Safety and efficacy of stent retrievers plus contact aspiration in patients with acute ischaemic anterior circulation stroke and positive susceptibility vessel sign in France (VECTOR): a randomised, single-blind trial.

BACKGROUND: Positive susceptibility vessel sign (SVS) in patients with acute ischaemic stroke has been associated with friable red blood cell-rich clots and more effective recanalisation using stent retrievers versus contact aspiration. We compared the safety and efficacy of stent retrievers plus contact aspiration (combined technique) versus contact aspiration alone as the first-line thrombectomy technique in patients with acute ischaemic anterior circulation stroke and SVS-positive occlusions. METHODS: Adaptive Endovascular Strategy to the Clot MRI in Large Intracranial Vessel Occlusion (VECTOR) was a prospective, randomised, open-label study with blinded evaluation. Patients with SVS-positive anterior circulation occlusions on pretreatment MRI and arterial puncture within 24 h of symptom onset were enrolled from 22 centres in France. A centralised web-based method was used by interventional neuroradiologists for dynamic randomisation by minimisation. Patients were randomly assigned 1:1 to the combined technique or contact aspiration alone. The primary outcome was expanded Thrombolysis in Cerebral Infarction (eTICI) grade 2c or 3 reperfusion after three or fewer passes on post-treatment angiogram, adjudicated by a blinded independent central imaging core laboratory. The intention-to-treat population was used to assess the primary and secondary outcomes. This trial is registered with ClinicalTrials.gov (NCT04139486) and is complete. FINDINGS: Between Nov 26, 2019, and Feb 14, 2022, 526 patients were enrolled, of whom 521 constituted the intention-to-treat population (combined technique, n=263; contact aspiration alone, n=258). The median age of participants was 74·9 years (IQR 64·4-83·3); 284 (55%) were female and 237 (45%) male. The primary outcome did not differ significantly between groups (152 [58%] of 263 patients for the combined technique vs 135 [52%] of 258 for contact aspiration; odds ratio [OR] 1·27; 95% CI 0·88-1·83; p=0·19). Procedure-related adverse events occurred in 32 (12%) of 263 patients in the combined technique group and 27 (11%) of 257 in the contact aspiration group (OR 1·14; 0·65-2·00; p=0·65). The most common adverse event was intracerebral haemorrhage (146 [56%] of 259 patients for the combined technique vs 123 [49%] of 251 for contact aspiration; OR 1·32; 0·91-1·90; p=0·13). All-cause mortality at 3 months occurred in 57 (23%) of 251 patients in the combined technique group and 48 (19%) of 247 in the contact aspiration group (OR 1·19; 0·76-1·86; p=0·45), none of which was treatment-related. INTERPRETATION: The results of the VECTOR trial do not show superiority of the combined stent retriever plus contact aspiration technique over contact aspiration alone in patients with SVS-positive occlusion with respect to achieving eTICI 2c-3 within three passes. These findings support the use of either the combined technique or contact aspiration alone as the initial thrombectomy strategy in patients with acute anterior circulation stroke with SVS on pretreatment MRI. FUNDING: Cerenovus.

Antithrombotic therapies for neurointerventional surgery: a 2021 French comprehensive national survey.

BACKGROUND: Neurointerventionists lack guidelines for the use of antithrombotic therapies in their clinical practice; consequently, there is likely to be significant heterogeneity in antithrombotic use between centers. Through a nationwide survey, we aimed to obtain an exhaustive cross-sectional overview of antithrombotic use in neurointerventional procedures in France. METHODS: In April 2021, French neurointerventional surgery centers were invited to participate in a nationwide 51-question survey disseminated through an active trainee-led research collaborative network (the JENI-RC). RESULTS: All 40 centers answered the survey. Fifty-one percent of centers reported using ticagrelor and 43% used clopidogrel as premedication before intracranial stenting. For flow diversion treatment, dual antiplatelet therapy was maintained for 3 or 6 months in 39% and 53% of centers, respectively, and aspirin was prescribed for 12 months or more than 12 months in 63% and 26% of centers, respectively. For unruptured aneurysms, the most common heparin bolus dose was 50 IU/kg (59%), and only 35% of centers monitored heparin activity for dose adjustment. Tirofiban was used in 64% of centers to treat thromboembolic complications. Fifteen percent of these comprehensive stroke centers reported using tenecteplase to treat acute ischemic strokes. Cangrelor appeared as an emergent drug in specific indications. CONCLUSION: This nationwide survey highlights the important heterogeneity in clinical practices across centers. There is a pressing need for trials and guidelines to further evaluate and harmonize antithrombotic regimens in the neurointerventional field.

Balloon-assisted coiling of intracranial aneurysms using the Eclipse 2L double lumen balloon.

BACKGROUND: Eclipse 2L is a new double lumen balloon microcatheter for neurovascular use, with several design features that separate it from previous generation devices. We aimed to report our initial experience of balloon-assisted coiling of intracranial aneurysms using the Eclipse 2L balloon. MATERIALS AND METHODS: Retrospective single-center review of patients who underwent balloon-assisted coiling with the Eclipse 2L balloon, for ruptured or unruptured intracranial aneurysms between 1 June 2016 and 31 December 2018. Cases with adjunctive use of stents and recurrences of previously embolized aneurysms were excluded. Patient files were used to extract aneurysm characteristics, complications, immediate and long-term results. RESULTS: We identified 120 patients with 126 aneurysms, of which 83 (65.8%) unruptured. Average aneurysm size was 5.9 mm (standard deviation 3.2 mm), with a dome-to neck-ratio of 1.7 (SD 0.6). Most aneurysms (79.3%) were wide necked. Immediate angiographic exclusion (Raymond-Roy grade I-II) was obtained in 95.1% of cases (81.7% grade I and 13.4% grade II). Procedural morbidity was 3.2% with no procedural mortality. Follow-up imaging was available for 115 aneurysms (91.2%). After an average follow-up period of 8.9 months (SD 7.3 months), 96.5% of aneurysms presented class I-II occlusion. Two aneurysms (1.7%) were retreated during follow-up. CONCLUSION: Balloon-assisted coiling using the Eclipse 2L double lumen balloon is feasible for aneurysms in a wide range of locations in the anterior and posterior circulation. The angiographic results and complication rates compare favorably with previously published studies.

Embolization of very small (≤3 mm) unruptured intracranial aneurysms: A large single-center experience on treatment of unruptured versus ruptured cases.

OBJECTIVE: In selected cases, embolization can be indicated for very small unruptured intracranial aneurysms. Previous studies reported high intraprocedural rupture rates. Recent improvements of endovascular devices and availability of small, soft platinum coils may lead to improved safety and efficacy profiles. METHODS: Retrospective review of embolizations for unruptured and ruptured intracranial aneurysms with maximal diameter ≤3 mm between January 1, 2009, and January 15, 2018. Infectious aneurysms were excluded. Patient files were used to extract aneurysm characteristics, complications, and immediate and long-term results. RESULTS: We identified 99 embolizations for 97 patients with 100 aneurysms, of which 70 aneurysms were unruptured. Initial success rate was 92.9%. We observed 1 asymptomatic intraprocedural perforation of an unruptured aneurysm, accounting for 1.4% of unruptured cases (1% of all embolizations). Neurological morbidity was 2.8% for unruptured aneurysms and 3.3% for ruptured aneurysms (P = 0.89). There was no procedural mortality. Follow-up was available for 85 (93.4%) patients. After 28.2 months (2-77), there was no aneurysmal bleeding; 2 (2.2%) aneurysms needed retreatment. Long-term results (30.5 months [3-77]) were available for all unruptured aneurysms. Among 64 successfully embolized unruptured aneurysms, 5 (7.8%) had residual neck filling and 1 (1.5%) needed retreatment. There were no significant differences in patient characteristics or complications between ruptured and unruptured aneurysms. CONCLUSIONS: In the context of technical evolution of endovascular devices, we observed a procedural perforation rate lower than previously reported, low morbidity and no mortality. Further prospective studies are warranted to update our knowledge about safety of embolization for very small intracranial aneurysms.

Beam hardening artifacts of liquid embolic agents: comparison between Squid and Onyx.

BACKGROUND: Initial clinical experience with Squid shows subjectively reduced artifacts on post-embolization CT scans compared with Onyx. To further investigate these observations, we aimed to perform a comparison of artifacts between Squid and Onyx in a controlled in vitro model. MATERIALS AND METHODS: Onyx 18 and all four variants of Squid (Squid 18, Squid 18 low density (LD), Squid 12, Squid 12 LD) were each injected in dimethylsulfoxide (DMSO) compatible test tubes. The tubes containing precipitated embolic material were inserted in a CT phantom for conventional and flat panel CT acquisitions. Beam hardening artifacts were quantified using objective and subjective measurements. RESULTS: Objective evaluation of artifacts within regions of interest (ROIs) placed around the embolic material on CT and flat panel CT images demonstrated significantly lower noise and Hounsfield unit (HU) range values for all four Squid products compared with Onyx 18. On both CT and flat panel CT, LD variants of Squid 18 and Squid 12 had significantly lower noise and HU range values than their normal density counterparts on longitudinal ROIs. When using subjective measures for diagnostic value within ROIs placed around the embolic material on both CT and flat panel CT images, the number of non-diagnostic ROIs was significantly higher for Onyx 18 than for all four Squid variants. CONCLUSION: All four variants of Squid induced fewer beam hardening artifacts than Onyx 18 on CT and flat panel CT acquisitions. LD variants of Squid induced fewer artifacts than their normal density counterparts.

Mechanical thrombectomy for repeated cerebral tumor embolism from a thoracic sarcomatoid carcinoma.

Cerebral embolism originating from intracardiac tumors represents a rare cause of stroke and has been documented in both adult and pediatric populations. We present a patient recently diagnosed with a right pulmonary hilum tumor, invading the pulmonary veins and the left atrium. Two consecutive episodes of large cerebral vessel occlusion in separate vascular territories occurred in the same day and were treated by mechanical thrombectomy. Embolic material retrieved on both occasions contained tumor fragments with peripheral endothelialization. To our knowledge, this is the first report with histological confirmation of cerebral embolism from an invasive extracardiac tumor.

Mechanical thrombectomy for repeated cerebral tumor embolism from a thoracic sarcomatoid carcinoma.

Cerebral embolism originating from intracardiac tumors represents a rare cause of stroke and has been documented in both adult and pediatric populations. We present a patient recently diagnosed with a right pulmonary hilum tumor, invading the pulmonary veins and the left atrium. Two consecutive episodes of large cerebral vessel occlusion in separate vascular territories occurred in the same day and were treated by mechanical thrombectomy. Embolic material retrieved on both occasions contained tumor fragments with peripheral endothelialization. To our knowledge, this is the first report with histological confirmation of cerebral embolism from an invasive extracardiac tumor.