans) des shunts duraux de type infantile, et 11 patients (5 M/6 F ; âge moyen : 5,7 ans) des shunts duraux apparus secondairement apres traitement endovasculaire de malformations anevrismales de l’ampoule de Galien et classes comme fistules durales de type adulte. Les resultats cliniques et angiographiques sont analyses, developpes et compares aux donnees de la litterature. Conclusion Les shunts arterioveineux duraux pediatriques sont des lesions vasculaires complexes dont l’evolution potentiellement pejorative necessite une prise en charge endovasculaire specifique.

Background and purpose Proximal large vessel occlusion (LVO) is present in up to 30% of minor strokes. There is no proven effectiveness of MT in the subgroup of minor stroke with LVO in the anterior circulation and data about mechanical thrombectomy (MT) in this subgroup of patients are sparse, with optimal management of these patients being yet not definitely addressed. The purpose of this case-control study was to evaluate MT in patients suffering from acute ischemic stroke (AIS) and LVO in the anterior circulation, presenting with minor to mild stroke symptoms (NIHSS Material and methods Case-control study involving 4 comprehensive stroke centers, having two approaches regarding management of minor and mild AIS patients harboring LVO in the anterior circulation. An intention-to-treat analysis was conducted. The primary end point was the rate of excellent outcome defined as the achievement of a modified Rankin Scale score of 0–1 at 3 months. Results In total, 301 patients were included, 170 with MT associated to best medical management (BMM, case group) and 131 with BMM alone as first line treatment (control group). Patients treated with MT were younger, more often received intravenous thrombolysis, and had shorter time to imaging. Twenty-four patients (18.3%) belonging to the medical group had rescue MT due to neurologic worsening. Overall, excellent outcome was achieved in 64.5% of patients, with no difference between the two groups. Stratified analysis according to key subgroups did not find heterogeneity in the treatment effect size. Conclusion Patients having underwent MT or BMM achieve excellent and favorable functional outcome at 3 months in similar proportions. However, baseline characteristics were different between the 2 groups, highlighting the urgent need for randomized clinical trials in this subset of patients.

Introduction Le Neuroform Atlas est une evolution du Neuroform EZ. Il s’agit d’un stent hybride en nitinol, principalement a cellules ouvertes mais avec quelques cellules fermees a la partie proximale du stent. Sa mise en place est compatible avec les microcatheters de 0,017 pouce de lumiere interne. Nous rapportons notre experience preliminaire avec le stent Neuroform Atlas. Materiels et methodes De juillet a novembre 2015, le traitement electif par coiling de 14 anevrismes (5 communicants anterieurs, 5 sylviens, 3 termino-carotidiens, 1 sommet du tronc basilaire) chez 14 patients (10 femmes, âge moyen de 59 ans) a ete conduit avec l’utilisation conjointe d’un ou 2 stents Neuroform Atlas. Tous les anevrismes etaient de decouverte fortuite. Resultats La taille moyenne du sac anevrismal etait de 10,1 mm pour un collet moyen de 5,3 mm. Neuf interventions ont ete conduites avec la mise en place premiere de 2 stents en « Y » ; dans 8/9 cas les 2 stents ont ete places avant coiling avec catheterisme du sac anevrismal au travers des mailles des 2 stents, dans 1/9 cas les 2 stents en « Y » ont ete places apres le coiling premier du sac. Trois interventions ont consiste au placement premier d’un seul stent en « T » dans des terminaisons carotidiennes en naviguant par la carotide controlaterale et l’artere communicante anterieure. Enfin, 2 procedures ont consiste au placement premier d’un seul stent avant coiling de 2 anevrismes sylviens. Toutes les interventions ont ete menees sous double anti-agregation prealable controlee et heparinotherapie peroperatoire. Une complication ischemique (1/14) a ete deploree avec une issue fatale. Conclusion Le profil reduit du Neuroform Atlas permet son utilisation dans des microcatheters « 10 » (lumiere interne de 0,017 pouce) rendant ainsi possible la realisation de reconstruction arterielle complexe. Le profil reduit du systeme ainsi que le design a cellules ouvertes du Neuroform Atlas rendent la reconstruction des bifurcations arterielles avec la technique du stenting en « Y » beaucoup plus aisee qu’avec le Neuroform de la generation precedente.

Objectif Une reperfusion TICI 2b (quasi-complete) ou TICI 3 (complete) est consideree comme un bon resultat angiographique et reconnue comme un facteur pronostic majeur apres traitement endovasculaire des infarctus cerebraux. Cependant, il n’est pas clairement etabli que le pronostic fonctionnel entre ces deux groupes soit identique. L’objectif de cette etude etait de comparer le pronostic fonctionnel des patients presentant une recanalisation TICI 3 avec ceux presentant une recanalisation TICI 2b. Materiels et methodes Etude retrospective bicentrique a partir de donnees angiographiques et cliniques collectees prospectivement. Cent quatre-vingt-deux patients presentant une occlusion intracrânienne (artere carotide interne et/ou artere cerebrale moyenne) traites par voie endovasculaire dans 2 centres avec un score de reperfusion final TICI 2b ou TICI 3 ont ete evalues a 3 mois selon le score de Rankin modifie (mRS). Les caracteristiques initiales (âge, score NIH, delai debut des symptomes-reperfusion, ASPECTS), le devenir clinique favorable (mRS ≤ 2) ou tres favorable (mRS 0-1), le taux d’hemorragie intracrânienne et la mortalite ont ete recueillis et compares par analyse uni-, puis multivariee. Resultats Les patients avec un score de recanalisation TICI 3 avaient un meilleur pronostic compares aux TICI 2b avec respectivement 75,9 % (72/95) contre 50,6 % (44/87) (p = 0,0004) de patients avec un mRS ≤ 2 et 63,1 % (60/95) vs 40,2 % (35/87) (p = 0,002) de patients avec un mRS 0-1. Les caracteristiques cliniques, la mortalite et le taux d’hemorragie etaient identique entre les 2 groupes. Conclusion Les patients presentant une reperfusion TICI 3 ont un meilleur pronostic fonctionnel que les patients TICI 2b. Ces resultats incitent a considerer dans les futures etudes cliniques les patients TICI 2b et TICI 3 de facon separee.

Introduction A la phase aigue des infarctus cerebraux, le score Alberta Stroke Program Early CT evalue sur l’IRM de diffusion (DWI-ASPECT) est correle au volume de l’infarctus cerebral et est un facteur independant du pronostic neurologique. La thrombectomie chez des patients avec une ischemie etendue reste actuellement controversee. Les patients avec un score ASPECT ≤ 6 ont ete soit exclus des etudes randomisees soit tres largement sous representes. L’objectif de notre etude etait donc d’evaluer l’impact de la recanalisation par thrombectomie chez les patients avec un score DWI-ASPECT ≤ 6. Materiel et methodes Deux cent vingt-cinq patients avec une occlusion de la circulation anterieure et un score DWI-ASPECT ≤ 6 ont ete identifies a partir de 2 registres prospectifs de 959 patients consecutifs traites par thrombectomie entre janvier 2012 et aout 2015. Les donnees cliniques, d’imagerie et du pronostic a 3 mois etaient recueillies de facon prospective. Le score DWI-ASPECT etait calcule sur l’IRM initiale par 2 neuroradiologues. Une recanalisation satisfaisante etaient definie comme un score Thrombolysis In Cerebral Infarction (TICI) ≥ 2b. Resultats Parmi les 225 patients inclus dans cette etude, 152 (67 %) avaient une recanalisation satisfaisante en fin de procedure. Les donnees cliniques initiales etaient identiques chez les patients recanalises et non recanalisees. Le score NIHSS initial median etait de 17,5. Les patients recanalises avaient des taux superieurs d’amelioration neurologique precoce (54,8 % vs 25 %, p p = 0,003) et un taux inferieur de mortalite a 3 mois (23 % vs 43 %, p = 0,007) que les patients non recanalises. Il n’y avait pas de difference concernant les transformations hemorragiques symptomatiques (8,6 % vs 11,8 %, p = 0,51). Conclusion Notre etude montre un net benefice de la recanalisation par thrombectomie chez les patients avec un score DWI-ASPECT ≤ 6. La recanalisation est notamment associee a une reduction de la mortalite a 3 mois sans sur-risque de transformation hemorragique. L’etendue de l’ischemie initiale ne doit donc pas exclure les patients de la thrombectomie.