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BACKGROUND AND PURPOSE: Flow diversion is an effective treatment for aneurysms of the ICA with compression-related neuro-ophthalmologic symptoms, especially when treatment is initiated early after symptom onset and aneurysm occlusion is complete. However, non-negligible complication rates have been reported. Our aim was to identify risk factors for morbidity/mortality and incomplete aneurysm occlusion. MATERIALS AND METHODS: We performed a secondary analysis of a previous publication, which included all patients treated with flow diversion for an unruptured aneurysm of the ICA with compression-related symptoms. RESULTS: Fifty-four patients with 54 aneurysms (48 women, 88.9%; mean age, 59.2 [SD, 15.9] years; range, 21–86 years) treated with flow diversion were included. We observed morbidity and mortality rates of 7.4% and 3.7%. Increasing age (OR per decade, 3.2; 95% CI, 1.23–8.49; P = .02) and dual-antiplatelet therapy with ticagrelor (OR, 13.9; 95% CI, 1.16–165.97; P = .04) were significantly associated with morbidity/mortality. After a median follow-up of 13.3 [SD, 10.5] months, the rates of complete aneurysm occlusion, neck remnant, and aneurysm remnant were 74%, 14%, and 12%. Incomplete occlusion at follow-up was less frequently observed in aneurysms treated with additional coil embolization (OR, 0.1; 95% CI, 0.01–0.86; P = .04). CONCLUSIONS: Although a promising treatment for compressive ICA aneurysms, flow diversion carries a relevant risk for complications and incomplete aneurysm occlusion. Our results may help identify patients in which flow diversion may not be the ideal treatment method. Additional coil embolization increased the likelihood of complete aneurysm occlusion at follow-up.

International audience; ABSTRACT: After five positive randomized controlled trials showed benefit of mechanical thrombectomy in the management of acute ischemic stroke with emergent large-vessel occlusion, a multi-society meeting was organized during the 17th Congress of the World Federation of Interventional and Therapeutic Neuroradiology in October 2017 in Budapest, Hungary. This multi-society meeting was dedicated to establish standards of practice in acute ischemic stroke intervention aiming for a consensus on the minimum requirements for centers providing such treatment. In an ideal situation, all patients would be treated at a center offering a full spectrum of neuroendovascular care (a level 1 center). However, for geographical reasons, some patients are unable to reach such a center in a reasonable period of time. With this in mind, the group paid special attention to define recommendations on the prerequisites of organizing stroke centers providing medical thrombectomy for acute ischemic stroke, but not for other neurovascular diseases (level 2 centers). Finally, some centers will have a stroke unit and offer intravenous thrombolysis, but not any endovascular stroke therapy (level 3 centers). Together, these level 1, 2, and 3 centers form a complete stroke system of care. The multi-society group provides recommendations and a framework for the development of medical thrombectomy services worldwide.; RÉSUMÉ : Les normes de pratique recommandées à l’échelle internationale lors d’interventions consécutives à un accident ischémique cérébral aigu . En octobre 2017, à Budapest, une rencontre pluridisciplinaire de spécialistes s’est organisée dans le cadre du 17 e congrès de la World Federation of Interventional and Therapeutic Neuroradiology . Cette rencontre portait sur l’établissement de normes relatives aux interventions consécutives à des accidents ischémiques aigus. Elle a eu lieu, précisons-le, après que cinq essais randomisés contrôlés (ERC) ont montré les avantages de la thrombectomie mécanique dans la prise en charge de patients victimes d’un accident ischémique cérébral aigu montrant des signes naissants d’occlusion des plus gros vaisseaux sanguins. Les normes dont il a été alors question visaient aussi à atteindre un consensus quant aux exigences minimales auxquelles devaient se conformer les établissements de santé offrant la thrombectomie mécanique. Dans l’idéal, tous les patients devraient être traités dans un établissement offrant un éventail complet de soins neuro-endovasculaires (de niveau 1). Toutefois, en raison de l’éloignement géographique, quelques patients demeurent incapables de se rendre dans un tel établissement dans des délais raisonnables. Dans cette optique, le groupe réuni à Budapest a défini de façon particulière des recommandations définissant les aspects permettant aux autres établissements (de niveau 2) d’organiser en amont des soins en thrombectomie destinés à des patients victimes d’accidents ischémiques cérébraux aigus mais pas d’autres maladies neurovasculaires. Enfin, d’autres établissements (de niveau 3) pourront compter sur une unité de traitement des AVC, notamment au moyen de la thrombolyse intraveineuse; toutefois, ils ne pourront offrir aucune autre thérapie endovasculaire. Réunis, l’ensemble de ces établissements de niveaux 1, 2 et 3 constitue un réseau complet de soins destinés aux patients victimes d’un AVC. Le groupe multidisciplinaire réuni lors de cette rencontre a ainsi élaboré des recommandations et un cadre de référence visant le développement de la thrombectomie dans le monde entier.

After the five positive randomized controlled trials showing the benefit of mechanical thrombectomy (MT) in the management of acute ischemic stroke (AIS) with emergent large vessel occlusion (ELVO), a multisociety meeting was organized during the 16th Congress of the World Federation of Interventional and Therapeutic Neuroradiology (WFITN), October 2015, Gold Coast (Australia). This meeting was dedicated to the training of physicians performing MT, and recommendations were published thereafter in multiple scientific journals.1 The same group of scientific societies decided to organize a similar meeting during the 17th WFITN Congress, October 2017, Budapest (Hungary). This multisociety meeting was dedicated to standards of practice in acute ischemic stroke intervention (AISI), aiming for a consensus on the minimum requirements for centers providing such treatment. In an ideal situation, all patients would be treated at a center offering a full spectrum of neuroendovascular care (a level 1 center). However, for geographical reasons, some patients are unable to reach such a center in a reasonable period of time. With this in mind, the group paid special attention to define recommendations on the prerequisites of organizing stroke centers providing MT for AIS, but not for other neurovascular diseases (a level 2 center). Finally, some centers will have a stroke unit and offer intravenous thrombolysis, but not any endovascular stroke therapy (a level 3 center). Together, these level 1, 2, and 3 centers form a complete stroke system of care. The requirements for these centers are summarized in table 1. View this table: Table 1 General summary of capabilities of level 1, 2, and 3 centers Due to the relatively short time elapsed since the evidence in favor of MT has been published, some organizational aspects still require scientific validation. However, considering the extremely fast growth of such activities around the world, the multisociety group considered it timely and rational to set-up recommendations and a framework for …

This study was funded by Penumbra, inc (9508). Competing interests The following investigators report financial conflicts with this study: Ps reports being a consultant for Penumbra and stryker, and receiving research support from Penumbra, Philips, and siemens. rP reports proctoring and consulting for Medtronic, Penumbra, and implemed. WW reports a proctor agreement with Microvention/Terumo, Medtronic, and Phenox, and being a consultant with Penumbra (speaker and chairman fees). JF reports being a consultant for Penumbra, acandis, Boehringer ingelheim, cerenovus, covidien, Medtronic, Microvention, route92, and stryker, and receiving research support from the german Ministry of science and education (BMBF), german Ministry of economy and innovation (BMWi), german research Foundation (DFg), european Union (eU), hamburgische investitions-und Förderbank (iFB), Medtronic, Microvention, Philips, and stryker. PM reports speaker and consulting fees from Medtronic, used for stroke education. TK and VMP received funding from the sponsor for imaging core lab oratory activities. VMP reports being a consultant for Penumbra (PrOMise study), Medtronic, stryker, and neurovasc. lP received funding from Penumbra for cec activities and is a consultant for Balt, cerenovus/neuravi, and Microvention. Background and purpose The recent randomized trials demonstrated the benefit of mechanical thrombectomy in stroke therapy. However, treatment using different strategies is an ongoing area of investigation. The PROMISE study analyzed the safety and effectiveness of the Penumbra System with the ACE68 and ACE64 reperfusion catheters in aspiration thrombectomy of stroke, using A Direct Aspiration First Pass Technique (ADAPT). Methods PROMISE was a prospective study which enrolled 204 patients with intracranial anterior circulation large vessel occlusion (LVO) ischemic stroke in 20 centers from February 2016 to May 2017. Initial treatment was with the ACE68/ACE64 catheters within 6 hours of symptom onset. Imaging and safety review was performed by an independent Core Laboratory and a Clinical Events Committee. The primary angiographic outcome was revascularization to mTICI 2b-3 at immediate post-procedure and the primary clinical outcome was 90-day modified Rankin Scale (mRS) score ≤2. Safety assessment included device-and procedure-related serious adverse events (SAEs), symptomatic intracranial hemorrhage (sICH), mortality, and embolization of new territory (ENT). Results Enrolled patients had a median age of 74 (IQR 65-80) years and a median admission NIHSS of 16 (IQR 11-20). The post-procedure mTICI 2b-3 revascularization rate was 93.1% and the 90-day mRS 0-2 rate was 61%. Device-and procedure-related SAEs at 24 hours occurred in 1.5% and 3.4%, respectively, 90-day mortality was 7.5%, sICH occurred in 2.9% while ENT occurred in 1.5%. Conclusions For frontline therapy of LVO stroke, the ACE68/ACE64 catheters for aspiration thrombectomy were found to be safe and showed similar efficacy to randomized trials using other revascularization techniques. Clinical Trial Registration NCT02678169; Pre-results.