Should indications for WEB aneurysm treatment be enlarged? Report of a series of 20 patients with aneurysms in "atypical" locations for WEB treatment.

BACKGROUND AND PURPOSE: Flow disruption with the WEB device is an innovative technique for the endovascular treatment of wide neck bifurcation aneurysms. Good clinical practice trials have shown high safety of this treatment with good efficacy. Technical developments (single layer devices and smaller microcatheters) facilitate the treatment, potentially leading to enlargement of indications. This series is collecting aneurysms in "atypical" locations for WEB treatment and analyzing safety and efficacy of this treatment. MATERIALS AND METHODS: In each participating center, patients with aneurysms treated with WEB were prospectively included in a local database. Patients treated for aneurysms in "atypical" locations were extracted. Patient and aneurysm characteristics, intraoperative complications, and anatomical results at the end of the procedure and at last follow-up were collected and analyzed. RESULTS: Five French neurointerventional centers included 20 patients with 20 aneurysms in "atypical" locations for WEB treatment treated with WEB. Aneurysm locations were ICA carotid-ophthalmic in 9 aneurysms (45.0%), ICA posterior communicating in 4 (20.0%), Pericallosal artery in 5 (25.0%), and basilar artery between P1 and superior cerebellar artery in 2 (10.0%). There were no complications (thromboembolic or intraoperative rupture) in this series. At follow-up (mean: 7.4 months), adequate occlusion was obtained in 100.0% of aneurysms. CONCLUSIONS: This series confirms that it is possible to enlarge indications of WEB treatment to "atypical" locations with good safety and efficacy. These data have to be confirmed in large prospective series.

Neuropsychological outcome after a first symptomatic ischaemic stroke with 'good recovery'.

BACKGROUND: Neuropsychological impairment after stroke when no motor, sensory or language deficits are left remains understudied. The primary aim of this study was to assess neuropsychological outcome in a specific population of patients after a first symptomatic stroke without previous cognitive decline and with a good motor, linguistic, and functional recovery (i.e. 'good outcome'). The secondary aims were to identify the profile of this potential impairment and relations between brain lesions and neuropsychological outcome. METHODS: Sixty consecutive patients were evaluated by a comprehensive neuropsychological assessment focusing specifically on executive and attentional functions but also on memory 109 days, on average, after the infarct. Patients were compared with 40 healthy controls matched for age and education. RESULTS: Patients showed lower performance in every cognitive domain compared with controls. Along with an important executive deficit, patients were also impaired on attention and memory. Patients were not more depressed than controls, although they were more apathetic. We also found a significant positive correlation between cognitive impairment and pre-existing white matter brain lesions assessed by MRI. CONCLUSIONS: We report the first study examining the impact of a first stroke on cognition but also on psychiatric disorders in patients with good functional outcome. We found that patients considered as asymptomatic were, in fact, exhibiting a multidomain cognitive deficit that could impact return to life as before stroke.

Reliability of the Diagnosis of Cerebral Vasospasm Using Catheter Cerebral Angiography: A Systematic Review and Inter- and Intraobserver Study.

BACKGROUND AND PURPOSE: Conventional angiography is the benchmark examination to diagnose cerebral vasospasm, but there is limited evidence regarding its reliability. Our goals were the following: 1) to systematically review the literature on the reliability of the diagnosis of cerebral vasospasm using conventional angiography, and 2) to perform an agreement study among clinicians who perform endovascular treatment. MATERIALS AND METHODS: Articles reporting a classification system on the degree of cerebral vasospasm on conventional angiography were systematically searched, and agreement studies were identified. We assembled a portfolio of 221 cases of patients with subarachnoid hemorrhage and asked 17 raters with different backgrounds (radiology, neurosurgery, or neurology) and experience (junior ≤10 and senior >10 years) to independently evaluate cerebral vasospasm in 7 vessel segments using a 3-point scale and to evaluate, for each case, whether findings would justify endovascular treatment. Nine raters took part in the intraobserver reliability study. RESULTS: The systematic review showed a very heterogeneous literature, with 140 studies using 60 different nomenclatures and 21 different thresholds to define cerebral vasospasm, and 5 interobserver studies reporting a wide range of reliability (κ = 0.14-0.87). In our study, only senior raters reached substantial agreement (κ ≥ 0.6) on vasospasm of the supraclinoid ICA, M1, and basilar segments and only when assessments were dichotomized (presence or absence of ≥50% narrowing). Agreement on whether to proceed with endovascular management of vasospasm was only fair (κ ≤ 0.4). CONCLUSIONS: Research on cerebral vasospasm would benefit from standardization of definitions and thresholds. Dichotomized decisions by experienced readers are required for the reliable angiographic diagnosis of cerebral vasospasm.

Endovascular treatment of brain arteriovenous malformations using onyx: results of a prospective, multicenter study.

BACKGROUND AND PURPOSE: To evaluate the safety and efficacy of onyx for embolization of brain arteriovenous malformations (BAVM). METHODS: A prospective, multicenter study was conducted in France to evaluate embolization of BAVM with onyx. From May 2003 to March 2005, 50 patients (26 females, 24 males; mean age: 34.8 years, range: 16-64years) were included. Clinical presentation was haemorrhage in 22 patients (44.0%), seizures in 16 patients (32.0%), headaches in six patients (12.0%) and progressive neurological deficit in two cases (4.0%). Four patients were asymptomatic (8.0%). RESULTS: One hundred and forty-ninesessions of embolization were performed: one to eight sessions/patient with a mean of 3.0sessions. One hundred and sixteen sessions (77.9%) were performed with onyx, 20 sessions (13.4%) with glue and 13 sessions (8.7%) with onyx and glue. Symptomatic acute postembolization haemorrhage (APEH) was observed in four cases (8.0% per patient). At 1 month, morbidity and mortality related to the treatment were of 8% and 2%, respectively. Complete BAVM occlusion was obtained in 8.3% of cases. In the remaining cases, occlusion rate was between 99 and 80% in 56.3% of patients, 79 and 60% in 16.7%, and less than 60 in 18.7%. In case of incomplete occlusion, complementary treatment was performed by radiosurgery. CONCLUSION: Onyx is suitable for BAVM embolization with acceptable morbidity and mortality.

The Role of Hemodynamics in Intracranial Bifurcation Arteries after Aneurysm Treatment with Flow-Diverter Stents.

BACKGROUND AND PURPOSE: Treatment of intracranial bifurcation aneurysms with flow-diverter stents can lead to caliber changes of the distal vessels in a subacute phase. This study aims to evaluate whether local anatomy and flow disruption induced by flow-diverter stents are associated with vessel caliber changes in intracranial bifurcations. MATERIALS AND METHODS: Radiologic images and demographic data were acquired for 25 patients with bifurcation aneurysms treated with flow-diverter stents. Whisker plots and Mann-Whitney rank sum tests were used to evaluate if anatomic data and caliber changes could be linked. Symmetry/asymmetry were defined as diameter ratio 1 = symmetric and diameter ratio <1 = asymmetric. Computational fluid dynamics was performed on idealized and patient-specific anatomies to evaluate flow changes induced by flow-diverter stents in the jailed vessel. RESULTS: Statistical analysis identified a marked correspondence between asymmetric bifurcation and caliber change. Symmetry ratios were lower for cases showing narrowing or subacute occlusion (medium daughter vessel diameter ratio = 0.59) compared with cases with posttreatment caliber conservation (medium daughter vessel diameter ratio = 0.95). Computational fluid dynamics analysis in idealized and patient-specific anatomies showed that wall shear stress in the jailed vessel was more affected when flow-diverter stents were deployed in asymmetric bifurcations (diameter ratio <0.65) and less affected when deployed in symmetric anatomies (diameter ratio ∼1.00). CONCLUSIONS: Anatomic data analysis showed statistically significant correspondence between caliber changes and bifurcation asymmetry characterized by diameter ratio <0.7 (P < .001). Similarly, computational fluid dynamics results showed the highest impact on hemodynamics when flow-diverter stents are deployed in asymmetric bifurcations (diameter ratio <0.65) with noticeable changes on wall sheer stress fields. Further research and clinical validation are necessary to identify all elements involved in vessel caliber changes after flow-diverter stent procedures.

Safety and Efficacy of Aneurysm Treatment with the WEB: Results of the WEBCAST 2 Study.

BACKGROUND AND PURPOSE: Flow disruption with the Woven EndoBridge (WEB) device is an innovative technique for the endovascular treatment of wide-neck bifurcation aneurysms. The initial version of the device (WEB Double-Layer) was evaluated in the WEB Clinical Assessment of IntraSaccular Aneurysm Therapy (WEBCAST) study, whereas the French Observatory study evaluated both WEB Double-Layer and Single-Layer versions of the device. WEBCAST 2 was designed to evaluate the WEB Single-Layer with Enhanced Visualization. MATERIALS AND METHODS: Patients with wide-neck bifurcation aneurysms for which WEB treatment was possible were included. Clinical data including adverse events and clinical status at 1 month and 1 year were collected and analyzed. A core laboratory evaluated anatomic results at 1 year following the procedure. RESULTS: Ten European neurointerventional centers included 55 patients (38 women; 27-77 years of age; mean, 54.4 ± 10.0 years) with 55 aneurysms. Aneurysm locations were the middle cerebral artery in 25 aneurysms (45.5%), the anterior communicating artery in 16 (29.1%), the basilar artery in 9 (16.4%), and the internal carotid artery terminus in 5 (9.1%). Procedural morbidity and mortality at 1 month were, respectively, 1.8% (1/55 patients) and 0.0% (0/55 patients). Morbidity and mortality at 1 year were, respectively, 3.9% (2/51 patients) and 2.0% (1/51 patients). At 1 year, complete occlusion was observed in 27/50 aneurysms (54.0%); neck remnant, in 13/50 (26.0%); and aneurysm remnant, in 10/50 (20.0%) (adequate occlusion in 40/50, 80.0%). CONCLUSIONS: WEBCAST 2 confirms the high safety and efficacy of WEB aneurysm treatment demonstrated in the WEBCAST and French Observatory studies.

[X-linked adult onset adrenoleukodystrophy. A case report]. / Adrénoleucodystrophie liée à l'X, forme cérébrale de l'adulte: à propos d'un cas.

The authors report a case of an X-linked-adrenoleukodystrophy (ALD) in a young adult presenting with hemianopsia. Adult onset cerebral ALD is rare and represents only 3% of cases of ALD. The observation describes clinical data, as well as conventional and spectroscopic MR imaging and related value in prognosis evaluation.

Retrospective Analysis of Delayed Intraparenchymal Hemorrhage after Flow-Diverter Treatment: Presentation of a Retrospective Multicenter Trial.

BACKGROUND AND PURPOSE: Intracranial aneurysm treatment with flow diverters has shown satisfying results in terms of aneurysm occlusion, and while some cases of delayed intraparenchymal hemorrhage have been described, no systematic analysis of the risk factors affecting its occurrence has been conducted in a large series of patients. This retrospective analysis of delayed intraparenchymal hemorrhage after flow-diverter treatment is a multicenter, retrospective study using a large series of treated patients to analyze factors affecting the occurrence of delayed intraparenchymal hemorrhage. MATERIALS AND METHODS: Patients treated with flow diverters and presenting with delayed intraparenchymal hemorrhage were included from December 2007 to December 2014 in 7 participating centers in France. Patient and aneurysm characteristics were recorded as were characteristics of bleeding (size, lateralization, and time to bleed), treatment, and clinical outcome after 1, 3, and 6 months. RESULTS: Delayed intraparenchymal hemorrhage occurred in 11 patients between 1 and 21 days after the procedure. In 10 of these patients, hemorrhages were ipsilateral to the treated aneurysms. Five of the 11 underwent surgery, and 9 of the 11 had good clinical outcomes at 6 months (mRS ≤2). CONCLUSIONS: The pathogenesis of delayed intraparenchymal hemorrhage occurring after flow-diverter treatment remains unclear. The multidisciplinary management of delayed intraparenchymal hemorrhage yields a relatively low morbidity-mortality rate compared with the initial clinical presentation.

WEB Treatment of Intracranial Aneurysms: Clinical and Anatomic Results in the French Observatory.

BACKGROUND AND PURPOSE: Flow disruption with the WEB device is a new technique for the endovascular treatment of wide-neck bifurcation aneurysms. To obtain precise data regarding the safety and efficacy of this treatment with high-quality methodology, the prospective French Observatory study was conducted. Analysis of these data is presented, including 1-year follow-up. MATERIALS AND METHODS: Patients with bifurcation aneurysms for which WEB treatment was indicated were included in this prospective, multicenter Good Clinical Practice study. Clinical data, including adverse events and clinical status at 1 month and 1 year, were collected and independently analyzed by a medical monitor. An independent core laboratory evaluated the anatomic results at 1 year following the procedure. RESULTS: Ten French neurointerventional centers included 62 patients (39 women), 33-74 years of age (mean, 56.6 ± 9.80 years) with 63 aneurysms. Aneurysm locations were the middle cerebral artery in 32 aneurysms (50.8%), anterior communicating artery in 16 (25.4%), basilar artery in 9 (14.3%), and internal carotid artery terminus in 6 (9.5%). Morbidity and mortality at 1 month were, respectively, 3.2% (2/62 patients) and 0.0% (0/62). Morbidity and mortality (unrelated to the treatment) at 1 year were, respectively, 0.0% (0/59) and 3.4% (2/59 patients). At 1 year, complete occlusion was observed in 30/58 aneurysms (51.7%); neck remnant, in 16/58 aneurysms (27.6%); and aneurysm remnant, in 12/58 aneurysms (20.7%). CONCLUSIONS: This prospective French Observatory study showed very good safety of aneurysm treatment with the WEB, with a high rate of adequate aneurysm occlusion at 1 year (79.3%).

[Imaging of cerebral ischemia within first hours: computed tomography (CT)]. / Imagerie de l'ischémie cérébrale dans les premières heures: scanner.

Imaging of stroke has evolved with the development of stroke units and the CE approval of intravenous thrombolysis in the first three hours after stroke onset. The goal of imaging in the acute phase of stroke is: to make the diagnosis of stroke; to rule out other diagnosis (above all hemorrhagic strokes); to precise the location of the arterial occlusion; to assess the level of hypoperfusion; to evaluate the viability and reversibility of brain lesions; to understand the origin of the stroke by evaluating cervical arteries. Constraints of imaging in the acute phase of stroke are: the need to be performed as fast as possible to not delay IV thrombolysis (time is brain); machines must be available 24 hours a day, 7 days a week as close as possible to the stroke unit. The aim of imaging are: in routine practice to evaluate the likely benefits (provided by penumbra imaging) and risks of IV thrombolysis; in term of "evidence based medicine" to better evaluate new specific stroke therapies in randomized studies (IV thrombolysis between 3 to 4 hours, use of anti GpIIbIIIa, intra-arterial mechanical or chemical thrombolysis...). Magnetic resonance imaging is considered the goal standard of stroke imaging allowing to evaluate in a "one stop shopping" the level of arterial occlusion, hypoperfusion and brain viability. However, stroke management is a regional issue and performing MR in extreme emergency is almost impossible in all stroke units outside or even within university hospitals 24 hours a day. CT-perfusion and CT angiography are therefore an accurate alternative tool for acute stroke imaging. Multislice CT is indeed available in almost all stroke units. The examination is very time-saving and clinically relevant to make the decision for IV thrombolysis.

WEB Treatment of Intracranial Aneurysms: Feasibility, Complications, and 1-Month Safety Results with the WEB DL and WEB SL/SLS in the French Observatory.

BACKGROUND AND PURPOSE: Safety analyses in the French Observatory have shown that treatment of intracranial aneurysms by using flow disruption with the Woven EndoBridge Device (WEB) is safe, with low morbidity and no mortality. The objective of this study was to analyze treatment feasibility, complications, and safety results in patients treated with the Woven EndoBridge Device Dual-Layer (WEB DL) and Woven EndoBridge Device Single-Layer/Single-Layer Sphere (WEB SL/SLS) in the French Observatory. MATERIALS AND METHODS: Patients with bifurcation aneurysms were included in this prospective, multicenter good clinical practices study. A medical monitor independently analyzed procedural and clinical data. The study started with the WEB DL, and secondarily, the WEB SL/SLS was authorized in the study. RESULTS: Between November 2012 and January 2014, 10 French centers included 62 patients with 63 aneurysms. Thirty patients with 31 aneurysms were treated with the WEB DL, and 32 patients with 32 aneurysms, with the WEB SL/SLS. The percentage of anterior communicating artery aneurysms treated with WEB SL/SLS was significantly higher (37.5%) compared with WEB DL (12.9%) (P = .04). The WEB SL/SLS was more frequently used in aneurysms of <10 mm than the WEB DL (respectively, 96.9% and 67.7%; P = .002). Morbidity was similar in both groups (WEB DL, 3.3%; WEB SL/SLS, 3.1%), and mortality was 0.0% in both groups. CONCLUSIONS: This comparative study shows increased use of WEB treatment in ruptured, small, and anterior communicating artery aneurysms when using WEB SL/SLS. There was a trend toward fewer thromboembolic complications with the WEB SL/SLS. With both the WEB DL and WEB SL/SLS, the treatment was safe, with low morbidity and no mortality.

[Intracranial extension of extracranial vertebral artery dissections. A review of 16 cases]. / Débord intracrânien des dissections de l'artère vertébrale extracrânienne. Etude de 16 patients (17 cas de dissections).

INTRODUCTION: Vertebral artery (VA) dissections can involve both the extracranial and intracranial portions of the VA. Intradural extension explains the occurrence of subarachnoid hemorrage (SAH). We have studied the rate of this extension, the risk of associated SAH and the therapeutic repercussions at the acute stage. METHODS: From 1985 to 2001, 42 patients with a recent extracranial VA dissection were admitted to our department of neurology. When the diagnosis of extracranial VA dissection (involving the first, second or third segment of the VA) was established, we looked for an ipsilateral intracranial extension (involving the fourth segment of the VA and/or the basilar artery). VA dissections strictly located at the intracranial level were excluded. RESULTS: Among 42 patients with angiographically diagnosed extracranial VA dissections, 16 patients (38 percent) had an ipsilateral intradural extension. Two of them developed an inaugural and spontaneous SAH. After a mean follow-up of 4 Months under antithrombotic treatment, none of the patients has developed SAH or recurrent SAH. CONCLUSIONS: Because of the potential risk for spontaneous SAH at the acute stage, it seems important to exclude an intracranial extension. Lumbar puncture should be undertaken to exclude SAH before consideration of antithrombotic therapy.

WEB intrasaccular flow disruptor-prospective, multicenter experience in 83 patients with 85 aneurysms.

BACKGROUND AND PURPOSE: The safety and efficacy of WEB flow disruption have been analyzed in small, retrospective series. The object of this study was to evaluate the safety and efficacy of WEB flow disruption in a large, multicenter, prospectively collected population. MATERIALS AND METHODS: Data from all patients treated with the WEB-DL device between June 2011 and October 2013 in 11 French neurointerventional centers were prospectively collected and retrospectively analyzed. Complications occurring during and after treatment were analyzed as well as morbidity and mortality at 1 month. Aneurysm occlusion status at the last follow-up was analyzed. RESULTS: Eighty-three patients with 85 aneurysms were included in this series. Technical success was achieved in 77 patients with 79 aneurysms (92.9%). Periprocedural complications were observed in 9 patients (10.8%), leading to permanent neurologic deficits in 3 (3.9%). Morbidity and mortality at 1 month were 1.3% and 0.0%, respectively. Angiographic follow-up was performed for 65/79 aneurysms (82.3%) 3-24 months after treatment (mean, 5.3 months). Complete aneurysm occlusion was observed in 37/65 aneurysms (56.9%); neck remnant, in 23/65 (35.4%); and aneurysm remnant, in 5/65 (7.7%). CONCLUSIONS: In this large prospective series of patients, WEB flow disruption was a safe and efficient technique.

[Stereotactic and diagnostic imaging in radiosurgery]. / Imagerie stéréotaxique et diagnostique en radiochirurgie.

Constant progress in medical imaging and particularly magnetic resonance imaging has profound impact in planning for stereotactic radiosurgery and radiotherapy. The purpose of this paper is to discuss the integration of medical imaging modalities in the planning process. Principles of generic algorithms to calculate stereotactic coordinates are treated for tomographic imaging and digital substraction angiography, and their accuracies are analyzed in a review of the literature. The algorithmic foundations and performance of automatic intermodality co-registration methods are developed. Finally, the MRI sequences useful in planning and follow-up are discussed and the role of MR angiographic sequences compared to conventional X-ray angiography in the particular case of the arteriovenous malformation planning.

[Radiosurgery for brain arteriovenous malformations]. / Radiochirurgie stéréotaxique des malformations artérioveineuses cérébrales.

Radiosurgery as treatment for arteriovenous malformations has shown a good efficacy in reducing intracranial bleeding due to rupture. The choice of therapeutic modalities is based on evolutive risk and arteriovenous malformations volume, patient profile and risks stratification following therapeutic techniques (microsurgery, radiosurgery, embolization). Nidus size, arteriovenous malformations anatomical localization, prior embolization or bleeding, distributed dose are predictive factors for radiosurgery's good results and tolerance. This review article will highlight arteriovenous malformations radiosurgery indications and discuss recent irradiation alternatives for large arteriovenous malformation volumes.

Long-term follow-up of 1036 cerebral aneurysms treated by bare coils: a multicentric cohort treated between 1998 and 2003.

BACKGROUND AND PURPOSE: The endovascular treatment (EVT) of cerebral aneurysms has experienced a revolution since 1991 with the introduction of platinum coil technology. During the past 10 years, there has been significant study of the feasibility of this technique, and clinical results of EVT have been published. The long-term durability of Guglielmi detachable coil (GDC) embolization of cerebral aneurysms still remains unknown. The purpose of this study was to evaluate the stability of anatomic occlusion of aneurysms and to assess the rate of recanalization and retreatment of these aneurysms. MATERIALS AND METHODS: Between January 1998 and December 2003, 1036 aneurysms (804 ruptured and 232 nonruptured) were treated consecutively with GDC coils in 5 neuroradiology centers. Procedural feasibility, acute angiographic occlusion results, morbidity, and mortality associated with this technique were assessed. All patients were regularly followed by digital subtraction angiography and MR imaging each year after treatment. RESULTS: Initial acute angiographic results in 1036 aneurysms demonstrated total occlusion in 731 patients (70.5%), subtotal occlusion in 252 (24.3%), incomplete occlusion in 20 (1.9%), and failures in 33% (3.3%) aneurysms. A remodeling technique was used in 10%. A second procedure was performed for 72 aneurysms (7%). The total aneurysm follow-up time was 49,923 months (4160.25 aneurysm-years). The retreatment period was either in the months following initial treatment in aneurysms incompletely occluded or in years due to recanalization or de novo aneurysms. Fewer than 5 patients rebled during 10 years of follow-up. Long-term follow-up angiograms were obtained in 899 aneurysms, with 646 total, 230 subtotal, and 23 incomplete results. CONCLUSIONS: Long-term follow-up of cerebral aneurysms is necessary to depict recanalization. Only 7% of the aneurysms were retreated. Use of bare coils gives a good long-term level of occlusion.