Treatment with flow diverter stent during pregnancy.

Intracranial aneurysms are rarely diagnosed during pregnancy. If treatment is necessary, surgery was traditionally preferred over embolization in case of ongoing pregnancy, due to concerns regarding foetal radiation exposure. We present a case of 21 mm unruptured carotid-ophthalmic aneurysm diagnosed during pregnancy and treated with flow diversion. Foetal radiation dose was estimated between 1 and 5 mGy, well below recommended limits. Double antiplatelet therapy with prasugrel and aspirin was administered between week 17 and week 37, followed by uneventful vaginal delivery at 39 weeks. The new-born infant did not present any clinical abnormalities. Post-natal angiography showed complete aneurysm occlusion. To our knowledge, this is the first report of flow diverter stent placement during ongoing pregnancy. Although a good outcome was observed in this case, this result should be interpreted with caution. Further studies are needed in order to better define the safety profiles of intracranial stents and double antiplatelet therapies during pregnancy.

Real-Time Estimation of Core Infarct in Angiography Using Collateral Flow.

BACKGROUND AND PURPOSE: In order to attribute a diagnostic value to angiographic runs performed before revascularization, we aimed at developing a regional evaluation of leptomeningeal collateral flow that can be used to detect and predict infarction when performing stroke endovascular procedures. MATERIALS AND METHODS: We evaluated all consecutive patients treated for occlusions in the anterior circulation in our center between 2009 and 2013, with MRI imaging performed before the endovascular procedure. Two readers performed an evaluation of collateral circulation in 5 cortical regions based on the vascular anatomy. Regional scores were correlated with the presence of infarction in the same cortical sector on pretreatment and follow-up imaging. Global collateral scores for each patient were correlated with infarct volumes. RESULTS: In 89 patients with 408 cortical regions, we found a significant correlation between the degree of zonal collateral flow and the absence of infarction in the same zone on pretreatment imaging. In a subgroup of 37 recanalized patients (Thrombolysis in Cerebral Infarction scale 3) with 173 cortical zones, retrograde collateral flow to the proximal M4 segment predicted the absence of infarction within the same zone on follow-up imaging (positive predictive value 88.7%). We found good inter-rater agreement for the presence of collateral flow to the M4 proximal segment or further - k = 0.77 (p = 0.05, 95% CI 0.66-0.88). Global collateral scores correlated with infarct volume on initial imaging; all patients with scores ≥4 had infarct volumes ≤70 ml, whereas all patients with global collateral scores ≤1 had infarct volumes ≥70 ml. CONCLUSION: Anatomic collateral flow evaluation using the angiographic runs performed during stroke endovascular procedures can provide a real-time estimation of the volume and location of core infarct. For each cortical region, good collateral flow is associated with the absence of infarct on pre-treatment imaging, and is predictive of the absence of infarct on follow-up imaging in recanalized patients.

Flow control using Scepter™ balloons for Onyx embolization of a vein of Galen aneurysmal malformation.

PURPOSE: We present a technical development of the endovascular treatment technique for vein of Galen aneurysmal malformation, using Onyx™ (ethylene vinyl alcohol copolymer) delivered under flow control through double-lumen balloon microcatheters. MATERIALS AND METHODS: An 11-month-old patient that initially presented with increasing head circumference was diagnosed with mural type vein of Galen aneurysmal malformation. Complete cure was obtained in a single endovascular treatment session. Onyx was delivered simultaneously through two double-lumen balloon microcatheters (Scepter™, Microvention, Terumo Group). In both arterial feeders, balloon inflation occluded the high-flow arterial-venous shunting and thus facilitated the controlled propagation of the embolic product in the afferent artery and the shunt point while preventing distal migration into the venous system. RESULTS: Two years post-procedure, MR imaging showed persistent occlusion of arterial-venous shunts with complete regression of the venous dilatation. On clinical examination, the patient had no neurological deficits, and no cognitive impairment was detected at neuropsychological testing. CONCLUSION: The use of double-lumen balloon microcatheters for flow control during delivery of Onyx represents a viable alternative for the endovascular treatment of vein of Galen aneurysmal malformations.

High frequency of intracranial arterial stenosis and cannabis use in ischaemic stroke in the young.

BACKGROUND: Leading aetiologies of ischaemic stroke in young adults are cervico-cerebral arterial dissections and cardio-embolism, but the causes remain undetermined in a considerable proportion of cases. In a few reports, intracranial arterial stenosis has been suggested to be a potential cause of ischaemic stroke in young adults. The aim of our work was to evaluate the frequency, characteristics and risk factors of intracranial arterial stenosis in a prospective series of young ischaemic stroke patients. METHODS: The study was based on a prospective consecutive hospital-based series of 159 patients aged 18-45 years who were admitted to our unit for an acute ischaemic stroke from October 2005 to December 2010. A structured questionnaire was used in order to assess common vascular risk factors such as hypertension, diabetes, hypercholesterolemia, use of tobacco, alcohol and illicit drugs, migraine, and, in women, oral contraceptive use. A systematic screening was performed, including the following: brain magnetic resonance imaging or, if not feasible, brain computed tomography scan, carotid and vertebral Duplex scanning and trans-cranial Doppler sonography, 3D time-of-flight magnetic resonance cerebral angiography or cerebral computed tomography angiography. Long-duration electrocardiography, trans-thoracic and trans-oesophageal echocardiography were performed and laboratory blood investigations were extensive. Urine samples were screened for cannabinoids, cocaine, amphetamine and methylene-dioxy-methamphetamine. When this initial work-up was inconclusive, trans-femoral intra-arterial selective digital subtraction angiography with reconstructed 3D images was performed. RESULTS: In this series, 49 patients (31%) had intracranial arterial stenosis. Other defined causes were found in 91 patients (57%), including cardio-embolism in 32 (20%), cervical dissection in 23 (14%), extracranial atherosclerosis in 7 (4%), haematological disorders in 7 (4%), small vessel disease in 1, and isolated patent foramen ovale in 21 (13%); in 19 patients (12%), ischaemic stroke was related to an undetermined aetiology. Comparing risk factors between patients with intracranial arterial stenosis and those with other definite causes showed that there were only two significant differences: a lower age and a higher frequency of vasoactive substances (especially cannabis) in patients with intracranial arterial stenosis. All intracranial arterial stenosis in patients who used vasoactive substances were located in several intracranial vessels. CONCLUSIONS: Intracranial arterial stenosis may be an important mechanism of stroke in young patients and it should be systematically investigated using vascular imaging. Strong questioning about illicit drug consumption (including cannabis) or vasoactive medication use should also be performed. It should be emphasized for health prevention in young adults that cannabis use might be associated with critical consequences such as stroke.

Local anesthesia versus general anesthesia during endovascular therapy for acute stroke: a propensity score analysis.

BACKGROUND: To date, the choice of optimal anesthetic management during endovascular therapy (EVT) of acute ischemic stroke patients remains subject to debate. We aimed to compare functional outcomes and complication rates of EVT according to the first-line anesthetic management in two comprehensive stroke centers: local anesthesia (LA) versus general anesthesia (GA). METHODS: Retrospective analysis of prospectively collected databases, identifying all consecutive EVT for strokes in the anterior circulation performed between January 1, 2018 and December 31, 2018 in two EVT-capable stroke centers. One center performed EVT under LA in the first intention, while the other center systematically used GA. Using propensity score analysis, the two groups underwent 1:1 matching, then procedural metrics, complications, and clinical outcomes were compared. Good outcome was defined as 90 days modified Rankin Scale (mRS) ≤2, and successful recanalization as modified Thrombolysis In Cerebral Ischemia (mTICI) 2b-3. RESULTS: During the study period, 219 patients were treated in the LA center and 142 in the GA center. Using the propensity score, 97 patients from each center were matched 1:1 according to the baseline characteristics. Local anesthesia was associated with a significantly lower proportion of good outcome (36.1% vs 52.0%, OR 0.53, 95% CI 0.33 to 0.87; p=0.039), lower rate of successful recanalization (70.1% vs 95.8%, OR 0.13, 95% CI 0.04 to 0.39; p<0.001), and more procedural complications (14.4% vs 3.0%, OR 3.44, 95% CI 1.09 to 14.28; p=0.018). There were no significant differences in 90-day mortality or symptomatic hemorrhagic transformation rates. CONCLUSIONS: In this study, systematic use of GA for stroke EVT was associated with better clinical outcomes, higher recanalization rates, and fewer procedural complications compared with patients treated under LA as the primary anesthetic approach.

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.

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.

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.

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.

Aneurysmal wall imaging in a case of cortical superficial siderosis and multiple unruptured aneurysms.

We report a case of interhemispheric and bifrontal cortical superficial siderosis in association with two intracranial aneurysms. The patient had no clinical history suggestive of aneurysm rupture, no feature of amyloid angiopathy or other apparent etiology for cortical siderosis. We performed high resolution brain MRI with dark blood T1 sequences before and after IV contrast injection. An anterior communicating aneurysm showed partial wall enhancement on the posterior wall whereas a left posterior communicating aneurysm did not. In the light of recent reports of the association of wall enhancement with unstable aneurysms, we considered wall enhancement to be a marker of inflammation and remodeling of the aneurysm wall, resulting in chronic hemorrhagic suffusion in the subarachnoid spaces. To our knowledge, this is the first report offering proof for a possible link between apparently unruptured aneurysms and cortical siderosis.

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.

Spontaneous thrombosis of a basilar tip aneurysm after ventriculoperitoneal shunting.

We present a case of a large unruptured basilar tip aneurysm with concomitant hydrocephalus. Complete thrombosis of the aneurysm was observed after ventriculoperitoneal shunting. Analyzing preoperative and postoperative MRI and DSA images, we identified reduced intracranial pressure and widening of the aneurysm-artery inclination angle as possible factors influencing spontaneous thrombosis. To the best of our knowledge, this is the first report of aneurysm thrombosis occurring after CSF diversion.

Aneurysmal wall imaging in a case of cortical superficial siderosis and multiple unruptured aneurysms.

We report a case of interhemispheric and bifrontal cortical superficial siderosis in association with two intracranial aneurysms. The patient had no clinical history suggestive of aneurysm rupture, no feature of amyloid angiopathy or other apparent etiology for cortical siderosis. We performed high resolution brain MRI with dark blood T1 sequences before and after IV contrast injection. An anterior communicating aneurysm showed partial wall enhancement on the posterior wall whereas a left posterior communicating aneurysm did not. In the light of recent reports of the association of wall enhancement with unstable aneurysms, we considered wall enhancement to be a marker of inflammation and remodeling of the aneurysm wall, resulting in chronic hemorrhagic suffusion in the subarachnoid spaces. To our knowledge, this is the first report offering proof for a possible link between apparently unruptured aneurysms and cortical siderosis.

Spontaneous thrombosis of a basilar tip aneurysm after ventriculoperitoneal shunting.

We present a case of a large unruptured basilar tip aneurysm with concomitant hydrocephalus. Complete thrombosis of the aneurysm was observed after ventriculoperitoneal shunting. Analyzing preoperative and postoperative MRI and DSA images, we identified reduced intracranial pressure and widening of the aneurysm-artery inclination angle as possible factors influencing spontaneous thrombosis. To the best of our knowledge, this is the first report of aneurysm thrombosis occurring after CSF diversion.

Balloon protection of the Labbé vein during transarterial embolization of a dural arterio-venous fistula.

INTRODUCTION: Endovascular treatment of type III dural arterio-venous fistulas can be challenging if the fistulous point is close to a functionally important cortical vein. METHODS: A technique is described for temporary balloon protection of the vein of Labbé during transarterial Onyx embolization of a type III dural arterio-venous fistula. One illustrative case is presented. Careful anatomic consideration of the concerned venous segment (at the insertion point into the lateral sinus) and the choice of balloon minimized the risk of venous rupture. RESULTS: Using this method, satisfactory progression of Onyx was obtained within the arterio-venous shunt while preserving the patency of the Labbé vein. CONCLUSION: Temporary balloon protection of the Labbé vein is a feasible option to preserve its patency during embolization of dural arterio-venous fistulas. To the authors' knowledge, this is the first report on the use of temporary balloon protection of a cortical vein.

Foramen magnum dural arteriovenous fistula presenting with epilepsy.

Intracranial dural arteriovenous fistulas (dAVFs) with perimedullary drainage represent a rare subtype of intracranial dAVF. Patients usually experience slowly progressive ascending myelopathy and/or lower brainstem signs. We present a case of foramen magnum dural arteriovenous fistula with an atypical clinical presentation. The patient initially presented with a generalised tonic-clonic seizure and no signs of myelopathy, followed one month later by rapidly progressive tetraplegia and respiratory insufficiency. The venous drainage of the fistula was directed both to the left temporal lobe and to the perimedullary veins (type III + V), causing venous congestion and oedema in these areas and explaining this unusual combination of symptoms. Rotational angiography and overlays with magnetic resonance imaging volumes were helpful in delineating the complex anatomy of the fistula. After endovascular embolisation, there was complete remission of venous congestion on imaging and significant clinical improvement. To our knowledge, this is the first report of a craniocervical junction fistula presenting with epilepsy.

Surgical management of spinal dural arteriovenous fistulas.

Spinal dural arteriovenous fistulas are the most common type of spinal arteriovenous malformations. Treatment options consist of microsurgical exclusion and/or endovascular embolization. We retrospectively identified all patients who benefited from surgical treatment at our tertiary center between January 2001 and December 2008. Clinical and imaging data were collected from patient files, including pre- and post-operative formal neurological examination, complete spine MRI and spinal digital subtraction angiography. Of our 30 patients, 25 were men and five were women with a median age of 62 years (range 24-76). The average delay between symptom onset and clinical diagnosis was 27 months (range 1-90). Complete cure of the fistula was obtained in all patients in a single surgical session with no procedural complications and no surgical morbidity. After a mean follow-up period of 32 months (range 14-128), 25 patients (83%) had improved, four were stable and one worsened. Despite recent advances in endovascular techniques and materials, there is a subgroup of patients for which surgery remains the best treatment option. Careful patient selection, a multidisciplinary approach and standardized surgical techniques can lead to excellent results with virtually no complications.

Endovascular treatment in two cases of bilateral ischemic stroke.

Acute bilateral intracranial large artery occlusion is a rare occurrence that can lead to bihemispheric ischemia and potentially devastating functional consequences. We discuss two cases that initially presented with unilateral symptoms and did not show signs of bilateral arterial occlusions on the initial MRI imaging. This became evident while performing the angiographic study at the beginning of the endovascular procedure. Both patients were successfully treated with bilateral mechanical thrombectomy as a complement to intravenous thrombolysis. We describe our method of simultaneous sequential bilateral thrombectomy. To our knowledge, this is the first report of successful endovascular therapy in bilateral ischemic stroke.

Successful transvenous embolization of brain arteriovenous malformations using Onyx in five consecutive patients.

BACKGROUND: There is an increasing application of endovascular treatment for brain arteriovenous malformations (BAVMs) using ethylene vinyl alcohol copolymer (Onyx). Historically, this treatment has been performed using a transarterial approach. OBJECTIVE: To report our experience with transvenous endovascular embolization with Onyx (TVEO). METHODS: Five consecutive patients with BAVMs underwent endovascular TVEO between June 2007 and March 2009 at the Interventional Neuroradiology Department of the University Hospital of Limoges. There were 3 men and 2 women with a mean age of 41.8 years (range, 19-57 years). The clinical presentation included symptoms caused by intracerebral hemorrhage (n = 4) and seizures (n = 1). According to the Spetzler-Martin classification scheme, 3 BAVMs (60%) were grade III, and 2 BAVMs (40%) were grade IV. Four BAVMs (80%) were supratentorial and 1 BAVM (20%) was infratentorial. Immediate and mid-term treatment (6 months) outcomes were angiographically and clinically analyzed according to the modified Rankin Scale. RESULTS: The transvenous approach was used in all patients (100%). The success rate of complete obliteration of the arteriovenous malformation nidus was 80% (4 of 5), confirmed by follow-up angiography performed immediately and at 6 months after TVEO. No procedure-related complications occurred during or after embolization. All patients remained unchanged (modified Rankin Scale score = 0-2) and clinically stable 6 months after TVEO. CONCLUSION: The transvenous approach using Onyx for the management of BAVMs is shown to be an efficient and safe alternative treatment in cases with no other conventional therapeutic choice and when some anatomic considerations are respected.