Safety and effectiveness of mechanical thrombectomy for primary isolated distal vessel occlusions: A monocentric retrospective comparative study.

BACKGROUND: Distal vessel occlusions represent about 25-40% of acute ischemic stroke (AIS), either as primary occlusion or secondary occlusion complicating mechanical thrombectomy (MT) for large vessel occlusion. OBJECTIVE: Our aim was to evaluate safety and effectiveness of MT associated with the best medical treatment (BMT) in the management of AIS patients with distal vessel occlusion in comparison with the BMT alone. METHODS: Retrospective analysis was conducted on AIS patients treated by MT+BMT for primary distal vessel occlusion between 2015 and 2020, and were compared with a historic cohort managed by BMT alone between 2006 and 2015 selected based on the same inclusion criteria. A secondary analysis was conducted using propensity score matching (PSM) including the following: NIHSS, age and treatment with intravenous thrombolysis (IVT) as covariates. RESULTS: Of 650 patients screened, 44 patients with distal vessel occlusions treated by MT+BMT were selected and compared with 36 patients who received BMT alone. After PSM, 28 patients in each group were matched without significant difference. Good clinical outcome defined as mRS≤2 was achieved by 53.6% of the MT+BMT group and 57% of the BMT group (OR, 0.87; 95%CI, 0.3-2.4; p = 1.00). The mortality rate was comparable in both groups (7% vs. 10.7% in MT+BMT and BMT patients, respectively; OR=0.64; 95%CI, 0.1-4; p = 1.00). Symptomatic intracranial hemorrhage (ICH) was seen in only one patient treated by MT+BMT (3.6%). CONCLUSION: Mechanical thrombectomy seems to be comparable with the best medical treatment regarding the effectiveness and safety in the management of patients with distal vessel occlusions.

Outcome and recanalization rate of tandem basilar artery occlusion treated by mechanical thrombectomy.

BACKGROUND: Tandem basilar artery occlusions (tBAO) are defined as concomitant basilar artery and extracranial dominant vertebral artery occlusions. The prognosis of such tBAO treated by mechanical thrombectomy (MT) has been scantly reported. The purpose of our study was to compare the safety and effectiveness of MT for patients with tBAO compared to those with non-tandem basilar artery occlusions (ntBAO). PATIENTS AND METHODS: Retrospective analysis of a database of patients who underwent MT at two academic centres. All patients treated for BAO were retrieved. Patients with tBAO, defined as a concomitant BAO and extracranial vertebral artery (VA) occlusion or severe stenosis ≥70% (V1 or proximal V2 segment) were compared with patients with ntBAO. RESULTS: A total of 15 patients with tBAO and 74 patients with ntBAO were enrolled. Successful reperfusion (modified thrombolysis in cerebral infarction score ≥2b) was obtained in 73.3% versus 90.5% (OR = 0.29, 95%CI: 0.07-1.15), good clinical outcome (3-months modified Rankin scale ≤2) was reached by 26.7% versus 32.4% (OR = 0.76; 95% CI: 0.24-2.63) and mortality at 3-months was 46.7% versus 31% (OR = 1.94; 95%CI: 0.63-6) of patients with tBAO versus ntBAO, respectively. Two patients (13.3%) with tBAO and three (4%) with ntBAO had symptomatic intracranial haemorrhage (OR = 3.64; 95% CI: 0.55-24). CONCLUSION: Mechanical thrombectomy for patients with tandem basilar artery occlusion tends to be associated with lower rates of successful reperfusion and good clinical outcome, and higher rate of mortality. Larger multicentre studies are warranted to better precise the proper selection and management of such patients.

Lipoprotein-associated phospholipase A2 during the hyperacute stage of ischemic and hemorrhagic strokes.

BACKGROUND: The objectives of the study were to compare lipoprotein-associated phospholipase A2 (Lp-PLA2) levels in a prospective cohort including both ischemic and hemorrhagic strokes at the hyperacute phase, and to investigate if these levels were associated with stroke severity. MATERIALS AND METHODS: Lp-PLA2 mass and activity were measured during the first 6 hours of symptom onset before any therapeutic intervention. The Lp-PLA2 level was analyzed by comparing the mass and activities in ischemic strokes and spontaneous intracerebral hemorrhages (ICH). Correlations between Lp-PLA2 levels and clinical scores as well as stroke volumes were made. The temporal evolution of Lp-PLA2 during the first week was analyzed in ischemic stroke patients. RESULTS: Lp-PLA2 mass was higher in ICH than in ischemic stroke (P = .001). Lp-PLA2 activity at admission correlated with initial and follow-up stroke volume in ICH (P = .003 and P = .004, respectively) but not in ischemic stroke. None of the measurements correlated with clinical severity for either diagnosis. Lp-PLA2 mass decreased during the first week after the use of statins in ischemic stroke, whereas the activity remained stable. CONCLUSIONS: Lp-PLA2 mass is higher in ICH compared with ischemic stroke during the hyperacute stage. Lp-PLA2 activity is associated with stroke volume in ICH but not in ischemic stroke. This suggests that Lp-PLA2 mass and activity could provide different information in the hyperacute stage of stroke.

Relationships between recent intraplaque hemorrhage and stroke risk factors in patients with carotid stenosis: the HIRISC study.

OBJECTIVE: Intraplaque hemorrhage (IPH) is an emerging marker of plaque instability. However, little is known about the relationships between IPH and traditional risk factors and whether these relationships differ between symptomatic and asymptomatic disease. METHODS AND RESULTS: Two hundred thirty-four patients with symptomatic (n=114) or asymptomatic (n=120) carotid stenosis underwent high-resolution plaque magnetic resonance imaging. Seventy-five patients had recent IPH (symptomatic, 33%; asymptomatic, 31%). In symptomatic stenosis, recent IPH was independently associated with degree of stenosis (odds ratio [OR]=4.21, 1.61-10.98 for North American Symptomatic Carotid Endarterectomy Trial >35%; OR=2.92, 1.18-7.24 for European Carotid Surgery Trial >60%), qualifying event (OR=4.13; 1.11-15.32 for stroke or hemispheric transient ischemic attack ≥1 hour versus transient ischemic attack <1 hour or ocular symptoms), time from ischemic event (OR=6.65, 1.56-28.35 for ≤2 weeks; OR=2.24, 0.87-5.81 for 2-12 weeks versus >12 weeks; P for trend=0.03). In asymptomatic stenosis, IPH was only associated with stenosis severity >70% by ECST (OR=6.65; 1.95-22.73) but not by the NASCET method. CONCLUSIONS: Our findings support the potential link between recent IPH and risk of ipsilateral stroke in symptomatic disease but also imply that prognostic studies should adjust for known stroke risk factors in multivariate analyses. In asymptomatic stenosis, the potential predictive value of recent IPH is less likely to be confounded by stroke risk factors.

[Neuroethics: ethical issues in neurosciences]. / La neuroóthique ou les enjeux éthiques des neurosciences.

Neuroethics is a field of bioethics on the ethical challenges of advances in neuroscience. Born in the early 2000s, neuroethics is considering a number of issues raised by the opportunities created by advances in knowledge and techniques in the field of neurology and psychiatry. In fact, what we learn about brain functions allows us to potentially influence our behavior and our actions, and questions human nature, freedom and individual responsibility, and even the place of morality in our society.

Intensive versus subcutaneous insulin in patients with hyperacute stroke: results from the randomized INSULINFARCT trial.

BACKGROUND AND PURPOSE: Intensive insulin therapy (IIT) has not yet proven its efficacy on stroke prognosis or in the reduction of MRI infarct growth. The INSULINFARCT study aims at determining in patients with hyperacute stroke whether IIT, with a better control of poststroke hyperglycemia, would reduce subsequent MRI infarct growth than usual care with subcutaneous insulin. METHODS: One hundred eighty patients with MRI-proven ischemic stroke and with National Institutes of Health Stroke Scale from 5 to 25 at admission (<6 hours) were randomized to receive IIT or usual subcutaneous insulin for 24 hours. Admission hyperglycemia was not required for recruitment. Control MRI and 3-month follow-up (with functional outcome and serious adverse events) were planned. The primary objective was to detect a difference in the proportion of patients with mean capillary glucose test <7 mmol/L during 24 hours. The secondary objective was to investigate whether IIT would reduce infarct growth. The analysis was planned in intention-to-treat. Patients with >3 missing capillary glucose test were excluded (n=4). RESULTS: The proportion of patients with mean capillary glucose test <7 mmol/L in the first 24 hours was higher in the IIT group (95.4% [83 of 87] versus 67.4% [60 of 89]; P<0.0001). The infarct growth was lower in the subcutaneous insulin group (median, 10.8 cm(3); 95% CI, 6.5-22.4 versus 27.9 cm(3); 14.6-40.7; 60% of increase; P=0.04). The 3-month functional outcome (45.6% [41 of 90] versus 45.6% [41 of 90]), death (15.6% [14 of 90] versus 10% [9 of 90]), and serious adverse events (38.9% [35 of 90] versus 35.6% [32 of 90]) were similar in the subcutaneous insulin and IIT group. CONCLUSIONS: The IIT regimen improved glucose control in the first 24 hours of stroke but was associated with larger infarct growths. IIT cannot be recommended in hyperacute ischemic stroke. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique Identifier: NCT00472381.

[Withdrawing and withholding treatments in acute severe stroke patients in the elderly]. / Limitations et arrêts de traitement à la phase aiguë des AVC graves chez le sujet âgé.

Stroke can produce irreversible brain damage of massive proportion leading to severe disability and poor quality of life. When prognosis is very poor, "do-not-resuscitate (DNR) orders" and "withhold- or withdrawal-of-treatment (WHDT)" may be discussed. Precise estimates of withhold and withdrawal of treatment are not available, but studies have shown that DNR orders are relatively frequent in acute stroke (up to 30% of all patients). DNR orders are closely associated with age, comorbidities, and severity of neurological deficit. The main explicit criteria for WHDT is the risk of "unacceptable" disability, which raises many ethical questions. Evaluation of neurological outcome is highly uncertain and difficult and does not always reflect quality of life. Decisions for life sustaining therapies in severe stroke are always difficult and often based on subjective and uncertain criteria. We have to improve prognosis estimation and our understanding of patient's preferences to promote patient centered care. Ethical approach may guide these complex decisions.

Supraventricular Arrhythmia Following Patent Foramen Ovale Percutaneous Closure.

BACKGROUND: Randomized studies have reported low rates of atrial fibrillation (AF) after patent foramen ovale (PFO) closure (<6%) but have relied on patient-reported symptomatic episodes, so the true incidence and timing of AF after PFO closure remain unknown. OBJECTIVES: The aim of this study was to prospectively determine the incidence, timing, and determinants of supraventricular arrhythmia following PFO closure on the basis of loop recorder monitoring. METHODS: Cardiac monitoring was proposed to all patients after PFO closure from June 2018 to October 2021 at a single center by means of implantable loop recorder monitoring in patients considered at higher risk for AF (age ≥ 55 years, associated cardiovascular risk factors, prior palpitations, or documented supraventricular ectopic activity) or 4-week external loop recorder monitoring in other patients. The primary endpoint was the incidence of AF, atrial flutter, or supraventricular tachycardia lasting >30 seconds within 28 days of the procedure. Determinants of the primary endpoint were assessed using a stepwise logistic regression model. RESULTS: A total of 225 patients were included. The primary endpoint occurred in 47 patients (20.9%), including 13 (9.9%) and 24 (28.9%) among patients monitored with external loop recorders and implantable loop recorders, respectively. Overall, the median delay from procedure to arrhythmia was 14.0 days (IQR: 6.5-19.0 days), and one-half of these patients reported symptomatic episodes. Determinants of the primary endpoint were older age (adjusted OR: 1.67 per 10-year increase; 95% CI: 1.18-2.36), device left disc diameter ≥25 mm (adjusted OR: 2.67; 95% CI: 1.19-5.98) and male sex (adjusted OR: 4.78; 95% CI: 1.96-11.66). CONCLUSIONS: Using loop recorder monitoring for ≥28 days, supraventricular arrhythmia was diagnosed in 1 in 5 patients, with a median delay of 14 days, suggesting that this postprocedural event has so far been underestimated.

Tissue at risk in the deep middle cerebral artery territory is critical to stroke outcome.

INTRODUCTION: The clinical efficacy of thrombolysis in stroke patients is explained by the increased rate of recanalization, which limits infarct growth. However, the efficacy could also be explained by the protection of specific sites of the brain. Here, we investigate where is this outcome-related tissue at risk using voxel-based analysis. METHODS: We included 68 acute stroke patients with middle cerebral artery (MCA) occlusion on the admission MRI performed within 6 h of symptoms onset (H6) and 16 controls. MCA recanalization was assessed using the magnetic resonance angiography performed at day 1 (D1). Apparent diffusion coefficient (ADC) changes were analyzed using a voxel-based method between patients vs. controls group at admission (H6) in non-recanalized vs. recanalized and in 3-month poor vs. good outcome patients at D1. RESULTS: Complete or partial MCA recanalization was observed in 52 of 68 patients. Good outcome at 3 months occurred in 40 patients (59%). In non-recanalized patients, ADC was decreased in the deep MCA and watershed arterial territory (the lenticular nucleus, internal capsule, and the overlying periventricular white matter). This decrease was not observed in recanalized patients at D1 or patients at H6. Fiber tracking suggested that the area is crossed by the cortico-spinal, cerebellar, and intra-hemispheric association tracts. Finally, this area almost co-localized with the area associated with poor outcome. CONCLUSIONS: A clinically relevant area of tissue at risk may occur in patients with MCA infarcts at the level of deep white matter fiber tracts. These findings suggest that neuroprotection research should be refocused on white matter.

Acute ischemic stroke in adolescents.

OBJECTIVE: Adolescence represents a transition period between childhood and adulthood, and only limited information exists about stroke characteristics in this population. Our aim was to describe the clinical and neuroradiologic features, etiologies, initial management, and outcome of ischemic stroke in adolescents. METHODS: This retrospective cohort study evaluated all consecutive patients 10 to 18 years with a first-ever ischemic stroke hospitalized between 2007 and 2017 in 10 French academic centers representing a population of ≈10 million. Extracted data from the national database served as validation. RESULTS: A total of 60 patients were included (53% male, median age 15.2 years). Diagnosis at first medical contact was misevaluated in 36%, more frequently in posterior than anterior circulation strokes (55% vs 20% respectively, odds ratio 4.8, 95% confidence interval 1.41-16.40, p = 0.01). Recanalization treatment rate was high (n = 19, 32%): IV thrombolysis (17%), endovascular therapy (11.7%), or both IV and intra-arterial thrombolysis (3.3%); safety was good (only 1 asymptomatic hemorrhagic transformation). Despite thorough etiologic workup, 50% of strokes remained cryptogenic. The most common determined etiologies were cardioembolism (15%), vasculitis and autoimmune disorders (12%, occurring exclusively in female patients), and arterial dissections (10%, exclusively in male patients). Recurrent ischemic cerebrovascular events occurred in 12% (median follow-up 19 months). Recurrence rate was 50% in patients with identified vasculopathy but 0% after cryptogenic stroke. Functional outcome was favorable (Rankin Scale score 0-2 at day 90) in 80% of cases. CONCLUSIONS: Ischemic strokes in adolescents harbor both pediatric and adult features, emphasizing the need for multidisciplinary collaboration in their management. Recanalization treatments appear feasible and safe.

Prediction of infarct growth based on apparent diffusion coefficients: penumbral assessment without intravenous contrast material.

PURPOSE: To compare predicted and final infarct lesion volumes determined by processing apparent diffusion coefficient (ADC) maps derived at admission diffusion-weighted (DW) magnetic resonance (MR) imaging in patients with acute stroke and to verify that predicted areas of infarct growth reflect at-risk penumbral regions based on recanalization status. MATERIALS AND METHODS: The French legislation waived the requirement for informed patient consent for the described research, which was based on patient medical files. However, patients and/or their relatives were informed that they could decline to participate in the research. Authors tested a semiautomated proprietary image analysis procedure in 98 patients with middle cerebral artery (MCA) stroke by modeling infarct growth on DW imaging-derived ADC maps. Predicted infarct growth (PIG) areas and predicted infarct volumes were correlated with final observed data. In addition, the effect of MCA recanalization on the correlation between predicted and observed infarct growth volumes was qualitatively assessed. RESULTS: Predicted and final infarct volumes (rho = 0.828; 95% confidence interval [CI]: 0.753, 0.882; P < .0001) and infarct growth volumes (rho = 0.506; 95% CI: 0.342, 0.640; P < .0001) were significantly correlated. Visual comparative examination revealed satisfactory qualitative consistency between predicted and follow-up lesion masks. In patients without MCA recanalization, PIG did not differ significantly from final observed infarct growth (median PIG obtained with 0.93 ADC ratio cutoff [PIG(ratio)] of 27.1 cm(3) vs median infarct growth of 19.8 cm(3), P = .17). MCA recanalization revealed an overestimation of PIG (median PIG(ratio) of 24.8 cm(3) vs median infarct growth of 12 cm(3), P = .005), suggesting that the PIG area was part of ischemic penumbra. CONCLUSION: Data show the feasibility of identifying at-risk ischemic tissue in patients with acute MCA stroke by using semiautomated analysis of ADC maps derived at DW imaging, without intravenous contrast material-enhanced perfusion-weighted imaging.

High-resolution MR imaging of the cervical arterial wall: what the radiologist needs to know.

The emergence of high-resolution rapid imaging methods has enabled magnetic resonance (MR) imagers to noninvasively image the fine internal structure of cervical arterial walls. In this article, a comprehensive guide to performing high-resolution MR imaging of cervical arteries is provided, including the choice of coils, sequences, and imaging parameters, as well as tips for optimal image quality. Explanations and illustrations are given of using high-resolution MR imaging to quantify plaque volume, determine atherosclerotic plaque burden, depict plaque composition, and ultimately identify unstable plaque before it leads to a clinical event. Finally, the role of high-resolution MR imaging in the diagnosis of cervical dissection and inflammatory disease of the arterial wall is emphasized.

Influence of nurse's involvement on practices during end-of-life decisions within stroke units.

OBJECTIVES: Decision-making processes concerning end-of-life decisions are not well understood for patients admitted into stroke units with severe stroke. To assess the influence of nurses on the medical perspectives and approaches that lead to withholding and/or withdrawing treatments related to end-of-life (EOL) decisions. PATIENTS AND METHODS: This secondary analysis nested within the TELOS French national survey was based on a physicians' self-report questionnaire and on a I-Score which was linked to nurses' involvement. Physician's responses were evaluated to assess the potential influence of nurse's involvement on physician's choices during an end-of-life decision. RESULTS: Among the 120 questionnaires analyzed, end-of-life decisions were more often made during a round-table discussion (58% vs. 35%, p = 0.004) when physicians declare to involve nurses in the decision process. Neurologists involved with nurses in decision making were more likely to withhold a treatment (98% vs. 88%, p = 0.04), to withdraw artificial feeding and hydration (59% vs. 39%, p = 0.04), and more frequently prescribed analgesics and hypnotics at a potentially lethal dose (70% vs. 48%, p = 0.03). CONCLUSION: The involvement of nurses during end-of-life decisions for patients with acute stroke in stroke units seemed to influence neurologists' intensivist practices and behaviors. Nurses supported the physicians' decisions related to forgoing life sustaining treatment for patients with acute stroke and may positively impact on the family's choice to participate in end-of-life decisions.

Stroke in elderly patients: management and prognosis in the ED.

PURPOSE: The aim of the study was to analyze the effect of age on management and prognosis of stroke. METHODS: A retrospective study was performed in consecutive patients admitted to an emergency department (ED) with a diagnosis of stroke. Comparison according to age (< 75 vs > or = 75 years old) was done, with a 1-year follow-up including autonomy and outcome. RESULTS: In older patients, brain magnetic resonance imaging (6% vs 27%, P < .001) and immediate referral to the stroke unit were less frequent (6% vs 28%, P < .001); median length of stay was longer (11 vs 8 days, P = .007); and in-hospital mortality tended to be higher (12% vs 6%, not significant). After discharge, 1-year mortality was higher (27% vs 14%, P = .004). In a multivariate analysis, severity of stroke, hemorrhagic stroke, and dementia were independent positive predictors of 1-year mortality, whereas age was not. CONCLUSION: Despite the fact that age was not an independent predictor when stroke severity was considered, our data suggest differences in the management of elderly compared with younger stroke patients admitted to the ED.

[Quality assurance indicators for risk management in the follow-up of medical care received by acute ischemic stroke patients]. / Des indicateurs de qualité et de gestion des risques pour suivre la prise en charge hospitalière des accidents vasculaires cérébraux.

Although recommendations for diagnosis and treatment of stroke are available, the aim of this study was to identify indicators of quality and risk management for acute ischemic stroke hospital patients. We conducted a descriptive study of stroke patients who were diagnosed less than 12 hours before admission to the Pitié-Salpêtrière hospital's neurology and stroke unit. Data were collected using a literature review and from existing recommendation. During the study period (August 2003 through April 2005) 310 eligible patients were identified. In 87.5% of the cases, patients suffered from a cerebral infarction and in 10.3% from an intracranial haemorrhage. The initial deficit was mild to severe. The average time between the first symptoms and admission in the stroke unit was 212 +/- 130 minutes. Forty percent of patients who underwent a thrombolysis did so within the first 3 hours. The average length of stay in the stroke unit was 17.5 days. Thirty-one percent of the patients were discharged to go home, 47% to a rehabilitation unit and 8% died. Ten indicators of quality and risk management are proposed, taking in account the events before admission, hospital care, side effects, duration of stay, discharge location and the handicap.

The silver effect of admission glucose level on excellent outcome in thrombolysed stroke patients.

Higher admission glucose levels (AGL) are associated with less favorable outcome in thrombolysis. But, could AGL's impact on outcome vary by onset-to-treatment (OTT) time? Is hyperglycemia associated with a shorter therapeutic time window for excellent outcome for thrombolysed stroke patients? We assessed predictive values of AGL, baseline NIHSS, age, and OTT time quartiles on excellent outcome (3-month modified Rankin score of 0-1) in 773 patients treated by rt-Pa. We added the AGL × OTT time quartile interaction in the model and separately analyzed the predictive values of AGL, age, and NIHSS for each OTT time quartile if the interaction was significant. AGL, baseline NIHSS, age, and OTT time quartiles were significant predictors. When added in the model, the AGL × OTT interaction was significant (OR: 0.96, 95% CI: 0.94-0.99, p: 0.0009). AGL was predictive only during the third OTT time quartile (181-224 min). During this period, the predicted rate of excellent outcome was 16% for AGL = 6.5 mmol/L and 8% for AGL = 8 mmol/L. The rate of excellent outcome was not decreased in hyperglycemic patients for OTT time ≤ 180 min (20 vs. 24.5% p: 0.37), but was decreased for OTT time > 180 min (9.6 vs. 26.7% p: 0.00001). Similar results were found in patients with MCA recanalization, but not in patients without recanalization. The therapeutic time window for excellent outcome is shortened in hyperglycemic patients. This would support the design of "freezing penumbra" randomized trials based on ultra-early AGL control.

Clinical, imaging, and histological presentations and outcomes of stroke related to sarcoidosis.

OBJECTIVES: Clinical involvement of the nervous system is uncommon during sarcoidosis. Cerebrovascular events are rarely reported during sarcoidosis and may be confused with primary angiitis of the central nervous system. The characteristics and outcomes of cerebrovascular events during sarcoidosis have not been well-evaluated. PATIENTS AND METHODS: We conducted a retrospective case series in our institution with an updated review of the literature from 1962 to 2017 to characterize the clinical presentation, imaging, histology and outcomes of stroke that were thought to be causally related to sarcoidosis. RESULTS: Fifty-one patients (31 men, median age at stroke diagnosis of 41 years) receiving a diagnosis of stroke and sarcoidosis, including 8 new cases from our institution and 43 from the literature review, were included. Stroke was the first manifestation of sarcoidosis in 64%. The stroke was ischemic in 69% and hemorrhagic in 31%. A total of 31% experienced a transient ischemic attack before ischemic stroke. A total of 36% of patients had multiple infarcts or hemorrhages. The median number of cardiovascular risk factors was 0. Concerning histological presentation, vascular or perivascular involvement was present in all cases. After a median follow-up of 12 months (after stroke), up to 50% of patients had developed a permanent neurological impairment, 16% had a recurrence of stroke, and 23% died. CONCLUSIONS: Cerebrovascular events may be the first manifestation of neurosarcoidosis, and have a prognosis impact in such patients, leading to death and permanent neurological impairment.

[Treatment of cerebral hemorrhage]. / Traitement des hémorragies cérébrales.

The incidence of cerebral hemorrhage in France is 25000 new cases per year. Their prognosis is especially grim: six months afterward, 30-50% of these patients have died and only 20% are able to live independently. Management of acute forms requires, above all, hospitalization in a specialized neurovascular unit of proven quality. Initial treatment includes general measures to avoid possible early aggravation and the prevention and treatment of some complications. Specific treatment by recombinant factor VII can be effective in the first 4 hours after symptoms begin. A phase III study is under way to confirm its efficacy against hematoma growth in the first 24 hours and prognosis at 3 months. According to the recent STICH study, surgery is indicated in the case of hydrocephaly, for large cerebellar hematomas and for cortical supratentorial hematomas located less than 1 cm from the cortical surface. Beyond these situations, surgery must be considered on a case-by-case basis, until other studies more clearly specify indications and techniques. The pathophysiology of cerebral hemorrhage remains poorly understood but numerous research pathways are being explored and should make it possible to identify new treatment targets to combat, in particular, cerebral edema and neuronal lesions.

A leap forward in the endovascular management of acute basilar artery occlusion since the appearance of stent retrievers: a single-center comparative study.

OBJECTIVE Contrary to acute ischemic stroke involving the anterior circulation, no randomized trial has yet demonstrated the safety and effectiveness of endovascular management in acute basilar artery occlusion (BAO). Recently developed thrombectomy devices, such as stentrievers and aspiration systems, have helped in improving the endovascular management of acute ischemic stroke. The authors sought to assess the impact of these devices in the endovascular treatment of acute BAO. METHODS A retrospective analysis of 34 consecutive patients treated in Pitié-Salpêtrière Hospital for acute BAO was carried out. All patients had undergone an endovascular procedure. In addition to the global results in terms of safety and effectiveness (recanalization rate and 3-month clinical outcome based on the modified Rankin Scale [mRS]), the authors aimed to determine if the patients treated with the most recently developed devices (i.e., the Solitaire stentriever or the ADAPT catheter) had better angiographic and clinical outcomes than those treated with older endovascular strategies. RESULTS The overall successful recanalization rate (thrombolysis in cerebral infarction score 2b-3) was 50% (17 of 34 patients). A good clinical outcome (mRS score 0-2 at 3-month follow-up) was achieved in 11 (32.3%) of 34 patients. The mortality rate at 3-month follow-up was 29.4% (10 of 34 patients). Patients treated with the Solitaire stentriever and the ADAPT catheter had a higher recanalization rate (12 [92.3%] of 13 patients vs 5 [23.8%] of 21 patients, p = 0.0002) and a shorter mean (± SD) procedure duration (88 ± 31 minutes vs 126 ± 58 minutes, p = 0.04) than patients treated with older devices. CONCLUSIONS The latest devices have improved the effectiveness of mechanical thrombectomy in acute BAO. Their use in further studies may help demonstrate a benefit in the endovascular management of acute BAO.