Trial of Thrombectomy for Stroke with a Large Infarct of Unrestricted Size.

BACKGROUND: The use of thrombectomy in patients with acute stroke and a large infarct of unrestricted size has not been well studied. METHODS: We assigned, in a 1:1 ratio, patients with proximal cerebral vessel occlusion in the anterior circulation and a large infarct (as defined by an Alberta Stroke Program Early Computed Tomographic Score of ≤5; values range from 0 to 10) detected on magnetic resonance imaging or computed tomography within 6.5 hours after symptom onset to undergo endovascular thrombectomy and receive medical care (thrombectomy group) or to receive medical care alone (control group). The primary outcome was the score on the modified Rankin scale at 90 days (scores range from 0 to 6, with higher scores indicating greater disability). The primary safety outcome was death from any cause at 90 days, and an ancillary safety outcome was symptomatic intracerebral hemorrhage. RESULTS: A total of 333 patients were assigned to either the thrombectomy group (166 patients) or the control group (167 patients); 9 were excluded from the analysis because of consent withdrawal or legal reasons. The trial was stopped early because results of similar trials favored thrombectomy. Approximately 35% of the patients received thrombolysis therapy. The median modified Rankin scale score at 90 days was 4 in the thrombectomy group and 6 in the control group (generalized odds ratio, 1.63; 95% confidence interval [CI], 1.29 to 2.06; P<0.001). Death from any cause at 90 days occurred in 36.1% of the patients in the thrombectomy group and in 55.5% of those in the control group (adjusted relative risk, 0.65; 95% CI, 0.50 to 0.84), and the percentage of patients with symptomatic intracerebral hemorrhage was 9.6% and 5.7%, respectively (adjusted relative risk, 1.73; 95% CI, 0.78 to 4.68). Eleven procedure-related complications occurred in the thrombectomy group. CONCLUSIONS: In patients with acute stroke and a large infarct of unrestricted size, thrombectomy plus medical care resulted in better functional outcomes and lower mortality than medical care alone but led to a higher incidence of symptomatic intracerebral hemorrhage. (Funded by Montpellier University Hospital; LASTE ClinicalTrials.gov number, NCT03811769.).

Temporal averaging angiographic reconstructions from whole-brain CT perfusion for the detection of vasospasm.

PURPOSE: The aim of this study is to evaluate the image quality and diagnostic performance of angiographic images reconstructed from whole-brain CT perfusion (CTP) using temporal averaging compared to CT angiography (CTA) for the detection of vasospasm. MATERIALS AND METHODS: 39 CT studies in 28 consecutive patients who underwent brain CTA with CTP for suspected vasospasm between September 2020 and May 2021 were retrospectively evaluated. The image quality of these two vascular imaging techniques was assessed either quantitatively (image noise, vascular enhancement, signal-to-noise (SNR) and contrast-to-noise (CNR) ratios,) and qualitatively (4 criteria assessed on a 5-point scale). Intra and interobserver agreements and a diagnostic confidence score on the diagnosis of vasospasm were measured. Radiation dose parameters (volume CT dose index (CTDIvol) and dose-length product (DLP)) were recorded. RESULTS: Both SNR and CNR were significantly higher with temporal averaging compared to CTA, increasing by 104% and 113%, respectively (p<0.001). The qualitative assessment found no significant difference in overall image quality between temporal averaging (4.33 ± 0.48) and brain CTA (4.19 ± 0.52) (p = 0.12).There was a significant improvement in intravascular noise and arterial contrast enhancement with temporal averaging. The evaluation of intra and interobserver agreements showed a robust concordance in the diagnosis of vasospasm between the two techniques. CONCLUSIONS: Temporal averaging appeared as a feasible and reliable imaging technique for the detection of vasospasm. The use of temporal averaging, replacing brain CTA, could represent a new strategy of radiation and contrast material doses reduction in these patients.

Pre-existing brain damage and association between severity and prior cognitive impairment in ischemic stroke patients.

BACKGROUND: We evaluated whether pre-existing brain damage may explain greater severity in cognitively-impaired patients with ischemic stroke (IS). METHODS: IS patients were retrieved from the population-based registry of Dijon, France. Pre-existing damage (leukoaraiosis, old vascular brain lesions, cortical and central brain atrophy) was assessed on initial CT-scan. Association between prestroke cognitive status defined as no impairment, mild cognitive impairment (MCI), or dementia, and clinical severity at IS onset assessed with the NIHSS score was evaluated using ordinal regression analysis. Mediation analysis was performed to assess pre-existing brain lesions as mediators of the relationship between cognitive status and severity. RESULTS: Among the 916 included patients (mean age 76.8 ± 15.0 years, 54.3% women), those with pre-existing MCI (n = 115, median NIHSS [IQR]: 6 [2-15]) or dementia (n = 147, median NIHSS: 6 [3-15]) had a greater severity than patients without (n = 654, median NIHSS: 3 [1-9]) in univariate analysis (OR=1.69; 95% CI: 1.18-2.42, p = 0.004, and OR=2.06; 95% CI: 1.49-2.84, p < 0.001, respectively). Old cortical lesion (OR=1.53, p = 0.002), central atrophy (OR=1.41, p = 0.005), cortical atrophy (OR=1.90, p < 0.001) and moderate (OR=1.41, p = 0.005) or severe (OR=1.84, p = 0.002) leukoaraiosis were also associated with greater severity. After adjustments, pre-existing MCI (OR=1.52; 95% CI: 1.03-2.26, p = 0.037) or dementia (OR=1.94; 95% CI: 1.32-2.86, p = 0.001) remained associated with higher severity at IS onset, independently of confounding factors including imaging variables. Association between cognitive impairment and severity was not mediated by pre-existing visible brain damages. CONCLUSION: Impaired brain ischemic tolerance in IS patients with prior cognitive impairment could involve other mechanisms than pre-existing visible brain damage.

Benefit of mechanical thrombectomy in acute ischemic stroke related to calcified cerebral embolus.

PURPOSE: Mechanical thrombectomies (MT) in patients with large vessel occlusion (LVO) related to calcified cerebral embolus (CCE) have been reported, through small case series, being associated with low reperfusion rate and worse outcome, compared to regular MT. The purpose of the MASC (Mechanical Thrombectomy in Acute Ischemic Stroke Related to Calcified Cerebral Embolus) study was to evaluate the incidence of CCEs treated by MT and the effectiveness of MT in this indication. METHODS: The MASC study is a retrospective multicentric (n = 37) national study gathering the cases of adult patients who underwent MT for acute ischemic stroke with LVO related to a CCE in France from January 2015 to November 2019. Reperfusion rate (mTICI ≥ 2B), complication rate and 90-day mRS were systematically collected. We then conducted a systematic review by searching for articles in PubMed, Cochrane Library, Embase and Google Scholar from January 2015 to March 2020. A meta-analysis was performed to estimate clinical outcome at 90 days, reperfusion rate and complications. RESULTS: We gathered data from 35 patients. Reperfusion was obtained in 57% of the cases. Good clinical outcome was observed in 28% of the patients. The meta-analysis retrieved 136 patients. Reperfusion and good clinical outcome were obtained in 50% and 29% of the cases, respectively. CONCLUSION: The MASC study found worse angiographic and clinical outcomes compared to regular thrombectomies. Individual patient-based meta-analysis including the MASC findings shows a 50% reperfusion rate and a 29% of good clinical outcome.

Detection of Myocardial Infarction by Cardiac Magnetic Resonance in Embolic Stroke Related to First Diagnosed Atrial Fibrillation.

INTRODUCTION: Elevated troponin levels are found in a significant number of patients who are diagnosed with acute embolic stroke (AES) after first diagnosed atrial fibrillation (AF). These myocardial injuries, which are known as cardiocerebral infarction (CCI), are potentially caused by coronary embolism and correspond to simultaneous cardiac and cerebral embolisms. However, this severe condition remains poorly understood. In this prospective study, we aimed to investigate the prevalence and the cardiac magnetic resonance (CMR) characteristics of CCI. MATERIALS AND METHODS: Consecutive patients with first diagnosed AF hospitalized for AES in a neurovascular intensive care unit from 2019 to 2020 were included. Troponin Ic kinetic were measured <72 h, MRI and coronary angiography or CT scan were performed <7 days after admission. Patients with significant coronary lesions were excluded. RESULTS: During the study period, 1150 patients with strokes were hospitalized in the neurovascular intensive care unit (ICU). Of these patients, 955 had an ischemic stroke and 97 had a transient ischemic attack. Among the 44 patients with AES and with first diagnosed AF, 34 patients underwent CMR and CMR analysis identified 12 MI. A significant rise in troponin (>0.10 µg/L) was observed in 35% of the total population (12/34 patients). More specifically, a rise was seen in 23% of the AES without MI group, 58% of the AES with MI. In addition, coronary embolism was identified in 3 patients who underwent coronary angiography (3/12) and MI was often (30%) localized in infero-latero-medial and infero-apical segments. Most AES were localized in the superficial sylvian territory. CONCLUSION: We found a high prevalence of CMR-confirmed double embolization sites in the acute phase of an embolic stroke. Further studies are required to better characterize the pathophysiology, clinical course and prognostic value of CCI. Moreover, optimal management strategies, including antiplatelet therapy, remain to be determined.

Flow Diverters for Intracranial Aneurysms: The DIVERSION National Prospective Cohort Study.

Background and Purpose- Flow diverters are used for endovascular therapy of intracranial aneurysms. We did a nationwide prospective study to investigate the safety and effectiveness of flow diversion at 12 months. Methods- DIVERSION was a national prospective cohort study including all flow diverters placement between October 2012 and February 2014 in France. The primary end point was the event-free survival rate at 12 months, defined as the occurrence of morbidity (intracranial hemorrhage, ischemic stroke, noncerebral hemorrhage, or neurological deficit due to mass effect), retreatment, or death within 12 months post-treatment. A quality control was carried out on 100% of the collected data and of at least 10% of the included patients in each center, chosen at random. All reported serious events were adjudicated by an independent Data Safety and Monitoring Board. Satisfactory occlusion was defined as 3 or 4 on Kamran scale by an independent imaging core laboratory at 12 months. Results- We enrolled 398 patients harboring 477 intracranial aneurysms. At least 1 morbidity-mortality event was noted in 95 of 408 interventions representing an event-free survival rate of 75.7% (95% CI, 71.1-79.7). The rate of permanent-related serious events and mortality was 5.9% and 1.2% at 12 months, respectively. Multivariate analysis showed that high baseline blood pressure (hazard ratio, 2.54; 95% CI, 1.35-4.79; P=0.039), diabetes mellitus (hazard ratio, 3.70; 95% CI, 1.60-8.6; P=0.0022), and larger aneurysms (hazard ratio, 1.07; 95% CI, 1.04-1.11; P<0.0001) were associated with the occurrence of a neurological deficit. The satisfactory occlusion rate at 12 months was 79.9%, and the absence of high baseline blood pressure (odds ratio, 2.01; 95% CI, 1.12-3.71; P=0.0193) and postprocedural satisfactory occlusion (odds ratio, 2.75; 95% CI, 1.49-5.09; P=0.0012) were associated with a 12-month satisfactory occlusion. Conclusions- A satisfactory occlusion was achieved in almost 80% of cases after flow diverter treatment with a permanent-related serious event and mortality rates of 5.9% and 1.2% at 12 months, respectively.

Liver Fat Content in People with Pituitary Diseases: Influence of Serum IGF1 Levels.

Non-alcoholic fatty liver disease (NAFLD) is commonly associated with obesity, metabolic syndrome, and type 2 diabetes. NAFLD is also seen in patients with endocrinopathies. However, the relationship between endocrine diseases and the development of NAFLD is not well known. In this study, we set out to determine whether liver fat content (LFC) was associated with IGF1 levels in people with pituitary diseases (PD). Eighty-nine patients with pituitary diseases and 74 healthy controls were included in this study. LFC was measured using MRI. Hepatic steatosis was defined as LFC>5.5%. Patients with PD were older, and had a higher BMI than healthy controls. LFC was significantly higher in people with PD than in controls (6.5% vs. 3.2%; p<0.001). LFC was negatively associated with the IGF1 level. The prevalence of steatosis was higher in PD patients than in controls (36.3% vs. 14.8%; p=0.002). In multivariate analysis, which included patients and controls, the predictive variables for steatosis were age, BMI and IGF1 levels, whereas the presence of pituitary diseases and gender were not associated with steatosis. Our data showed that LFC was strongly associated with IGF1 levels. These results suggest that steatosis associated with PD is probably a consequence of a low IGF1 level in these patients.

CT analysis of the aorta in giant-cell arteritis: a case-control study.

OBJECTIVES: Giant cell arteritis (GCA) is a large-vessel vasculitis whose diagnosis is confirmed by temporal artery biopsy. However, involvement of large vessels, especially the aorta, can be shown by imaging, which plays an increasing role in GCA diagnosis. The threshold above which aortic wall thickening, as measured by computed tomography (CT), is considered pathological is controversial, with values ranging from 2 to 3 mm. This study assessed aortic morphology by CT scan and its diagnostic value in GCA. METHODS: Altogether, 174 patients were included (64 with GCA, 43 with polymyalgia rheumatica and 67 controls). All patients had a CT scan at diagnosis or at inclusion for controls. Aortic wall thickness, aortic diameter and scores for atheroma were measured. Assessor was blinded to each patient's group. RESULTS: Aortic diameters and atheroma scores were similar between groups. Aortic wall thickness was greater in the GCA group, even after the exclusion of GCA patients with aortic wall thickness ≥3 mm. The receiver operating characteristic (ROC) curve showed that a wall thickness of 2.2 mm was the optimal threshold to diagnose GCA (sensitivity, 67%; specificity, 98%). CONCLUSIONS: Measuring aortic wall thickness by CT scan is effective to diagnose GCA. The optimal threshold to regard aortic wall thickening as pathological was ≥2.2 mm. KEY POINTS: • Imaging, including CT scan, plays an increasing role in GCA diagnosis • CT measurement of aortic wall thickness is useful to diagnose GCA • A 2.2-mm threshold allows the diagnosis of thickened aortic wall in GCA.

Impact of Mechanical Thrombectomy on the Organization of the Management of Acute Ischemic Stroke.

BACKGROUND: Several trials and meta-analyses have recently demonstrated the superiority of endovascular therapy over standard medical treatment in patients presenting with acute ischemic stroke. In order to offer the best possible treatment to a maximum number of patients, many stroke care networks probably have to be reorganized. After analyzing the reliability of data in the literature, an algorithm is suggested for a pre-hospital and in-hospital alert system to improve the timeliness of subsequent treatment: a drip-and-ship approach. SUMMARY: Five recent well-designed randomized studies have demonstrated the benefit of endovascular therapy associated with intravenous fibrinolysis by recombinant tissue plasminogen activator (rt-PA) for acute ischemic stroke with confirmation by recent meta-analyses. The keys for success are a very short time to reperfusion, within 6 h, a moderate to severe pre-treatment deficit (National Institute of Health around 17), cerebral imaging able to identify proximal large vessel occlusion in the anterior circulation, a limited infarct core and a reversible penumbra, the use of the most recent devices (stent retriever) and a procedure that avoids general anesthesia, which reduces blood pressure. To meet these goals, every country must build a national stroke infrastructure plan to offer the best possible treatment to all patients eligible for intravenous fibrinolysis and endovascular therapy. The plan may include the following actions: inform the population about the first symptoms of stroke, provide the call number to improve the timeliness of treatment, increase the number of comprehensive stroke centers, link these to secondary and primary stroke centers by telemedicine, teach and train paramedics, emergency doctors and radiologists to identify the stroke infarct, proximal large vessel occlusion and the infarct core quickly, train a new generation of endovascular radiologists to improve access to this therapy. KEY MESSAGE: After 20 years of rt-PA, this new evidence-based therapy is a revolution in stroke medicine that will benefit patients. However, a new robust and multi-disciplinary care strategy is necessary to transfer the scientific data into clinical practice. It will require reorganization of the stroke infrastructure, which will include comprehensive stroke centers and secondary and primary stroke centers. The winners will be patients with severe stroke.

Navigation-guided transmodiolar approach for auditory nerve implantation via the middle ear in humans.

The aim of this study was to assess the surgical feasibility of a transmodiolar approach via the middle ear cavity for an auditory nerve implantation in humans. In the first part of the study, 6 adult human temporal bones underwent a navigator-guided transmodiolar implantation via the middle ear space after a radical mastoidectomy. In the second part, 122 temporal bone CT scans were analyzed for anatomical parameters relevant to this approach. The nerve implantation was feasible in all temporal bones in laboratory conditions, with a mean target registration error of 0.065 ± 0.0583 mm (n = 6). Evaluation of anatomical parameters on CT scans also supported the feasibility. There was a significant interindividual variation of the modiolar axis and the entry point in relation to visible anatomical landmarks, highlighting the necessity for surgical preplanning.

Donepezil decreases annual rate of hippocampal atrophy in suspected prodromal Alzheimer's disease.

INTRODUCTION: The purpose of this study was to study the effect of donepezil on the rate of hippocampal atrophy in prodromal Alzheimer's disease (AD). METHODS: A double-blind, randomized, placebo-controlled parallel group design using donepezil (10 mg/day) in subjects with suspected prodromal AD. Subjects underwent two brain magnetic resonance imaging scans (baseline and final visit). The primary efficacy outcome was the annualized percentage change (APC) of total hippocampal volume (left + right) measured by an automated segmentation method. RESULTS: Two-hundred and sixteen only subjects were randomized across 28 French expert clinical sites. In the per protocol population (placebo = 92 and donepezil = 82), the donepezil group exhibited a significant reduced rate of hippocampal atrophy (APC = -1.89%) compared with the placebo group (APC = -3.47%), P < .001. There was no significant difference in neuropsychological performance between treatment groups. DISCUSSION: A 45% reduction of rate of hippocampal atrophy was observed in prodromal AD following 1 year of treatment with donepezil compared with placebo.

Endovascular treatment of acute ischemic stroke in France: a nationwide survey.

BACKGROUND AND PURPOSE: Developments in endovascular treatment have opened new promising prospects for treating acute ischemic stroke. In France, EVT is increasingly used, especially when intravenous thrombolysis is contraindicated or has failed. However, it has not been documented how neurointerventional centers are organized practically for the treatment of AIS. The present survey aims to address this. MATERIALS AND METHODS: The centers in France that are authorized to perform EVT for AIS were invited to participate to an electronic survey. The survey was composed of 33 questions, divided into 6 subheadings: (1) general information, (2) imaging modalities, (3) patient selection, (4) anesthesiology, (5) endovascular procedure and (6) imaging follow-up. RESULTS: The response rate was high at 93.9%. Neuroradiology centers are organized to perform mechanical thrombectomy around the clock in 80.6% of the institutions. MRI was the most commonly used imaging modality to examine acute stroke, alone in 64.5% or in combination with CT in 22.6%. The median number of neurointerventionalists was 3 per center and the median number of procedures performed in 2012 was 925. Since the medical treatment is complex, an anesthesiologist is often required during the procedure (87.1%). Technical issues are also developed in the manuscript. CONCLUSIONS: This survey shows that French neuroradiology departments have made important efforts to implement EVT of AIS with a high quality of care for the patients; the majority of the centers used MRI to evaluate the disease and anesthesiologists are involved in order to optimize medical care during EVT.

Collateral circulation in acute stroke: assessing methods and impact: a literature review.

Collateral circulation plays an important role in the clinical and radiological outcome after acute ischemic stroke. Several modalities are used to evaluate these alternative pathways with a growing interest in recent years. We conducted a literature review of studies evaluating collaterals at the acute phase of a carotid territory ischemic stroke. Most of them were based on conventional angiography and CT angiography, several on the basis of MRI and transcranial Doppler and, more recently, on the basis of dynamic CT angiography, which seems to be the most appropriate modality. Populations studied in these publications are often heterogeneous (especially concerning the occlusion site and the treatments performed) and many classifications have been proposed.

Solitaire FR as a first-line device in acute intracerebral occlusion: a single-centre retrospective analysis.

INTRODUCTION: Analysing the clinical and angiographical effectiveness of the Solitaire FR as a mechanical thrombectomy device in acute intracerebral occlusion. METHODS: Sixty-two patients were retrospectively included between January 2010 and March 2012. All of them underwent mechanical thrombectomy with the Solitaire FR device with or without intravenous thrombolysis. Twenty-five patients had an occlusion of the basilar artery, 1 had a posterior cerebral artery occlusion. There were 16 M1 middle cerebral artery occlusions, 9 carotid T occlusions and 11 tandem occlusions. Clinical status was evaluated using the National Institute of Health Stroke Scale (NIHSS) before and 24 hours after treatment and at discharge. The Modified Rankin Scale (mRS) was evaluated at 3 months. RESULTS: Mean age of patients was 64.8 years. Mean NIHSS score on admission was 19.8. Stand-alone thrombectomy was used in 47 patients (75.8%). Recanalization was successful (TICI score 2b or 3) in 23 of 26 (88.5%) patients with posterior circulation occlusion and in 23 of 36 (63.9%) patients with anterior circulation occlusion. NIHSS improved by more than 10 points for 15 of 59 patients with initial NIHSS over 10. MRS was 0-2 in 25 of 62 patients (40.3%). Overall, 23 patients out of 62 died (37%). No complications related to the Solitaire device occurred. CONCLUSION: These results confirm that the Solitaire FR device is safe and effective in stand-alone thrombectomy.

The evolution of lung computed tomography findings in COVID-19 from 2020 to 2023: more signs of co-infection.

Significant changes were observed in the lung imaging of hospitalised COVID-19 patients from 2020 to 2023, with the emergence of more signs of co-infection https://bit.ly/3TaQlJ2.

Prevalence of major embolic findings and incidental findings on early cardiac CT in patients with suspected ischemic stroke.

PURPOSE: The purpose of this study was to assess the type and prevalence of stroke and non-stroke-related findings diagnosed on early cardiac computed tomography (CT) in patients with suspected stroke. The secondary objective was to assess the clinical consequences on the management of patients with non-stroke-related conditions identified by early cardiac CT. MATERIALS AND METHODS: This single-center, retrospective, observational study included 1111 consecutive patients with suspected ischemic stroke between November 2018 and March 2020 who underwent cardiac CT examination in addition to the usual brain CT protocol (i.e., non-enhanced brain CT, perfusion brain CT when needed, aortic arch and supra-aortic CT angiography, and post contrast brain CT). There were 562 women and 549 men with a median age of 74 years (range: 60-85 years). Of these, 415 (415/1111; 37.4%) patients had ischemic stroke and 692 (692/1111; 62.3%) had no stroke. Cardiac CT examinations were retrospectively reviewed for cardiac CT findings at high embolic risk and clinically significant extracardiac incidental findings. RESULTS: Among 1111 included patients, 89 (89/1111; 8.0%) had a stroke-related condition identified on early cardiac CT. This was significantly more frequent in patients with ischemic stroke (66/415; 15.9%) by comparison with those without ischemic stroke (23/696; 3.3%) (P < 0.001), with 41 patients (41/415; 9.9%) diagnosed with left atrial thrombus. Cardiac CT revealed a clinically significant non-stroke-related finding in 173 patients (173/1111; 15.6%), including 17 pulmonary embolisms (1.5%), seven suspicious pulmonary lesions (0.6%), and three breast lesions suspected to be malignant (0.3%). Twenty out of 173 patients (20/173; 11.5%) with incidental findings on early cardiac CT had a change in their management. CONCLUSION: This study shows that adding early cardiac CT to brain CT during the acute phase of an ischemic stroke leads to a higher rate of etiological diagnoses and highlights the major interest of looking at the bigger picture.

Incremental value of the combined brain-cardiac CT protocol on prediction of atrial fibrillation after stroke.

Introduction: Atrial fibrillation (AF) is one of the most common causes of ischemic stroke. It is essential to target patients at highest risk of AF detected after stroke (AFDAS), who should benefit from a prolonged rhythm screening strategy. Cardiac-CT angiography (CCTA) was added to the stroke protocol used in our institution in 2018. We sought to assess, for AFDAS, the predictive value of atrial cardiopathy markers by a CCTA performed on admission for acute ischemic stroke. Patients and Methods: From November 2018 to October 2019, consecutive stroke patients with no history of AF were included. Let atrial volume (LAV), epicardial adipose tissue (EAT) attenuation and volume, and LAA characteristics were measured on CCTA. The primary endpoint was the presence of AFDAS at follow-up, diagnosed by continuous electrocardiographic monitoring, long-term external Holter monitoring during hospital stay, or implantable cardiac monitor (ICM). Results: Sixty of the 247 included patients developed AFDAS. Multivariable analysis shows independent predictors of AFDAS: age >80 years (HR 2.46; 95%CI (1.23-4.92), p = 0.011), indexed LAV >45 mL/m2 (HR 2.58; 95%CI (1.19-5.62), p = 0.017), EAT attenuation > -85HU (HR 2.16; 95%CI (1.13-4.15), p = 0.021) and LAA thrombus (HR 2.50; 95%CI (1.06-5.93), p = 0.037). Added consecutively to AFDAS prediction AS5F score (combining age and NIHSS >5), these markers had an incrementally better predictive value compared with the global Chi2 of the initial model (p = 0.001, 0.035, and 0.015 respectively). Discussion and conclusion: Adding CCTA to the acute stroke protocol to assess markers of atrial cardiopathy associated with AFDAS may help to better stratify the AF screening strategy, including the use of an ICM.

Deep Learning-Based Reconstruction vs. Iterative Reconstruction for Quality of Low-Dose Head-and-Neck CT Angiography with Different Tube-Voltage Protocols in Emergency-Department Patients.

Objective: To compare the image quality of computed tomography angiography of the supra-aortic arteries (CTSA) at different tube voltages in low doses settings with deep learning-based image reconstruction (DLR) vs. hybrid iterative reconstruction (H-IR). Methods: We retrospectively reviewed 102 patients who underwent CTSA systematically reconstructed with both DLR and H-IR. We assessed the image quality both quantitatively and qualitatively at 11 arterial segmental levels and 3 regional levels. Radiation-dose parameters were recorded and the effective dose was calculated. Eighty-six patients were eligible for analysis Of these patients, 27 were imaged with 120 kVp, 30 with 100 kVp, and 29 with 80 kVp. Results: The effective dose in 120 kVp, 100 kVp and 80 kVp was 1.5 ± 0.4 mSv, 1.1 ± 0.3 mSv and 0.68 ± 0.1 mSv, respectively (p < 0.01). Comparing 80 kVp + DLR vs. 120 and 100 kVp + H-IR CT scans, the mean overall arterial attenuation was about 64% and 34% higher (625.9 ± 118.5 HU vs. 382.3 ± 98.6 HU and 468 ± 118.5 HU; p < 0.01) without a significant difference in terms of image noise (17.7 ± 4.9 HU vs. 17.5 ± 5.2; p = 0.7 and 18.1 ± 5.4; p = 0.3) and signal-to-ratio increased by 59% and 33%, respectively (37.9 ± 12.3 vs. 23.8 ± 9.7 and 28.4 ± 12.5). This protocol also provided superior image quality in terms of qualitative parameters, compared to standard-kVp protocols with H-IR. Highest subjective image-quality grades for vascular segments close to the aorta were obtained with the 100 kVp + DLR protocol. Conclusions: DLR significantly reduced image noise and improved the overall image quality of CTSA with both low and standard tube voltages and at all vascular segments. CT that was acquired with 80 kVp and reconstructed with DLR yielded better overall image quality compared to higher kVp values with H-IR, while reducing the radiation dose by half, but it has limitations for arteries that are close to the aortic arch.

Acute myocardial infarction related to coronary artery embolism: A systematic cardiac and cerebral magnetic resonance imaging study.

BACKGROUND: Coronary artery embolism (CAE) is a rare, non-atherosclerotic cause of acute myocardial infarction (MI). Atrial fibrillation (AF) is the most frequent cause of CAE, and can be associated with multiple embolisms, particularly in the brain. AIMS: To characterize CAE-related myocardial injury, assess the proportion of cardiocerebral infarction and characterize brain injuries associated with dual embolism. METHODS: In this prospective study, patients with CAE-associated MI underwent (1) cardiac magnetic resonance imaging (MRI) to assess the extent of infarct transmurality and myocardial necrosis size and (2) brain MRI to assess the proportion of simultaneous cardiocerebral infarction. We screened 1401 consecutive patients with de novo acute MI from January 2019 to June 2021. CAE was diagnosed based on clinical, angiographic and diagnostic imaging criteria. RESULTS: Overall, 29/1401 patients presented with CAE (2.1%), of whom 21 underwent cardiac and cerebral MRI. Of these, nine (43%) had an ischaemic stroke, and AF was the leading cause of CAE in 14 patients (67%). Multiple CAE were common at coronary angiography (33%). Four patients (19%) had left atrial appendage thrombus - 4/9 patients (44%) with a stroke but 0/12 patients without a stroke. On cardiac MRI, the median (interquartile range) number of segments with acute infarction was 3 (0-11) in patients with stroke and 3 (1-6) in those without. Most acute ischaemic strokes (78%) were localized in the superficial sylvian territory and only 2/21 patients (10%) had stroke sequelae. CONCLUSION: MI-related to CAE was associated with infarctions of average size but multiple locations. Systematic brain MRI revealed that 33% of cases were associated with a stroke, which was generally asymptomatic. Further studies are required to better characterize the pathophysiology, clinical course and prognostic value of CAE. Moreover, optimal management strategies remain to be determined.

Remodeling technique for endovascular treatment of ruptured intracranial aneurysms had a higher rate of adequate postoperative occlusion than did conventional coil embolization with comparable safety.

PURPOSE: To compare the safety and efficacy of the remodeling technique with that of conventional coil embolization in a large multicenter series involving the endovascular treatment of ruptured intracranial aneurysms, the CLARITY study (Clinical and Anatomic Results in the Treatment of Ruptured Intracranial Aneurysms). MATERIALS AND METHODS: The institutional review board approved the CLARITY study, and written informed consent was obtained from all patients. A total of 768 patients (age range, 19-80 years; mean age ± standard deviation, 51.0 years ± 11.1) with 768 ruptured aneurysms were treated with either conventional coil embolization (608 patients, 79.2%) or the remodeling technique (160 patients, 20.8%). Patient and aneurysm characteristics, the rate of adverse events related to the treatment or initial intracranial hemorrhage, and patient outcome were compared between treatment groups by using the χ(2), Fisher exact, or Student t test. RESULTS: The overall rate of treatment-related complications, with or without clinical manifestations, was 17.4% (106 of 608 patients) with coil embolization and 16.9% (27 of 160 patients) with remodeling (P = .999). The difference in the rates of thromboembolic events, intraoperative rupture, and early repeat bleeding between the treatment groups was not statistically significant. The cumulative morbidity and mortality rate related to the treatment in the remodeling group (3.8%, six of 160 patients) was similar to that in the coil embolization group (5.1%, 31 of 608 patients) (P = .678). Likewise, the global cumulative morbidity and mortality rates related to both the treatment and the initial hemorrhage did not differ significantly between groups (16.2% [26 of 160 patients] with remodeling and 19.6% [119 of 608 patients] with coil embolization, P = .366). The rate of adequate aneurysm occlusion, however, was significantly higher in the remodeling group (94.9%, 150 of 158 aneurysms) than in the coil embolization group (88.7%, 534 of 602 aneurysms) (P = .017). CONCLUSION: In our large series of patients treated for ruptured aneurysms, the remodeling technique-despite being performed in aneurysms with unfavorable characteristics-was as safe as conventional coil embolization and more efficacious in terms of the rate of adequate postoperative occlusion. These results indicate that the remodeling technique can be routinely used in the treatment of ruptured aneurysms.