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BACKGROUND AND PURPOSE: The modified TICI Infarction grading system is a metric currently used to evaluate angiographic results of thrombectomy for large-vessel occlusion in ischemic stroke. Originally designed for evaluating MCA territories, it is currently used for other vessel occlusions, including the posterior circulation. We postulate that the modified TICI use for the posterior circulation is not accurate due to the different vascular territories supplied by vertebrobasilar vasculature, making grading more complex. MATERIALS AND METHODS: We collected angiographic results from 30 patients who presented with acute posterior circulation occlusions between 2015 and 2018 and underwent thrombectomy in our institution. Eight observers were asked to evaluate the TICI scores before and after thrombectomy. The multirater statistics were computed using Fleiss κ analysis. Further data were collected regarding the potential brain territories at risk and the existence of atherosclerotic disease in the basilar artery. RESULTS: The overall agreement κ reached 0.277 (SD, 0.013), which suggests a “fair” agreement among the raters. On average, 45% of observers achieved a high accuracy in predicting brain areas at risk of ischemia. As for the existence of basilar atherosclerotic disease, a high agreement (defined as at least 5 of 6 observers) was seen in 20 of the 30 patients. CONCLUSIONS: Despite TICI being ubiquitous in stroke diagnostics, the high variability of posterior circulation TICI scores calls into question its use in these strokes. Other methods should be developed to assess recanalization in the posterior circulation.

Background In light of multiple trials showing efficacy of mechanical thrombectomy with highest level of supporting evidence, limited information is available on how treating physicians around the world make decisions in real-life regarding patient selection for (EVT). Regional differences exists where for the same patient presentation and attributes, the decision to treat endovascularly could differ based on local practice and resource settings. In this study we seeked to determine the effect of regional and country specific factors on endovascular treatment and how those decisions could differ in a simulated ‘ideal’ setting if resources were not to be constrained. Methods We conducted a multidisciplinary survey of Neurosurgeons, Neurointerventional Radiologists, Neurologists, and other clinicians involved in acute stroke care around the world in an effort to understand prevailing approaches in management of stroke using a case-based approach (n=603 from 38 countries). The participants were presented with 10 randomly assigned cases with varying patient characteristics. Respondents were asked which treatment they would selected for each patient in their ‘current’ practice setting versus ‘ideal’ conditions. The rate of EVT selection was calculated and compared across different world countries. The propensity to add EVT under ‘ideal’ conditions were compared across geographic regions taking into account physician age, experience, specialty, and academic practice setting. Results In the case scenarios 75.5% of the respondents proceeded with EVT under ‘current’ practice setting and were stratified into 7 geographic regions (6070 responses). Regions with relatively lower than average positive rates in proceeding with EVT were South America (58% n=24) and South Asia (60.5% of n=24), compared to 78% global. Average age of the treating clinicians in South America was 37.3 versus 44.8 global average (H=373.6; p Conclusion In the selection of patients to undergo endovascular treatment, there exists a significant difference in rate of EVT procedures performed across countries and regions in the world reflecting local resources and practice settings. The decision to proceed with EVT reflects factors such as center volumes and clinician age & experience as contributing factors with younger clinicians in centers with lower volumes being more likely to consider EVT in an ‘ideal’ setting. Disclosures N. Kashani: None. J. Ospel: None. M. Almekhlafi: None. A. Wilson: None. A. Rabinstein: None. W. Kunz: None. B. Campbell: None. M. Foss: None. F. Turjman: None. U. Fischer: None. B. Baxter: None. P. Sylaia: None. S. Yoshimura: None. J. Heo: None. B. Kim: None. M. Hill:None. G. Saposnik: None. B. Menon: None. M. Goyal: None.

cited By 0; Objectives: To determine the cost-effectiveness of stent retriever thrombectomy (SRT) added to standard of care (SOC) in large vessel occlusion (LVO) strokes, adopting the French societal perspective given the lack of published studies with such perspective. Methods: We developed an hybrid model (decision tree until one year post-stroke followed by a Markov model from one year onward). The time horizon was 20 years. We calculated transition probabilities across the modified Rankin Scale (mRS) based on a published meta-analysis. The main outcome measure was quality adjusted life-years (QALYs) gained. Resources and input costs were derived from a literature search. We calculated the incremental cost-effectiveness ratio (ICER) expressed as cost/QALY. We used 1-way deterministic and probabilistic sensitivity analysis (PSA) to evaluate the model uncertainty. Results: In the base-case, adding SRT to SOC resulted in increased effectiveness of 0.73 QALY while total costs were reduced by 3,874€ (ICER of −5,400€/QALY). In the scenario analysis adopting the French healthcare system perspective, the ICER was 4,901€/QALY. Parameters the most influential were the relative risks of SRT over SOC for 90-days mortality and for 90-days mRS 0–2, and the time horizon. PSA showed the 95% confidence interval of the ICER was −21,324 to 4,591€/QALY, with SRT having 85.5% chance to be dominant and 100% to be cost-effective at a threshold of 50,000€/QALY. Conclusion: SRT was dominant from a French societal perspective, from 9 years post-stroke onwards. Cost-effectiveness of SRT added to SOC becomes undisputable with evidences from payer and societal viewpoints. © 2019 Elsevier Masson SAS

The functional benefit of stent retriever thrombectomy in acute ischemic stroke has been clearly demonstrated in recent positive MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT and THRACE trials. Thrombectomy, in association with intravenous thrombolysis, should now be offered to patients with documented occlusion of the distal internal carotid or proximal middle cerebral arteries, with a relatively normal unenhanced computed tomography (CT), and within 6hours after the onset of symptoms. Thrombectomy results in a mean absolute decrease in handicap of 22% (14 to 31%). Of the 3 up to 8 patients treated, 1 is independent at 3 months according to the initial selection. In case of a contraindication to thrombolysis, early primary thrombectomy should be considered. In acute basilar artery occlusion, thrombectomy should be performed alone or combined with thrombolysis. In an effort to increase the number of patients treated, a very rapid transfer to interventional neuroradiology centers is mandatory. In the future, thrombectomy should be evaluated in patients with distal arterial occlusion, or beyond 6hours after the onset of symptoms, or when the time of symptoms onset is unknown.

Revue Neurologique - In Press.Proof corrected by the author Available online since samedi 6 mai 2017

International audience; Background and purposeA direct aspiration first pass technique (ADAPT), involving the first-line use of a large-bore distal aspiration catheter, is a new strategy in the mechanical thrombectomy of acute ischemic stroke caused by large-vessel occlusion. However, its impact on reperfusion rates, clinical outcomes and complication rates has not been fully examined. MethodsWe conducted a systematic review of the literature searching multiple databases for reports on thrombectomy of acute stroke with ADAPT and performed meta-analyses of clinical and radiographic outcomes. ResultsWe selected 16 articles that included a total of 1378 patients treated with ADAPT. The mean admission National Institutes of Health Stroke Scale score was 17 and pre-treatment intravenous thrombolysis was used in 51% of cases. The successful recanalization (thrombolysis in cerebral ischemia 2b-3) rate was 66% [95% confidence interval (CI), 59-72%] with ADAPT and a rescue stent retriever was used in 31% of cases (95% CI, 24-37%) yielding an overall thrombolysis in cerebral ischemia 2b-3 rate of 89% (95% CI, 85-92%). We found a pooled estimate of 50% (95% CI, 45-54%) for functional independence (modified Rankin Scale score 0-2) at 90days, 15% (95% CI, 10-21%) for mortality within 90days and 5% (95% CI, 3-7%) for symptomatic intracranial hemorrhage. ConclusionsADAPT therapy is associated with similar reperfusion rates, clinical outcomes and complication rates compared with thrombectomy with stent retrievers. However, the major limitations of current evidence (i.e. retrospective studies and selection bias) indicate a need for adequately powered, multicenter randomized controlled trials to determine the best strategy.

Intravenous thrombolysis was the only proven effective reperfusion therapy for acute ischemic stroke within 4h30 until December 2014. Stroke management has been revolutionized after the publication of the recent positive trials, such as MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT, and THRACE. Each of these demonstrates a clear benefit of stent retriever thrombectomy in association with thrombolysis in acute stroke patients with a documented occlusion of the distal internal carotid or the proximal middle cerebral artery within 6 h of symptoms onset. According to the initial selection, the number of patients to be treated by thrombectomy in order to have one independent patient varies from 3 to 8.To guarantee these results, thrombectomy should be performed by an interventional neuroradiologist within 60–90 min after imaging confirmation, which requires a very fast transfer of patients to hospitals, where interventional neuroradiology is available without delaying thrombolysis. Samu plays a key role in this. In case of contraindication to thrombolysis, early primary thrombectomy should also be considered within 6 h of last seen normal. In acute basilar artery occlusion, thrombectomy should be performed alone or combined with thrombolysis. A close cooperation between all the teams is crucial with the goal of gaining maximum time to the patient.

BACKGROUND AND PURPOSE: Endovascular treatment of bifurcation middle cerebral artery aneurysms with a wide neck could be challenging, and many lesions are still treated by a surgical approach. The pCONus is a newly emerging device for wide-neck bifurcation intracranial aneurysms. To date, a single report on the treatment of intracranial aneurysms including all locations has been published. We report our experience with pCONus in the treatment of wide-neck MCA aneurysms. MATERIALS AND METHODS: MCA aneurysms treated with pCONus in 4 European centers were retrospectively reviewed. RESULTS: Forty MCA aneurysms (mean dome size, 7.7 mm; mean neck size, 5.6 mm) were treated in 40 patients (mean age, 62 years). Aneurysm coiling was performed after deployment of 1 pCONus in 95% (38/40) of cases and after deployment of 2 pCONus devices in 5% (2/40). No procedural angiographic complications were observed. Reversible neurologic complications were noted in 5% (2/40), and permanent neurologic complication, in 2.5% (1/40) at 1 month. There was no mortality. No aneurysms bled or rebled after treatment. Immediate angiographic results were complete aneurysm occlusion in 25% (10/40), neck remnant in 47.5% (19/40), and aneurysm remnant in 27.5% (11/40). Follow-up (mean, 6.8 months) was available for 33 aneurysms (82.5%). Stable or improved results were observed in all except 3 cases, including 48.5% complete occlusions (16/33), 30.3% neck remnants (10/33), and 21.2% aneurysm remnants (7/33). There was no in-stent stenosis or jailed branch occlusion. There was no angiographic recurrence of initially totally occluded aneurysms. CONCLUSIONS: MCA aneurysms with a wide neck are amenable to treatment with pCONus.

BACKGROUND AND PURPOSE Tandem anterior circulation lesions in the setting of acute ischemic stroke (AIS) are a complex endovascular situation that has not been specifically addressed in trials. We determined the predictors of successful reperfusion and good clinical outcome at 90 days after mechanical thrombectomy (MT) in patients with AIS with tandem lesions in a pooled collaborative study. METHODS This was a retrospective analysis of consecutive patients presenting to 18 comprehensive stroke centers with AIS due to tandem lesion of the anterior circulation who underwent MT. RESULTS A total of 395 patients were included. Successful reperfusion (modified thrombolysis in cerebral infarction score 2b-3) was achieved in 76.7%. At 90 days, 52.2% achieved a good outcome (modified Rankin Scale score 0-2), 13.8% suffered a parenchymal hematoma and 13.2% were dead. Lower National Institutes of Health Stroke Scale score [odds ratio (OR), 1.26; 95% confidence intervals (CI), 1.07-1.48, P = 0.004], Alberta Stroke Program Early CT Score ≥7 (OR, 2.00; 95% CI, 1.07-3.43, P = 0.011), intravenous thrombolysis (OR, 1.47; 95% CI, 1.01-2.12, P = 0.042) and stenting of the extracranial carotid lesion (OR, 1.63; 95% CI, 1.04-2;53, P = 0.030) were independently associated with successful reperfusion. Lower age (OR, 1.58; 95% CI, 1.26-1.97, P < 0.001), absence of hypercholesterolemia (OR, 1.77; 95% CI, 1.10-2.84, P = 0.018), lower National Institutes of Health Stroke Scale scores (OR, 2.04; 95% CI, 1.53-2.72, P < 0.001), Alberta Stroke Program Early CT Score ≥7 (OR, 2.75; 95% CI, 1.24-6.10, P = 0.013) and proximal middle cerebral artery occlusion (OR, 1.59; 95% CI, 1.03-2.44, P = 0.035) independently predicted a good 90-day outcome. CONCLUSIONS Intravenous thrombolysis and emergent stenting of the extracranial carotid lesion were predictors of a successful reperfusion after MT of patients with AIS with tandem lesion of the anterior circulation.

Background and Purpose— Tandem steno-occlusive lesions were poorly represented in randomized trials and represent a major challenge for endovascular thrombectomy in acute anterior circulation strokes. The impact of the cervical carotid lesion cause (ie, atherosclerotic versus dissection) on outcome of tandem patients endovascularly treated remains to be assessed. Methods— We retrospectively analyzed individual data of prospectively collected consecutive tandem patients treated with endovascular thrombectomy. The primary outcome was favorable outcome at 90 days (modified Rankin Scale score of 0–2). Secondary efficacy outcomes included successful reperfusion (modified Thrombolysis in Cerebrovascular Infarction scores of 2b-3), time to reperfusion, and safety outcomes encompassed procedural complications, symptomatic intracerebral hemorrhage, and 90-day mortality. Results— Among the 295 included patients, 65 had cervical carotid dissection and 230 had cervical carotid atherosclerotic cause. The rate of favorable outcome was 56.3% in the dissection group versus 47.6% in the atherosclerotic arm (center-, age-, and admission National Institutes of Health Stroke Scale–adjusted odds ratio, 1.08; 95% confidence interval, 0.50–2.30; P =0.85). No significant differences were observed in secondary outcomes. The rates of successful reperfusion, symptomatic intracerebral hemorrhage, and 90-day mortality were 78.5% versus 74.5% ( P =0.13), 4.6% versus 5.2% ( P =1.0), and 7.8% versus 15.3% ( P =0.94) in the dissection versus atherosclerotic groups, respectively. The median procedural time was 76 minutes (interquartile range, 52–95 minutes) in the dissection group and 67 minutes (interquartile range, 45–98 minutes) in the atherosclerotic group ( P =0.24). Conclusions— We found no differences in the outcomes of patients with anterior circulation tandem atherosclerotic and dissection lesions treated with endovascular thrombectomy. Further studies are warranted.

Intrasaccular flow diverters are increasingly being used in the treatment of wide-neck and bifurcation aneurysms. We performed a systematic review and meta-analysis of existing literature on the Woven EndoBridge device in the treatment of intracranial aneurysms.A comprehensive literature search was performed through October 1, 2015. We extracted information on baseline aneurysm and patient characteristics. Outcomes studied included immediate and midterm (3 month) angiographic outcomes (complete occlusion as well as adequate occlusion, defined as complete occlusion or neck remnant), aneurysm retreatment, intraoperative rupture, perioperative morbidity and mortality, thromboembolic complications, and treatment failure. Meta-analysis was performed by using the random-effects model.Fifteen uncontrolled series were included in this analysis, including 565 patients with 588 aneurysms, of which 127 were ruptured. Initial complete and adequate occlusion rates were 27% (95% CI, 15%-39%) and 59% (95% CI, 39%-78%), respectively. Midterm complete and adequate occlusion rates after a median of 7 months were 39% (95% CI, 26%-52%) and 85% (95% CI, 78%-91%), respectively. Perioperative morbidity and mortality rates were 4% (95% CI, 1%-8%) and 1% (95% CI, 0%-2%), respectively. Midterm adequate occlusion rates for ruptured aneurysms were 85% (95% CI, 67%-98%), compared with 84% (95% CI, 72%-94%) for unruptured aneurysms (P = .89). Patients with ruptured aneurysm had similar rates of perioperative morbidity to patients with unruptured aneurysm (2%; 95% CI, 0%-26% versus 2%; 95% CI, 0%-6%, respectively; P = .35).Early evidence derived from uncontrolled studies suggests that Woven EndoBridge treatment has a good safety profile and promising rates of adequate occlusion, especially given the complexity of aneurysms treated. Further prospective clinical trials are needed to confirm these results and better define the risks and benefits of use of the Woven EndoBridge device in treating wide-neck and wide-neck bifurcation aneurysms.

cited By 18; International audience; Objectives: To assess the efficacy and safety profile of stent-retriever thrombectomy (SRT) in acute anterior ischemic stroke patients with tandem occlusion. Materials and methods: Using the MEDLINE database, we conducted a systematic review and meta-analysis of all studies that included patients with acute ischemic stroke attributable to tandem occlusion who received treatment with SRT between November 2010 and May 2015. Results: The literature search identified 11 previous studies involving a total of 237 subjects out of whom 193 (81.4 %) were treated with acute stent placement for the extracranial internal carotid artery occlusion. Mean initial NIHSS score was 17, and median time from onset to recanalization was 283.5 min. Mean intravenous thrombolysis rate was 63.8 %. In the meta-analysis, the recanalization rate reached 81 % (95 % CI, 73–89). Meta-analysis of clinical outcomes showed a pooled estimate of 44 % (95 % CI, 33–55; 10 studies) for favourable outcome, 13 % (95 % CI, 8–20; 10 studies) for mortality, and 7 % (95 % CI, 2–13; eight studies) for symptomatic intracranial haemorrhage. Conclusion: SRT with emergency carotid stenting is associated with acceptable safety and efficacy in acute anterior stroke patients with tandem occlusion compared to natural history. However, the best modality to treat proximal stenosis is based on an individual case basis. Key Points: • Stent retriever thrombectomy of tandem occlusion is efficient and safe. • Emergent carotid stenting during thrombectomy increase symptomatic intracranial haemorrhage without impact mortality. • Thrombectomy of tandem anterior circulation occlusion may be the first therapeutic option © 2016, European Society of Radiology.

Ischemic stroke is the primary cause of acquired disability in the world and its treatment is still a challenge. Intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rt-PA) administered within 4½ hours of the onset of the symptoms is the only approved medical treatment in the acute phase of cerebral infarction. However, its efficacy is limited where there is proximal intracranial arterial occlusion, and there are many contraindications. The endovascular approach, combined or not with IV thrombolysis, allows high rates of recanalization to be achieved within a short period of time, with a low rate of procedural complications when thrombolysis is less effective (internal carotid artery, M1 segment of the middle cerebral artery). In these situations, endovascular techniques are playing an increasing role in the treatment of these patients even though there is still no indisputable scientific proof of their efficacy. The priority at present is to finish the French THRACE study, but it is already time to think about the next one.

Resume La prise en charge therapeutique de l’accident vasculaire cerebral (AVC) ischemique, qui est la premiere cause de handicap dans le monde, est un defi. La thrombolyse intraveineuse (IV) avec l’activateur tissulaire du plasminogene administre dans les 4 heures et 30 minutes du debut des symptomes est le seul traitement medicamenteux valide a la phase aigue de l’infarctus cerebral. Cependant, son efficacite est limitee en cas d’occlusion arterielle intracrânienne proximale et il existe de multiples contre-indications. L’approche endovasculaire combinee ou pas avec la thrombolyse IV permet d’obtenir des taux de recanalisation eleves dans un delai court avec un taux de complications procedurales faible, lorsque la thrombolyse est moins efficace (artere carotide interne, segment M1 de l’artere cerebrale moyenne). Dans ces conditions, les techniques endovasculaires jouent un role de plus en plus important dans la prise en charge de ces patients bien qu’il n’y ait pas encore de preuve scientifique incontestable de leur efficacite. La priorite actuelle est de finaliser l’etude francaise THRACE, mais il est deja temps de reflechir a la prochaine etude.

Since the demonstration of the efficacy of intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rt-PA) 20 years ago with the publication of NINDS, no medical or interventional treatment had shown further clinical benefit in acute cerebral infarction. Although three randomized trials (IMS 3 SYNTHESIS, MR RESCUE) using first-generation devices (MERCI system) failed to show benefit of intra-arterial revascularization,1–3 the therapeutic management of acute ischemic stroke has been revolutionized by the recent results of six randomized controlled trials (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT, THRACE) comparing the usual medical management (including IV thrombolysis within 4.5 h of symptoms onset) with stent retriever thrombectomy in acute anterior ischemic stroke with proximal intracranial artery occlusion (distal internal carotid artery or proximal middle cerebral artery).4–9

We, as a group of international multi-disciplinary neurointerventional societies involved in the endovascular management of acute ischemic stroke, have put forth these training guidelines. We believe that a neuroscience background, dedicated neurointerventional training, and stringent peer review and quality assurance processes are critical to ensuring the best possible patient outcomes. Well-trained neurointerventionalists are a critical component of an organized and efficient team needed to deliver clinically effective mechanical thrombectomy for acute ischemic stroke patients.

Ischemic stroke is a leading cause of death and disability worldwide. Much of the long-term disability occurs in patients with Emergent Large Vessel Occlusion (ELVO). In fact, in these patients, occlusion of a major intracerebral artery results in a large area of brain injury often resulting in

cited By 10; International audience; BACKGROUND AND PURPOSE: Endovascular coiling of wide-neck intracranial aneurysms is associated with low rates of initial angiographic occlusion and high rates of recurrence. The WEB intrasaccular device has been developed specifically for this indication. To date, there has been no report of the long-term follow-up of a series of patients with aneurysms treated with this type of device, to our knowledge. Our aim was to evaluate a 1-year follow-up of angiographic results in a prospective single-center series of patients treated with the WEB-Single-Layer (SL) device. MATERIALS AND METHODS: All patients treated with the WEB-SL device in our center between August 2013 and May 2014 were prospectively included. One-year angiographic outcomes were assessed. Results at follow-up were graded as complete occlusion, neck remnant, or residual aneurysm. RESULTS: Eight patients with 8 unruptured wide-neck aneurysms were enrolled in this study. Average dome width was 7.5 mm (range, 5.4-10.7 mm), and average neck size was 4.9mm(range, 2.6-6.5 mm). One-year angiographic follow-up obtained in all aneurysms included 1 complete aneurysm occlusion (12.5%), 6 neck remnants (75%), and 1 aneurysm remnant (12.5%). Of 8 aneurysms, worsening of aneurysm occlusion was observed in 2 (25%) by compression of the WEB device. There was no angiographic recurrence of initially totally occluded aneurysms. No bleeding was observed during the follow-up period. CONCLUSIONS: Endovascular therapy of intracranial aneurysms with the WEB-SL device allows treatment of wide-neck aneurysms with a high rate of neck remnant at 1 year, at least partially explained by WEB compression. Initial size selection and technologic improvements could be an option for optimization of aneurysm occlusion in WEB-SL treatment.

International audience; BACKGROUND AND PURPOSE: Endovascular treatment of wide-neck anterior communicating artery aneurysms can often be challenging. The Woven EndoBridge (WEB) device is a recently developed intrasaccular flow disrupter dedicated to endovascular treatment of intracranial aneurysms. The aim of this study was to investigate the feasibility, safety, and efficacy of the WEB Dual-Layer and WEB Single-Layer devices for the treatment of wide-neck anterior communicating artery aneurysms.MATERIALS AND METHODS: Patients with anterior communicating artery aneurysms treated with the WEB device between June 2013 and March 2014 in 5 French centers were analyzed. Procedural success, technical complications, clinical outcome at 1 month, and immediate and 3- to 6-month angiographic follow-up results were analyzed.RESULTS: Ten patients with unruptured anterior communicating artery aneurysms with a mean neck diameter of 5.4 mm were treated with the WEB. Treatment failed in 3 of the 10 aneurysms without further clinical complications. One patient developed a procedural thromboembolic event, and the other 6 had normal neurologic examination findings at 1-month follow-up. Immediate anatomic outcome evaluation showed adequate occlusion (total occlusion or neck remnant) in 6 of 7 patients. Angiographic control was obtained in all patients, including 6 adequate aneurysm occlusions (3 complete occlusions and 3 neck remnants) at short-term follow-up.CONCLUSIONS: In our small series, treatment of wide-neck anterior communicating artery aneurysms with the WEB device was feasible and safe. However, patient selection based on the aneurysm and initial angiographic findings in the parent artery is important due to the limitations of the WEB device navigation.

Resume Introduction Les fistules arterio-veineuses durales rachidiennes (FAVDR) a drainage veineux peri-medullaires, pathologie rare, posent des problemes diagnostiques et surtout de strategie therapeutique. Patients et methodes Les auteurs rapportent une serie de 10 patients recrutes en 7 ans, tous traites par embolisation. Resultats Il s’agissait de 6 hommes et 4 femmes, âges de 31 a 74 ans (moyenne de 58,4 ans), dont la FAVDR a ete diagnostiquee au bout de 2 jours a 5 ans d’evolution (moyenne de 15,3 mois). Les formes de debut paucisymptomatiques ou trompeuses (troubles sensitifs longtemps isoles, lombo-sciatalgie, claudication, monoplegie), mais aussi les decompensations aigues etaient frequentes. L’IRM rachidienne a constamment montre une lesion centromedullaire hyperintense en T2, associee a des images serpigineuses dans seulement 70 p. 100 des cas. L’angiographie a permis de localiser la fistule en region thoracique (5 fois haute de Th1 a Th7 ; 3 fois basse de Th8-Th12) ou lombaire (2 fois). L’embolisation, 3 fois en echec, a ete efficace d’emblee (3 cas), apres 2 (2 cas) ou 3 gestes (2 cas). Conclusions Les resultats du traitement par embolisation dans cette serie (positifs pour 70 p. 100 des cas), restent inferieurs a ceux obtenus d’emblee avec la chirurgie dans la litterature (96,8 p. 100 a 97,9 p. 100), mais au prix d’une technique plus invasive. La strategie proposee pourrait etre de tenter l’occlusion de la fistule par voie endovasculaire en premiere intention, mais si elle n’est pas complete, de discuter un abord chirurgical sans attendre. En cas d’occlusion confirmee, une IRM et une angiographie devraient etre effectuees a 6 mois pour detecter une repermeabilisation.

Objectifs Le traitement des anevrismes intracrâniens par coils endovasculaires est le traitement de premiere ligne. A ce jour, aucune donnee n’a ete publiee sur les resultats a long terme des microspires d’embolisation Trufill DCS Orbit® et Orbit Galaxy® avec evaluation independante. A la demande de la Haute Autorite de sante (HAS), dans le cadre du renouvellement du remboursement des coils Codman TRUFILL, nous presentons ici les resultats a long terme en termes d’efficacite et de securite des microspires d’embolisation Trufill DCS Orbit® et Orbit Galaxy® en pratique clinique courante. Methodes Un total de 167 patients avec 167 anevrismes (dont 39,1 % rompus) a ete recrute dans sept centres francais pendant l’etude observationnelle prospective TRULINE. Le critere principal etait la securite a long terme, evaluee par le taux combine de morbi-mortalite observe au cours de la procedure et jusqu’a 1 an (12–18 mois) postprocedure. Pour la securite, les analyses principales ont ete faites sur la population en intention de traiter (patients avec traitement par coils endovasculaires : n = 163) et tous les evenements indesirables ont ete revus par un comite de surveillance et de suivi independant. Pour l’efficacite, les analyses principales ont ete faites sur la population per protocole (patients traites avec plus de 70 % de coils Trufill DCS Orbit®/Orbit Galaxy® et non retraites pendant la periode de suivi : n = 124) et un laboratoire central independant evaluait les resultats angiographiques. Resultats A 1 an postprocedure, une atteinte neurologique etait observee chez 6,5 % (IC95 % : 3,5–11,8) des patients et 2,6 % (IC95 % : 1,0–6,8) des patients avaient une deterioration neurologique permanente. Trois deces ont ete observes, non lies a la procedure ou aux coils. A 1 an, une occlusion complete a ete observee pour 52 anevrismes (4,2 %), un collet residuel pour 28 anevrismes (9,2 %) et un anevrisme residuel pour 16 anevrismes (16,7 %) traites avec plus de 70 % de coils Trufill DCS Orbit®/Orbit Galaxy®. Pendant le suivi jusqu’a 1 an, l’incidence globale de la recurrence etait de 30,2 % avec un intervalle moyen de 13,8 ± 4,5 mois et le retraitement pour recanalisation majeure a ete necessaire pour 9 patients (6,3 %). Aucune complication clinique n’a ete observee chez les patients retraites. Conclusion L’etude TRULINE confirme que le traitement des anevrismes intracrâniens par coils endovasculaires avec les microspires d’embolisation Trufill DCS Orbit® et Orbit Galaxy® est sur et efficace.

Stroke is the third leading cause of death in the USA. An estimated 795,000 new or recurrent stroke events occur annually, mostly ischemic in nature. Arterial recanalization and subsequent reperfusion performed shortly after symptom onset can help to restore brain function in acute ischemic stroke (AIS). The only treatment currently approved by the United States Food and Drug Administration is intravenous tissue plasminogen activator, administered within 4.5 h of symptom onset. However, this short window often precludes effective intervention. Mechanical neurothrombectomy devices offer many potential advantages over pharmacologic thrombolysis, including more rapid achievement of recanalization, enhanced efficacy in treating large-vessel occlusions, and a potentially lower risk of hemorrhagic events. The goal of this chapter is to describe the state-of-the-art neurothrombectomy devices and stenting techniques for endovascular treatment of acute ischemic stroke, as well as to highlight recent advances in reperfusion therapies. Ongoing clinical trials, some with randomized, controlled designs, are included.

BACKGROUND AND PURPOSE: Wide-neck intracranial aneurysms in patients with acute SAH are often challenging lesions to treat by neurosurgical and endovascular approaches. The aim of this study was to investigate the feasibility, safety, and efficacy of the use of temporary Solitaire AB stent–assisted technique with coiling for the treatment of acutely ruptured wide-neck aneurysms without perioperative antiplatelet therapy. MATERIALS AND METHODS: A retrospective review of our endovascular data base identified all patients treated in the acute phase with a temporary stent–assisted technique by use of a fully resheathable Solitaire AB stent and coiling. One-year clinical and angiographic outcomes were evaluated. RESULTS: Eight patients (5 women and 3 men; mean age, 57.5 years) with 8 ruptured wide-neck aneurysms were treated. There were 3 complications without clinical impact. Postoperative complete occlusion was achieved in 5 aneurysms, and 3 had a neck remnant. Three patients had an mRS score of 0, and 1 an mRS score of 3. Among the 4 patients admitted with a World Federation of Neurological Societies grade of V, 1 died, 1 improved to an mRS score of 1, and the other 2 achieved mRS scores of 4 and 5. Five had a stable occlusion, and 2 of the 3 incompletely occluded aneurysms underwent recanalization. CONCLUSIONS: In this small series, temporary placement of the Solitaire AB stent during coiling was a feasible and effective treatment for acutely ruptured wide-neck aneurysms. This technique, avoiding the need for perioperative antiplatelet therapy, could be a valuable option for the treatment of such lesions when the balloon remodeling technique is either not an option or unsuccessful.

The size of intracranial aneurysms is the only characteristic shown to correlate with their rupture. However, the critical size for rupture has varied considerably among previous accounts and remains a point of controversy. Our goal was to identify statistically significant clinical and morphological factors predictive of the occurrence of rupture and aneurysm size in patients referred for endovascular treatment. We retrospectively recorded the following factors from 74 patients who presented with ruptured (40) or unruptured (34) aneurysms: aneurysm morphology (uni/multilobulated), location (anterior/posterior), maximum diameter, diameter of the neck, and the patient's age and sex. We performed stepwise discriminant, and stepwise and logistic regression analysis to identify factors predicting rupture and the size of the aneurysm at rupture. The mean diameter of the ruptured aneurysms was 11.9 ± 6.3 mm, range 3.0–33.0 mm, and that of the unruptured aneurysm 13.5 ± 5.8 mm, range 5.0–30 mm. Stepwise discriminant analysis identified aneurysm morphology (P < 0.001) and location in the intracranial circulation (P < 0.001) as statistically significant factors in predicting rupture. Stepwise regression analysis revealed that aneurysm morphology and the size of the neck were predictors of aneurysm size at rupture.

The aim of this work was to assess the depth separation of a new X-ray digital stereo angiographic system through visualization on a stereoscopic monitor. Before starting the clinical trial of this new stereo-digital angiographic system, it seemed to us mandatory to assess the inherent performance of the system to depict depth information, as well as the ability of the users to work with it. With this idea we designed a global test based on the observation of a physical test object by the potential users of the system, during a session long enough to simulate an angiographic study. The acquisition system consisted of a twin focal-spot X-ray tube and a standard DSA DG 300 (General Electric/CGR). The stereo display was controlled by a liquid crystal modulator placed in front of a black-and-white monitor. Special polarized glasses worn by the observers allowed right- and left-image separation. Depth separation was measured in ten observers by means of a stereoscopic test object. Six of the ten observers were able to locate accurately three-dimensional patterns separated by a 12- to 1.5-mm gap. No learning effect was noticed. This result suggested that stereo display through wireless polarized glasses coupled to up-to-date digital subtraction angiography technology may provide an accurate and ergonomic way to a dimensional enhancement of X-ray angiography.

Journal of Neuroradiology - In Press.Proof corrected by the author Available online since mardi 1 avril 2014

Three recent, simultaneous publications report the neutral results of three randomized studies (SYNTHESIS Expansion, Interventional Management of Stroke (IMS) III, and Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE)) comparing IV thrombolysis therapy or standard care (MR RESCUE) to the endovascular treatment (EVT) of acute ischemic stroke (AIS) [1–3]. The results of these three trials might lead to the erroneous conclusion that endovascular treatment has no or little place in the management of AIS. However, careful analysis of the IMS III, SYNTHESIS, and MR RESCUE studies is mandatory prior to assessment of the value of EVT of AIS. Also, the limits of the current and future trials should be outlined. The European Society of Minimally Invasive Neurological Therapy (ESMINT) and European Society of Neuroradiology (ESNR) represent the interventional neuroradiology community in Europe and have engaged in the definition of rules regarding trials evaluating the EVT of AIS [4, 5]. It is clearly their role to provide a precise analysis of recent and future trials. In the last 20 years, treatment of AIS has evolved to include neuroprotection, IV thrombolysis (IVT), and endovascular treatment. Despite numerous studies of a very large number

Resume Introduction Les anevrysmes mycotiques ou post-infectieux de la carotide interne intra-caverneuse sont une pathologie rare. Cas clinique Nous rapportons l’observation d’un patient ayant presente, trois semaines apres une extraction dentaire, une ophtalmoplegie gauche d’installation progressive, ainsi que des cephalees a type d’hemicrânie gauche, dans un contexte febrile. Les differents examens neuroradiologiques et microbiologiques ont permis de diagnostiquer une infection des sinus sphenoidaux et ethmoidaux avec une extension du processus infectieux au sinus caverneux gauche. Il existait egalement un anevrysme de la carotide interne gauche dans sa portion intra-caverneuse. Conclusions Le risque de rupture de ce type d’anevrysme est difficile a evaluer. Le traitement consiste toujours en une antibiotherapie adaptee et prolongee, avec parfois en addition un traitement neurochirurgicale ou endovasculaire de l’anevrysme. Pour ce patient, nous avons un suivi de quatre ans sans intervention, montrant la stabilite du diametre de l’anevrysme.

We describe a case of a 70-Year-old man who presented subacute pseudo-dementia due to a dural fistula. Neurological assessment and the reversibility of the symptoms after embolization support the originality of this observation.

Superselective angiography is the most accurate technique in the analysis of brain arteriovenous malformation (AVM) angioarchitecture. Therefore, we reviewed the selective and superselective angiograms of 100 consecutive patients with intracerebral AVMs. Our purpose was to determine which parameters of angioarchitecture were significantly correlated with a clinical presentation of hemorrhage. The vascular characteristics evaluated on the angiograms were the size of the AVM, the location of the AVM, the type of nidus, the type of feeders, the characteristics of venous drainage, and the number and location of aneurysms. The parameters found to correlate with hemorrhage were deep venous drainage (P = 0.01), feeding by perforators (P = 0.01), intranidal aneurysm(s) (P = 0.004), multiple aneurysms (P = 0.001), feeding by the vertebrobasilar system (P = 0.002), and location in the basal ganglia (P = 0.04). Six parameters of AVM angioarchitecture were correlated with a clinical presentation of hemorrhage. Among these parameters, three (feeding by perforators, number of aneurysms, and presence of intranidal aneurysms) were well displayed by superselective angiogram.

We reviewed 11 cases of intramedullary cavernous haemangiomas (IMCH) studied by MRI, to assess its diagnostic value in these lesions. Follow-up MRI was obtained in five patients 7 days-2 years following the initial study. In one case a postoperative examination was obtained. The diagnosis was pathologically proven in ten cases, and supported in the last by a family and personal history of cavernous haemangiomas. A reticulate appearance with areas of mixed signal intensity in both T1- and T2-weighted images was the most common finding. Homogeneous high, low or intermediate signal intensity was each found in one case. Two small lesions gave low signal. A rim of low signal was less common than in cerebral cavernous haemangiomas. In one case, the brain showed more than 20 lesions with the MRI appearances of cavernous haemangiomas. In two of five patients, serial preoperative MRI showed progressive disappearance of high-signal areas on both T1- and T2-weighted images. To find a haemorrhagic intramedullary lesion on MRI is not rare. Although the appearances are not pathognomonic, an IMCH can be suggested. We suggest that the following characteristics may help: (1) a personal and/or family history of cavernous haemangiomas; (2) typical MRI appearances of mixed acute, subacute and chronic haemorrhage; (3) a tendency for signal intensity to decrease on follow-up; (4) normal spinal angiography; and (5) associated brain lesions.

A series of 12 patients with tectal plate gliomas, is presented treated by direct surgery. Mean age was 19 years. All patients presented with signs of raised intracranial pressure and supratentorial hydrocephalus on CT scan. Diplopia was the most common local sign. CT scan and MR imaging showed 4 intrinsic, 6 exophytic, and 2 ventrally infiltrating tectal tumours. The histological diagnosis was low-grade astrocytoma in 7, high-grade astrocytoma in 2, oligodendroglioma in one, oligo-astrocytoma in one, and ependymoma in one case. The suboccipital supra- and transtentorial approach was used in every cases. Tumour resection was generous at the level of the superior colliculi, but on the contrary, resection was limited at the level of inferior colliculi due to the auditory risk. Tumour removal was total (macroscopically) in 9 cases and partial in 3 cases. There were 4 surgical complications and one death related to surgery. Parinaud's syndrome was the most-common postoperative sequelae. Auditory hallucinations and the acoustic neglect syndrome were seen once. In three cases additional radiotherapy and chemotherapy were given once with severe sequelae. The treatment of tectal plate gliomas is controversial. The role of different therapeutic options remains open. We consider the tectal plate as a relatively safer territory for surgery than the ventral part of the midbrain. The brain stem auditory evoked potentials (BAEPs) and middle latency potentials (MLPs) monitoring can help to determine the appropriate limit of surgery.

CT scans and MR images were analyzed in 12 patients with histologically proved tectal plate gliomas. In an attempt to identify the nature of these lesions, their radiological characteristics were correlated with the histological results. In four of our patients CT scan failed to show the tumour. MR imaging demonstrated the tectal distortion in all cases. Contrast enhancement, calcification, cystic portions, exophytic nature were observed in both high and low-grade gliomas. We conclude that in the case of intrinsic tectal tumours, the most probable diagnosis is that of low-grade astrocytoma while in the case of exophytic tectal tumours, the differential diagnosis from pineal region tumour is required and a histological verification is necessary.

Flow diversion prostheses represent a new endovascular approach aimed at treating patients with large wide-neck aneurysms. Our objective is to present this new technology, to review the clinical studies on efficacy, and to emphasize its current limits. Flow diversion prostheses consist of a cylinder made of a large number of braided microfilaments providing a large metallic surface when deployed and inducing a blood flow diversion outside the aneurysm. Two different brands are currently available. Clinical data supporting their efficacy are currently limited to six non comparative cohort studies that included between 18 and 107 patients. Procedural implantation was shown to be feasible in more than 90% and safe with a thirty-day mortality between 2.8 and 5.5%. Complete occlusion rates at twelve months varied between 85.7 and 100%. Even though promising, the current status of flow diversion prostheses needs further evaluation with randomized, prospective, clinical trials with comparison to conventional strategies including endovascular coiling or surgical clipping.

The authors report the case of a patient who presented a ruptured aneurysm of the anterior communicating artery and an unruptured aneurysm of the middle cerebral artery arising at the site of a fenestration of the MCA. The fenestration was undiagnosed on the preoperative angiogram but discovered during the surgery carried out for clipping of the aneurysms. In the literature, cases of fenestration of the MCA are sporadically reported and are incidental findings; an aneurysm may be associated on an artery other than the fenestrated MCA; an aneurysm arising at the site of the MCA fenestration is a very rare occurrence.

Wegener granulomatosis (WG) is an uncommon systemic necrotizing vasculitis that demonstrates renal and respiratory tropism. While the pathogenesis of WG remains controversial, autoimmune and inflammatory mechanisms are likely to be involved. The nervous system could be affected in up to 54% of cases. Although central nervous system involvement has been reported in 7-11% of cases, aneurysmal subarachnoid hemorrhage (SAH) occurrence is exceptional.We describe the third reported case of WG-related aneurysmal SAH and then discuss the diagnosis and pathogenesis of WG along with the physiopathology of intracranial aneurysm in light of recent data reported in the literature.A 63-year-old woman with WG was referred to our neurosurgical department for aneurysmal SAH. The vasculitis diagnosis had been established 4 years earlier when she presented with chronic sinusitis, recurrent cystitis, and renal failure. The cerebral angiography revealed an anterior communicating artery dysplastic aneurysm. The neurosurgical management of the aneurysm was scheduled but delayed because the patient was experiencing a vasculitis flare-up. Immunosuppressive therapy and intravenous corticotherapy were given, with the patient's improvement, allowing neurosurgical clipping of the aneurysm.Wegener granulomatosis-related aneurysmal SAH is an exceptional condition in neurovascular pathology. As inflammatory mechanisms are involved in the pathogenesis of aneurysm, the vasculitis flare-up could account for this SAH. The management of WG could benefit from anti-inflammatory therapy, as could the vasculitis-related SAH. SAH occurrence in patients with systemic vasculitis could indicate a vasculitis flare-up.