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OBJECTIVE The role of endovascular treatment in the management of patients with brain arteriovenous malformations (AVMs) remains uncertain. AVM embolization can be offered as stand-alone curative therapy or prior to surgery or stereotactic radiosurgery (SRS) (pre-embolization). The Treatment of Brain AVMs Study (TOBAS) is an all-inclusive pragmatic study that comprises two randomized trials and multiple registries. METHODS Results from the TOBAS curative and pre-embolization registries are reported. The primary outcome for this report is death or dependency (modified Rankin Scale [mRS] score > 2) at last follow-up. Secondary outcomes include angiographic results, perioperative serious adverse events (SAEs), and permanent treatment-related complications leading to an mRS score > 2. RESULTS From June 2014 to May 2021, 1010 patients were recruited in TOBAS. Embolization was chosen as the primary curative treatment for 116 patients and pre-embolization prior to surgery or SRS for 92 patients. Clinical and angiographic outcomes were available in 106 (91%) of 116 and 77 (84%) of 92 patients, respectively. In the curative embolization registry, 70% of AVMs were ruptured, and 62% were low-grade AVMs (Spetzler-Martin grade I or II), while the pre-embolization registry had 70% ruptured AVMs and 58% low-grade AVMs. The primary outcome of death or disability (mRS score > 2) occurred in 15 (14%, 95% CI 8%–22%) of the 106 patients in the curative embolization registry (4 [12%, 95% CI 5%–28%] of 32 unruptured AVMs and 11 [15%, 95% CI 8%–25%] of 74 ruptured AVMs) and 9 (12%, 95% CI 6%–21%) of the 77 patients in the pre-embolization registry (4 [17%, 95% CI 7%–37%] of 23 unruptured AVMs and 5 [9%, 95% CI 4%–20%] of 54 ruptured AVMs) at 2 years. Embolization alone was confirmed to occlude the AVM in 32 (30%, 95% CI 21%–40%) of the 106 curative attempts and in 9 (12%, 95% CI 6%–21%) of 77 patients in the pre-embolization registry. SAEs occurred in 28 of the 106 attempted curative patients (26%, 95% CI 18%–35%, including 21 new symptomatic hemorrhages [20%, 95% CI 13%–29%]). Five of the new hemorrhages were in previously unruptured AVMs (n = 32; 16%, 95% CI 5%–33%). Of the 77 pre-embolization patients, 18 had SAEs (23%, 95% CI 15%–34%), including 12 new symptomatic hemorrhages [16%, 95% CI 9%–26%]). Three of the hemorrhages were in previously unruptured AVMs (3/23; 13%, 95% CI 3%–34%). CONCLUSIONS Embolization as a curative treatment for brain AVMs was often incomplete. Hemorrhagic complications were frequent, even when the specified intent was pre-embolization before surgery or SRS. Because the role of endovascular treatment remains uncertain, it should preferably, when possible, be offered in the context of a randomized trial.

OBJECTIVE The Treatment of Brain Arteriovenous Malformations Study (TOBAS) is a pragmatic study that includes 2 randomized trials and registries of treated or conservatively managed patients. The authors report the results of the surgical registry. METHODS TOBAS patients are managed according to an algorithm that combines clinical judgment and randomized allocation. For patients considered for curative treatment, clinicians selected from surgery, endovascular therapy, or radiation therapy as the primary curative method, and whether observation was a reasonable alternative. When surgery was selected and observation was deemed unreasonable, the patient was not included in the randomized controlled trial but placed in the surgical registry. The primary outcome of the trial was mRS score > 2 at 10 years (at last follow-up for the current report). Secondary outcomes include angiographic results, perioperative serious adverse events, and permanent treatment-related complications leading to mRS score > 2. RESULTS From June 2014 to May 2021, 1010 patients were recruited at 30 TOBAS centers. Surgery was selected for 229/512 patients (44%) considered for curative treatment; 77 (34%) were included in the surgery versus observation randomized trial and 152 (66%) were placed in the surgical registry. Surgical registry patients had 124/152 (82%) ruptured and 28/152 (18%) unruptured arteriovenous malformations (AVMs), with the majority categorized as low-grade Spetzler-Martin grade I–II AVM (118/152 [78%]). Thirteen patients were excluded, leaving 139 patients for analysis. Embolization was performed prior to surgery in 78/139 (56%) patients. Surgical angiographic cure was obtained in 123/139 all-grade (89%, 95% CI 82%–93%) and 105/110 low-grade (95%, 95% CI 90%–98%) AVM patients. At the mean follow-up of 18.1 months, 16 patients (12%, 95% CI 7%–18%) had reached the primary safety outcome of mRS score > 2, including 11/16 who had a baseline mRS score ≥ 3 due to previous AVM rupture. Serious adverse events occurred in 29 patients (21%, 95% CI 15%–28%). Permanent treatment-related complications leading to mRS score > 2 occurred in 6/139 patients (4%, 95% CI 2%–9%), 5 (83%) of whom had complications due to preoperative embolization. CONCLUSIONS The surgical treatment of brain AVMs in the TOBAS registry was curative in 88% of patients. The participation of more patients, surgeons, and centers in randomized trials is needed to definitively establish the role of surgery in the treatment of unruptured brain AVMs. Clinical trial registration no.: NCT02098252 (ClinicalTrials.gov)

BACKGROUND AND PURPOSE Delayed cerebral ischemia (DCI) and angiographic vasospasm following subarachnoid hemorrhage (SAH) have been associated for more than 50years. We aimed to examine whether the knowledge gained by theoretical research on vasospasm has actually translated into better patient outcomes in practice. METHODS This is a narrative review of the concept of vasospasm as a cause of DCI after SAH. We discuss recent studies that have assessed the accuracy and reliability of the diagnostic tests (transcranial Doppler ultrasound [TCD], CT angiography, and catheter angiography), which are used to identify SAH patients at-risk of DCI. RESULTS Both the diagnostic accuracy of TCD and the reliability of CT angiography to identify patients in severe vasospasm are poor. For the gold standard catheter angiography, the repeatability of the diagnosis of vasospasm, made by multiple raters, is only fair. Interventions on angiographic vasospasm have never been proven to improve patient outcomes. A pragmatic trial integrating the meaning of the diagnosis of vasospasm into a study protocol that assesses the value of endovascular interventions in the prevention of DCI after SAH seems to be in order. Such a trial could provide a pragmatic definition of clinically meaningful vasospasm. CONCLUSION We must move beyond research conceived as an enterprise aiming to acquire theoretical knowledge to one where research is integrated into clinical practice to improve clinical outcomes in real time.

The Comprehensive Aneurysm Management (CAM) study is a pragmatic trial designed to manage unruptured intracranial aneurysm (UIA) patients within a care research framework.CAM is an all-inclusive study. Management options are allocated according to an algorithm combining pre-randomization and clinical judgment. Eligible patients are offered 1:1 randomized allocation of intervention versus conservative management and 1:1 randomization allocation of surgical versus endovascular treatment. Ineligible patients are registered. The primary outcome is survival without dependency (modified Rankin Scale score3) at 10 years. All UIA patients at 1 center are reported.Between February 2020 and July 2021, 403 UIA patients were recruited: 179 (44%) in one of the randomized controlled trials (RCTs) and 224 (56%) in one of the registries. Conservative management was recommended for 205 of 403 patients (51%); of 198 (49%) patients considered for curative treatment, 159 (80%) were randomly allocated conservative (n = 81) or curative treatment (n = 78). These patients were younger and had larger aneurysms than those in the observation registry (P = 0.004). In 39 of 198 patients (20%), conservative management was not considered reasonable (17 patients were recommended endovascular, 2 surgery, and 20 the RCT comparing endovascular with surgical treatment). In total, 70 patients were recruited in the RCT comparing surgery and endovascular treatment. After informed discussion at time of consent, 141 of 159 patients (89%) agreed with the randomly allocated management plan, while 11% crossed over to the alternative management option.CAM was successfully integrated into routine practice. Meaningful conclusions can be obtained if multiple centers actively participate in the trial.

Structure and intensity forecasts of 19 tropical cyclones (TCs) during the 2020 Atlantic hurricane season are investigated using two NWP systems. An experimental 4-km global ECMWF model (“EC4”) with upgraded moist physics is compared against a 9-km version (“EC9”) to evaluate the influence of resolution. EC4 is then benchmarked against the 4-km regional COAMPS-TC system (“CO4”) to compare systems with similar resolutions. EC4 produced stronger TCs than EC9, with a >30% reduction of the maximum wind speed bias in EC4 resulting in lower forecast errors. However, both ECMWF predictions struggled to intensify initially weak TCs, and the radius of maximum wind (RMW) was often too large. In contrast, CO4 had lower biases in central pressure, maximum wind speed, and RMW. Regardless, minimal statistical differences between CO4 and EC4 intensity errors were found for ≥36 h forecasts. Rapid intensification cases yielded especially large intensity errors. CO4 produced superior forecasts of RMW, together with an excellent pressure-wind relationship. Differences in the results are due to contrasting physics and initialization schemes. ECMWF uses a global data assimilation with no special treatment of TCs, whereas COAMPS-TC constructs a vortex (for TCs with initial intensity ≥55 kt) based on data provided by forecasters. Two additional ECMWF experiments were conducted. The first yielded improvements when the drag coefficient was reduced at high wind speeds, thereby weakening the coupling between the low-level winds and the surface. The second produced overly intense TCs when explicit deep convection was used, due to unrealistic mid-upper-tropospheric heating.

Background: The prognosis for patients with recurrent glioblastoma (GBM) is dismal, and the question of repeat surgery at time of recurrence is common. Re-operation in the management of these patients remains controversial, as there is no randomized evidence of benefit. An all-inclusive pragmatic care trial is needed to evaluate the role of repeat resection. Methods: 3rGBM is a multicenter, pragmatic, prospective, parallel-group randomized care trial, with 1:1 allocation to repeat resection or standard care with no repeat resection. To test the hypothesis that repeat resection can improve overall survival by at least 3 months (from 6 to 9 months), 250 adult patients with prior resection of pathology-proven glioblastoma for whom the attending surgeon believes repeat resection may improve quality survival will be enrolled. A surrogate measure of quality of life, the number of days outside of hospital/nursing/palliative care facility, will also be compared. Centers are invited to participate without financial compensation and without contracts. Clinicians may apply to local authorities to approve an investigator-led in-house trial, using a common protocol, web-based randomization platform, and simple standardized case report forms. Discussion: The 3rGBM trial is a modern transparent care research framework with no additional risks, tests, or visits other than what patients would encounter in normal care. The burden of proof remains on repeat surgical management of recurrent GBM, because this management has yet to be shown beneficial. The trial is designed to help patients and surgeons manage the uncertainty regarding optimal care. Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT04838782.

International audience; This review paper reports on the state-of-the-art concerning observations of surface winds, waves and currents from space and their use for scientific research and subsequent applications. The development of observations of sea state parameters from space dates back to the 1970s, with a significant increase in the number and diversity of space missions since the 1990s. Sensors used to monitor the sea-state parameters from space are mainly based on microwave techniques. They are either specifically designed to monitor surface parameters or are used for their abilities to provide opportunistic measurements complementary to their primary purpose. The principles on which is based the estimation of the sea surface parameters are first described, including the performance and limitations of each method. Numerous examples and references on the use of these observations for scientific and operational applications are then given. The richness and diversity of these applications are linked to the importance of knowledge of the sea state in many fields. Firstly, surface wind, waves and currents are significant factors influencing exchanges at the air/sea interface, impacting oceanic and atmospheric boundary layers, contributing to sea level rise at the coasts, and interacting with the sea-ice formation or destruction in the polar zones. Secondly, ocean surface currents combined with wind-and wave-induced drift contribute to the transport of heat, salt and pollutants. Waves and surface currents also impact sediment transport and erosion in coastal areas. For operational applications, observations of surface parameters are necessary on the one hand to constrain the numerical solutions of predictive models (numerical wave, oceanic or atmospheric models), and on the other hand to validate their results. In turn, these predictive models are used to guarantee safe, efficient and successful offshore operations, including the commercial shipping and energy sector, as well as tourism and coastal activities. Long time series of global sea-state observations are also becoming increasingly important to analyze the impact of climate change on our environment. All these aspects are recalled in the article, relating to both historical and contemporary activities in these fields. Article Highlights • The different techniques and satellite missions to monitor winds, waves and currents at the ocean surface from space are described • Sea-state observations from space are widely used in operational meteorology, as well as for research on ocean, atmosphere and climate processes • Sea-state observations from space are also actively used by the offshore industry, as well as in coastal zone management

Background: Two early basilar artery occlusion (BAO) randomized controlled trials did not establish superiority of endovascular thrombectomy (EVT) over medical management. While many providers continue to recommend EVT for acute BAO, perceptions of equipoise in randomizing patients with BAO to medical management may differ between clinician specialties. Methods: We conducted an international survey (1/1/22-3/31/22) regarding management strategies in acute BAO prior to the announcement of 2 trials indicating superiority of EVT, and compared responses between interventionalists (INT) and non-interventionalists (nINT). Selection practices for routine EVT based on neuroimaging and clinical features were compared between the two groups using descriptive statistics. Results: Among the 1245 respondents (nINT=702), INT more commonly believed that EVT was superior to medical management in acute BAO (98.5% vs. 95.1%, p0.05), although nINT more commonly preferred perfusion imaging (24.2% vs. 19.7%, p=0.04). Among respondents who indicated they would randomize to medical management, INT were more likely to randomize when the NIHSS was ≥10 (15.9% vs. 6.9%, p Conclusions: Following the publication of two neutral clinical trials in BAO EVT, most stroke providers believed EVT to be superior to medical management in carefully selected patients, with most indicating they would not randomize a patient to medical treatment. There were small differences in preference of advanced neuroimaging, although these preferences were unsupported by clinical trial data.

Background: The Human Immunodeficiency Virus (HIV) is a chronic pathology, progressively evolving towards a severe immunodepression without antiretroviral treatment. This severe immunodepression corresponds to the Acquired Immunodeficiency Syndrome (AIDS) stage, which favoring the occurrence of opportunistic infections. like Cryptococcosis, a systemic fungal infection with a neuromeningeal tropism due to a mycosis called Cryptococcus neoformans (opportunistic yeast fungus). In Gabon, the last study was conducted in 2016 at Lambaréné Hospital Center, where the authors reported two cases of neuromeningeal cryptococcosis (NMC) with HIV in a rural area, who were not adhering to antiretroviral treatment (ART). Objective: Determine the prevalence, clinical and paraclinical feature of Neuromeningeal Cryptococcosis (NMC) associated with people living with HIV (PLHIV) in the internal medicine department. Materials and Methods: This were a retrospective study of adult inpatient who presented with neuromeningeal cryptococcosis associated with HIV in the internal medicine department of HIA-OBO over a period of 6 years from December 01, 2015 to December 31, 2021. Results: The prevalence was 8,4%. We collected 6 PLHIV inpatients, two men and four women. The most affected age group was 40 to 50 years old with a female predominance. The clinical feature was dominated by the deterioration of the general state (100%), headaches (50%), hemiplegia and fever in 50% of the cases. The main CSF cytochemical outcome were hyperproteinorachia (100%) and hypoglycorachia (83.3%). The diagnosis of NMC was suspected on clinical and biological signs, then confirmed with the identification of cryptococci either by a direct exam with India ink or by culture of the CSF (83.3%). The level of CD4 cells was ≤ 100 cells/mm3 in 66.7% of cases. Thus, classifying PLHIV with this opportunistic disease at stage C3 AIDS according to the CDC Atlanta classification. Conclusion: The clinical signs, the HIV context, the stage of clinical and immunological immunosuppression in PLHIV helped in the diagnosis of NMC; confirmed by the results of direct examination (India ink test) and/or CSF culture on Sabouraud medium to detect Cryptococcus neoformans.

Le Dialogue des chiens situe la critique de l’Espagne dans le cadre de la représentation pénitentielle d’une humanité prisonnière du péché. Pourtant, ce pessimisme religieux est contredit par la fantaisie, la belle humeur des deux entreparleurs cabots, qui parlent moins pour faire la morale que pour jouir du plaisir un peu louche de critiquer, de digresser. Ce plaisir renonce à parler à la société, prend acte du double constat de l’impossibilité d’une parole politique et de la toute puissance de la mauvaise foi, pour proposer un point de vue distant, complice, désabusé et amusé. Abstract The Dialogue of the Dogs places the criticism of Spain within the framework of the penitential representation of a humanity trapped in sin. However, this religious pessimism is contradicted by the fantasy, the good humor of the two talking mutts, who speak less to moralize than to enjoy the slightly shady pleasure of criticizing, of digressing. This pleasure renounces to speak to the society, takes note of the double observation of the impossibility of a political speech and of the omnipotence of bad faith, to propose a distant, complicit, disillusioned and amused point of view.

Background: The proper imaging modality for use in the selection of patients for endovascular thrombectomy (EVT) presenting in the late window remains controversial, despite current guidelines advocating the use of advanced imaging in this population. We sought to understand if clinicians with different specialty training differ in their approach to patient selection for EVT in the late time window. Methods: We conducted an international survey of stroke and neurointerventional clinicians between January and May 2022 with questions focusing on imaging and treatment decisions of large vessel occlusion (LVO) patients presenting in the late window. Interventional neurologists, interventional neuroradiologists, and endovascular neurosurgeons were defined as interventionists whereas all other specialties were defined as non-interventionists. The non-interventionist group was defined by all other specialties of the respondents: stroke neurologist, neuroradiologist, emergency medicine physician, trainee (fellows and residents) and others. Results: Of 3000 invited to participate, 1506 (1027 non-interventionists, 478 interventionists, 1 declined to specify) physicians completed the study. Interventionist respondents were more likely to proceed directly to EVT (39.5% vs. 19.5%; p < 0.0001) compared to non-interventionist respondents in patients with favorable ASPECTS (Alberta Stroke Program Early CT Score). Despite no difference in access to advanced imaging, interventionists were more likely to prefer CT/CTA alone (34.8% vs. 21.0%) and less likely to prefer CT/CTA/CTP (39.1% vs. 52.4%) for patient selection (p < 0.0001). When faced with uncertainty, non-interventionists were more likely to follow clinical guidelines (45.1% vs. 30.2%) while interventionists were more likely to follow their assessment of evidence (38.7% vs. 27.0%) (p < 0.0001). Conclusion: Interventionists were less likely to use advanced imaging techniques in selecting LVO patients presenting in the late window and more likely to base their decisions on their assessment of evidence rather than published guidelines. These results reflect gaps between interventionists and non-interventionists reliance on clinical guidelines, the limits of available evidence, and clinician belief in the utility of advanced imaging.

© 2023 American Society of Neuroimaging., Background and purpose: Two early basilar artery occlusion (BAO) randomized controlled trials did not establish the superiority of endovascular thrombectomy (EVT) over medical management. While many providers continue to recommend EVT for acute BAO, perceptions of equipoise in randomizing patients with BAO to EVT versus medical management may differ between clinician specialties. Methods: We conducted an international survey (January 18, 2022 to March 31, 2022) regarding management strategies in acute BAO prior to the announcement of two trials indicating the superiority of EVT, and compared responses between interventionalists (INTs) and non-interventionalists (nINTs). Selection practices for routine EVT and perceptions of equipoise regarding randomizing to medical management based on neuroimaging and clinical features were compared between the two groups using descriptive statistics. Results: Among the 1245 respondents (nINTs = 702), INTs more commonly believed that EVT was superior to medical management in acute BAO (98.5% vs. 95.1%, p < .01). A similar proportion of INTs and nINTs responded that they would not randomize a patient with BAO to EVT (29.4% vs. 26.7%), or that they would only under specific clinical circumstances (p = .45). Among respondents who would recommend EVT for BAO, there was no difference in the maximum prestroke disability, minimum stroke severity, or infarct burden on computed tomography between the two groups (p > .05), although nINTs more commonly preferred perfusion imaging (24.2% vs. 19.7%, p = .04). Among respondents who indicated they would randomize to medical management, INTs were more likely to randomize when the National Institutes of Health Stroke Scale was ≥10 (15.9% vs. 6.9%, p < .01). Conclusions: Following the publication of two neutral clinical trials in BAO EVT, most stroke providers believed EVT to be superior to medical management in carefully selected patients, with most indicating they would not randomize a BAO patient to medical treatment. There were small differences in preference for advanced neuroimaging for patient selection, although these preferences were unsupported by clinical trial data at the time of the survey.

Background The Low-profile Visible Intraluminal Support device (LVIS Jr) has become a commonly used intracranial stent for the treatment of intracranial aneurysms. However long-term stability and effectiveness remains to be seen. The purpose of the study was to assess the long-term efficacy, safety and durability of LVIS Jr. in a retrospective multicenter registry. Methods Patients with saccular aneurysms treated at centers across Canada using LVIS Jr for intracranial aneurysms were included in this retrospective registry between the dates of January 2013 and April 2019. Self reported outcomes were collected and used to assess both perioperative and long term safety and effectiveness. Both univariate and multivariate analysis were performed. Results Total of 196 patients (132 Women; mean age of 57.6 years) underwent endovascular aneurysm treatment with at least 1 LVIS Jr. stent. Mean aneurysm dome size was 7.4 mm, and mean neck size of 4.3 mm. Mean clinical and imaging follow up were 950 and 899 days respectively. Class I/II was achieved in 85% on long term follow up. Periprocedural morbidity and mortality was 4.6% and 2% and additional delayed morbidity and mortality was 3% and 2.5%. Aneurysm size >10 mm was independent predictor of periprocedural complication (OR 2.59, p = 0.048) while an increased dome to neck ratio >1.5 was independent predictor of increased delayed complications (OR 3.99, p = 0.02). Conclusion The LVIS Jr. intracranial stent is an effective device in the treatment of intracranial aneurysms. Satisfactory long term occlusion rates can be achieved safely with stent-assisted coil embolization.