Brush Sign on pre-treatment imaging is associated with good functional outcome in stroke patients treated with mechanical thrombectomy: A prospective monocentric study.

BACKGROUND: The Brush Sign (BrS) is a radiological biomarker (MRI) showing signal decrease of subependymal and deep medullary veins on paramagnetic-sensitive magnetic resonance sequences. Previous studies have shown controversial results regarding the prognostic value of BrS. We aimed to assess whether BrS on T2*-weighted sequences could predict functional prognosis in patients treated with mechanical thrombectomy (MT). METHODS: We included all consecutive patients with large artery occlusion related stroke in anterior circulation treated with MT between February 2020 and August 2022 at Reims University Hospital. Multivariable logistic regression models were used to investigate factors associated with BrS and its impact on outcomes. RESULTS: Of the 327 included patients, 124 (37,9%) had a BrS on baseline MRI. Mean age was 72 ± 16 years and 184 (56,2 %) were female. In univariate analysis, BrS was associated with a younger age (67 vs 74; p<0.001), a higher NIHSS score (16(10-20) vs 13(8-19); p = 0.047) history of diabetes (15.3% vs 26.1 %; p = 0.022) and a shorter onset to MRI time (145.5 (111.3-188.5) vs 162 (126-220) p = 0.008). In multivariate analyses, patients with a BrS were younger (OR:0.970 (0.951 - 0.989)), tend to have a higher NIHSS score at baseline (OR:1.046 (1.000 - 1.094) and were less likely to have diabetes (OR: 0.433; 0.214-0.879). The presence of BrS was independently associated with functional independence (OR: 2.234(1.158-4,505) at 3 months but not with mortality nor with symptomatic intracerebral hemorrhage. CONCLUSION: BrS on pre-treatment imaging could be considered as a biomarker of physiological adaptation to cerebral ischemia, allowing prolonged viability of brain tissue and might participate in the therapeutic decision.

Impact of Day 1 carotid patency on outcome in dissection-related tandem occlusions treated with mechanical thrombectomy.

BACKGROUND: The clinical benefit of mechanical thrombectomy(MT) for stroke patients with tandem occlusion is similar to that of isolated intracranial occlusions. However, the management of cervical internal carotid artery(ICA) occlusion during the MT, particularly in the setting of carotid dissection, remains controversial. We aimed to investigate the clinical impact of cervical ICA patency at day 1 on 3-month functional outcome. METHODS: We collected data from the Endovascular Treatment in Ischemic Stroke, a prospective national registry in 30 French centers performing MT between January 2015 and January 2022. Inclusion criteria were consecutive tandem occlusions related to cervical ICA dissection treated with MT. Tandem occlusions of other etiology, isolated cervical ICA occlusions without intracranial thrombus and patients without day-1 ICA imaging were excluded. Primary endpoint was the 3-month functional outcome. Secondary endpoints included intracranial hemorrhage(ICH), excellent outcome, mortality and early neurological improvement. A sensitivity analysis was performed in patients with intracranial favorable recanalization after MT. RESULTS: During the study period, 137 patients were included of which 89(65%) presented ICA patency at day 1. The odds of favorable outcome did not significantly differ between patients with patent and occluded ICA at day 1(68.7 vs 59.1%;aOR=1.30;95%CI 0.56-3.00,p=0.54). Excellent outcome, early neurological improvement, mortality and ICH were also comparable between groups. Sensitivity analysis showed similar results. CONCLUSION: ICA patency at day 1 in patients with tandem occlusions related to dissection did not seem to influence functional outcome. Endovascular recanalization of the cervical ICA including stenting might not be systematically required in this setting.

Endovascular Therapy or Medical Management Alone for Isolated Posterior Cerebral Artery Occlusion: A Multicenter Study.

BACKGROUND: Whether endovascular therapy (EVT) added on best medical management (BMM), as compared to BMM alone, is beneficial in acute ischemic stroke with isolated posterior cerebral artery occlusion is unknown. METHODS: We conducted a multicenter international observational study of consecutive stroke patients admitted within 6 hours from symptoms onset in 26 stroke centers with isolated occlusion of the first (P1) or second (P2) segment of the posterior cerebral artery and treated either with BMM+EVT or BMM alone. Propensity score with inverse probability of treatment weighting was used to account for baseline between-groups differences. The primary outcome was 3-month good functional outcome (modified Rankin Scale [mRS] score 0-2 or return to baseline modified Rankin Scale). Secondary outcomes were 3-month excellent recovery (modified Rankin Scale score 0-1), symptomatic intracranial hemorrhage, and early neurological deterioration. RESULTS: Overall, 752 patients were included (167 and 585 patients in the BMM+EVT and BMM alone groups, respectively). Median age was 74 (interquartile range, 63-82) years, 329 (44%) patients were female, median National Institutes of Health Stroke Scale was 6 (interquartile range 4-10), and occlusion site was P1 in 188 (25%) and P2 in 564 (75%) patients. Baseline clinical and radiological data were similar between the 2 groups following propensity score weighting. EVT was associated with a trend towards lower odds of good functional outcome (odds ratio, 0.81 [95% CI, 0.66-1.01]; P=0.06) and was not associated with excellent functional outcome (odds ratio, 1.17 [95% CI, 0.95-1.43]; P=0.15). EVT was associated with a higher risk of symptomatic intracranial hemorrhage (odds ratio, 2.51 [95% CI, 1.35-4.67]; P=0.004) and early neurological deterioration (odds ratio, 2.51 [95% CI, 1.64-3.84]; P<0.0001). CONCLUSIONS: In this observational study of patients with proximal posterior cerebral artery occlusion, EVT was not associated with good or excellent functional outcome as compared to BMM alone. However, EVT was associated with higher rates of symptomatic intracranial hemorrhage and early neurological deterioration. EVT should not be routinely recommended in this population, but randomization into a clinical trial is highly warranted.

"National survey for preliminary evaluation of neuroradiological protocols in patients with infective endocarditis".

OBJECTIVES: The aim of this study was to identify imaging protocols in patients with infective endocarditis through a nationwide survey. METHODS: An electronic evolutionary survey was sent to interventional Neuroradiologists among neuroradiological centers, under the aegis of the Société Française de Neuroradiologie. Among 33 contacted centers, 25 completed the survey (21 universitary hospitals and 4 peripheric hospitals). RESULTS: Most of the centers (88%) used systematic imaging screening in IE patients. MRI was the first imaging method used in 66% of cases, while CT was used in 44%. When no IIA was detectable in CT-scan screening, 6 (54,54%) stopped investigations, while 9 (81,81%) continued with MRI exploration in case of hemorrhage, ischemia or enhancement. Sulcal hemorrhage on MRI was an indication of complementary DSA in 25 centers (100%). Regarding IIA characterization, 12 centers (48%) used systematic DSA, whereas for 10 centers (40%), DSA was conditioned by hemorrhage or patient status. CONCLUSION: We highlighted large variations in Neuroimaging exploration and follow-up of IE patients in real-world practices. Expert guidelines able to standardize practices are warranted to improve the management of this serious and often misdiagnosed pathology.

Safety and effectiveness of the LVIS and LVIS Jr devices for the treatment of intracranial aneurysms: Final results of the LEPI multicenter cohort study.

BACKGROUND: The Low profile visualized intraluminal support (LVIS)/LVIS Jr is a self-expanding braiding stent for the treatment of intracranial aneurysm. This study is to determine the safety and effectiveness of the LVIS/LVIS Jr for the treatment of intracranial aneurysms in a real-world setting. METHODS: This prospective, observational, multicenter study enrolled patients with unruptured, ruptured and recanalized intracranial aneurysms treated with the LVIS stents, between February 2018 to December 2019. Primary endpoint was the cumulative morbidity and mortality rate (CMMR) assessed at 12 months follow-up (FU). RESULTS: A total of 130 patients were included (62.3 % women, mean age 55.9 ± 11.4) on an intention-to-treat basis. Four patients (3.1 %) had 2 target aneurysms; 134 total aneurysms were treated. The aneurysms were mainly located on the middle cerebral artery (41/134; 30.6 %) and the anterior communicating artery (31/134; 23.1 %). The CMMR at 1 year linked to the procedure and/or device was 4.6 % (6/130). The overall mortality was 1.5 % (2/130), none of these deaths adjudged as being linked to the procedure and/or device. All aneurysms (134/134, 100 %) were successfully treated with LVIS stent and/or other devices. At a mean FU of 16.8 months post-procedure, complete/nearly complete occlusion was achieved in 112 aneurysms (92.6 %), and only 3 patients (2.5 %) required aneurysm retreatment. CONCLUSION: This study provides evidence that the LVIS/LVIS Jr devices are safe and effective in the treatment of complex intracranial aneurysms, with very high rates of adequate occlusion at FU. These angiographic results are stable over time with an acceptable complication rate. TRIAL REGISTRATION: ClinicalTrial.gov under NCT03553771.

Susceptibility Vessel Sign in Relation With Time From Onset to Magnetic Resonance Imaging.

Background and Purpose: In acute ischemic stroke, the susceptibility vessel sign (SVS) on T2* MR-sequence witnesses the red blood cell content of the clot. Although clot composition strongly depends on its age in vitro, the relationship between SVS and time has not been studied. In this study, we evaluated whether the presence of SVS was related to the time from symptom onset. Methods: We retrospectively analyzed our institutional registry of patients with acute stroke between November 2007 and June 2018. We included patients with an ischemic stroke confirmed by diffusion-weighted imaging magnetic resonance imaging within 8 hours from symptom onset caused by M1 or M2 occlusion and with interpretable T2*-weighted images. We compared clinical and imaging variables among SVS+ and SVS− patients. Time from onset was split into tertiles. Independent markers of SVS+ were identified using multivariable logistic regression. The probability of being SVS+ given time from symptoms onset was modeled using Probit regression. Results: Among the 608 patients included, 433 (71.2%) were SVS+. The odds of being SVS+ increased with time from symptom onset (P trend=0.005). In the multivariable analysis, factors independently associated with a SVS+ were symptom onset to magnetic resonance imaging ([130­180 min] odds ratio [OR], 1.62 [95% CI, 1.03­2.53]; [>180 min] OR, 3.14 [95% CI, 1.92­5.12]), type of magnetic resonance imaging-scanner (OR, 2.83 [95% CI, 1.82­4.41]), cardioembolic cause (OR, 1.51 [95% CI, 1.02­2.24]), and baseline National Institutes of Health Stroke Scale (OR, 1.05 [95% CI, 1.01­1.08]). The probability of being SVS+ increased with time from symptom onset (P=0.004): around 60% at 1 hour, 70% at 3 hours, 80% at 6 hours, and 90% at 8 hours. Conclusions: In acute ischemic stroke, the presence of SVS depends on time from onset to imaging.

Surface-modified flow diverter p48-MW-HPC: Preliminary clinical experience in 28 patients treated in two centers.

BACKGROUND AND PURPOSE: Flow diversion is increasingly used for endovascular treatment of distal intracranial aneurysms and has led to the development of small diameter flow diverters such as p48-MW (phenox, Bochum, Germany). Use of flow diverters is limited, however, as patients require dual antiplatelet treatment to avoid thromboembolic complications. Hydrophilic Polymer Coating was developed to reduce platelet aggregation on the p48-MW (p48-MW-HPC). This study reports preliminary experience with p48-MW-HPC in aneurysm treatment in two centers. MATERIALS AND METHODS: Patients with ruptured, unruptured, and recanalized aneurysms treated with p48-MW-HPC were prospectively included and retrospectively analyzed for safety and efficacy. Safety was evaluated by analyzing intra- and postoperative complications as well as thromboembolic events depicted by DWI in the 72 h post-procedure. Efficacy was evaluated at 6 months based on aneurysm occlusion. RESULTS: From April 2019 to May 2020, 28 patients aged 25-82 years with 29 aneurysms were treated. Two thromboembolic events (7.1%) were reported with good clinical outcome. Final morbidity and mortality were both 0.0%. Post-operative DWI-MRI was depicting lesions in 70.0% of patients. Short-term (6 months) anatomical results were complete aneurysm occlusion in 87.0% of aneurysms, neck remnant in 8.7%, and aneurysm remnant in 4.3%. CONCLUSION: This preliminary clinical evaluation conducted in a relatively small sample size shows high feasibility (100.0%) of p48-MW-HPC aneurysm treatment, without morbidity or mortality, and high efficacy (complete occlusion in 90.0%). Additional larger comparative studies are needed to confirm these results and optimize perioperative antiplatelet treatment.

Intraoperative Complications of Endovascular Treatment of Intracranial Aneurysms with Coiling or Balloon-assisted Coiling in a Prospective Multicenter Cohort of 1088 Participants: Analysis of Recanalization after Endovascular Treatment of Intracranial Aneurysm (ARETA) Study.

Background Thromboembolic events and intraoperative rupture are the most frequent neurologic complications of intracranial aneurysm coiling. Their frequency has not been evaluated in recent series. Purpose To provide an analysis of complications, clinical outcome, and participant and aneurysm risk factors after aneurysm coiling or balloon-assisted coiling within the Analysis of Recanalization after Endovascular Treatment of Intracranial Aneurysm, or ARETA, cohort. Materials and Methods Sixteen neurointerventional departments prospectively enrolled participants treated for ruptured and unruptured aneurysms between December 2013 and May 2015. Participant demographics, aneurysm characteristics, and endovascular techniques were recorded. Data were analyzed from participants within the overall cohort treated with coiling or balloon-assisted coiling for a single aneurysm. Rates of neurologic complications were analyzed, and associated factors were studied by using univariable analyses (Student t test, χ2 test, or Fisher exact test, as appropriate) and multivariable analyses (logistic regressions). Results A total of 1088 participants (mean age ± standard deviation, 54 years ± 13; 715 women [65.7%]) were analyzed. Thromboembolic events and intraoperative rupture were reported in 113 of 1088 participants (10.4%) and 34 of 1088 participants (3.1%), respectively. Poor clinical outcome (defined as modified Rankin Scale score of 3-6) was reported in 29 of 113 participants (25.7%) with thromboembolic events and in 11 of 34 participants (32.4%) with intraoperative rupture (P = .44). Factors associated with thromboembolic events were female sex (odds ratio [OR], 1.7; 95% confidence interval [CI]: 1.1, 2.8; P = .02) and middle cerebral artery location (OR, 1.9; 95% CI: 1.2, 3.0; P = .008). Factors associated with intraoperative rupture were anterior communicating artery location (OR, 2.2; 95% CI: 1.1, 4.7; P = .03) and small aneurysm size (OR, 3.0; 95% CI: 1.5, 6.3; P = .003). Conclusion During aneurysm coiling or balloon-assisted coiling, thromboembolic events were more frequent than were intraoperative rupture. Both complications were associated with poor clinical outcome in a similar percentage of participants. Risk factors for thromboembolic events were female sex and middle cerebral artery location. Risk factors for intraoperative rupture were small aneurysm size and anterior cerebral or communicating artery location. © RSNA, 2020.

Patient and aneurysm factors associated with aneurysm rupture in the population of the ARETA study.

BACKGROUND AND PURPOSE: Identifying patients with intracranial aneurysms (IA) who have a high risk of rupture is critical to determine optimal management. ARETA (Analysis of Recanalization after Endovascular Treatment of intracranial Aneurysm) is a prospective, multicenter study, dedicated to evaluating endovascular treatment of IA. We aimed to identify factors associated with ruptured status, using this very large series of patients with ruptured and unruptured aneurysms. METHODS: Several analyses were conducted in the ARETA population: univariate and multivariate analyses in the whole population of patients and aneurysms to determine patient and aneurysm factors associated with aneurysm rupture, as well as a matched pair analysis (based on aneurysm size) conducted in the subgroup of patients with only one aneurysm to analyze the patient and aneurysm factors simultaneously. RESULTS: From December 2013 to May 2015, 1289 patients with 1761 aneurysms were included in ARETA. The multivariate analysis identified four patient factors: elevated blood pressure (EBP), no familial history, single IA, and active smoking, and four aneurysm factors: size≥5mm, narrow neck, irregular shape, and ACA/Acom location, associated with rupture status. In the matched pair analysis, five risk factors of rupture were identified: no familial history of aneurysm, narrow neck, active smoking, ACA/Acom location, and irregular shape. CONCLUSIONS: The most important patient factors associated with IA rupture are smoking and EBP. Given that size is a well-identified aneurysm factor, narrow neck also seems to be associated with aneurysm rupture. Further studies are needed to confirm this factor and determine underlying mechanisms. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01942512.

Mechanical thrombectomy practices in France: Exhaustive survey of centers and individual operators.

BACKGROUND AND PURPOSE: Mechanical thrombectomy (MT) has dramatically changed the landscape of stroke care as well as stroke care organization. Public health institutions are faced with the challenge of swiftly providing equal access to this high technical level procedure with rapidly broadening indications, and constantly developing techniques. The aim of this study was to present a current nationwide overview of technical MT practices in France as well as local organizations. MATERIALS AND METHODS: Thrombectomy capable French stroke centers, and physicians performing MT were invited to participate to a nationwide survey, disseminated through an existing trainee-led research network (the JENI-RC) under the aegis of the French Society of Neuroradiology. The survey was composed of 64 questions to collect both individual practices and general center-based information. RESULTS: All French centers (100%) answered the survey, and 74% (110/148) of active interventional neuroradiologists (INR) performing MT completed individual questionnaires. The mean number of INR per center performing MT was 3.7±1.85, and 85% of the centers were organized for 24/7 continuity of care. MRI was the most commonly used imaging modality for stroke diagnosis and patients' selection, and perfusion imaging was routinely available in 85% of the centers. Half of centers performed yearly between 100 and 200 MT. Anesthesiologic, and technical considerations are also developed in the manuscript. CONCLUSIONS: This nationwide survey highlights the impressive response to the challenge of reorganization of stroke care with regards to mechanical thrombectomy in France. Technical and management disparities remain. Most centers remain understaffed to properly function in the long term, but the inflow of INT trainees is substantial.

"Adaptative endovascular strategy to the CloT MRI in large intracranial vessel occlusion" (VECTOR): Study protocol of a randomized control trial.

A correlation between the susceptibility vessel sign (SVS) and red thrombi has been identified in MRI. We hypothesized that the Embotrap allow better retrieving of SVS+ thrombi. The AdaptatiVe Endovascular strategy to the CloT MRI in large intracranial vessel Occlusion (VECTOR) trial is a multicenter, prospective and randomized study designed to compare a first-line strategy combining Embotrap added to contact aspiration (CA) versus CA alone in patients with SVS+ occlusions.

Magnetic Resonance Imaging or Computed Tomography Before Treatment in Acute Ischemic Stroke.

Background and Purpose- The acute management of stroke patients requires a fast and efficient screening imaging modality. We compared workflow and functional outcome in acute ischemic stroke patients screened by magnetic resonance imaging (MRI) or computed tomography (CT) before treatment in the THRACE trial (Thrombectomie des Artères Cérébrales), with the emphasis on the duration of the imaging step. Methods- The THRACE randomized trial (June 2010 to February 2015) evaluated the efficacy of mechanical thrombectomy after intravenous tPA (tissue-type plasminogen activator) in ischemic stroke patients with proximal occlusion. The choice of screening imaging modality was left to each enrolling center. Differences between MRI and CT groups were assessed using univariable analysis and the impact of imaging modality on favorable 3-month functional outcome (modified Rankin Scale score of ≤2) was tested using multivariable logistic regression. Results- Four hundred one patients were included (25 centers), comprising 299 MRI-selected and 102 CT-selected patients. Median baseline National Institutes of Health Stroke Scale score was 18 in both groups. MRI scan duration (median [interquartile range]) was longer than CT (MRI: 13 minutes [10-16]; CT: 9 minutes [7-12]; P<0.001). Stroke-onset-to-imaging time (MRI: median 114 minutes [interquartile range, 89-138]; CT: 107 minutes [88-139]; P=0.19), onset-to-intravenous tPA time (MRI: 150 minutes [124-179]; CT: 150 minutes [123-180]; P=0.38) and onset-to-angiography-suite time (MRI: 200 minutes [170-250]; CT: 213 minutes [180-246]; P=0.57) did not differ between groups. Imaging modality was not significantly associated with functional outcome in the multivariable analysis. Conclusions- Although MRI scan duration is slightly longer than CT, MRI-based selection for acute ischemic stroke patients is accomplished within a timeframe similar to CT-based selection, without delaying treatment or impacting functional outcome. This should help to promote wider use of MRI, which has inherent imaging advantages over CT. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT01062698.

Pretreatment lesional volume impacts clinical outcome and thrombectomy efficacy.

OBJECTIVE: We aimed to characterize the association between pretreatment lesional volume measured on diffusion-weighted images and functional outcome, and estimate the impact on thrombectomy efficacy for ischemic stroke with anterior proximal intracranial arterial occlusion. METHODS: Anterior circulation ischemic stroke patients who had pretreatment diffusion-weighted imaging in the THRACE study were included. Lesional volume was semiautomatically segmented. Logistic regression was applied to model clinical outcome as a function of lesional volume. Outcomes included functional independence (modified Rankin Scale [mRS] 0-2), degree of disability (ordinal mRS 0-6), and mortality at 3 months. RESULTS: Of 298 included patients, with median lesional volume 17.2ml (interquartile range [IQR], 9.2-51.8) and median mRS 2 (IQR, 1-4), 51.0% achieved functional independence. Increased lesional volume was an independent predictor for a lower probability of functional independence (odds ratio [OR], 0.90 [95% confidence interval {CI}, 0.81-0.99] per 10ml; p < 0.001), a less favorable degree of disability (common OR, 0.86 [95% CI, 0.81-0.90] per 10ml; p < 0.001), and a higher mortality rate (OR, 1.21 [95% CI, 1.08-1.37] per 10ml; p < 0.001). For additional thrombectomy, the number of patients needed to treat to achieve functional independence in 1 patient increased with lesional volume (10 for a volume of 80ml; 15 for 135ml). No significant treatment-by-dichotomized volume interaction for functional independence and mortality was observed. INTERPRETATION: Pretreatment lesional volume is an independent predictor for functional outcome in acute ischemic stroke with proximal intracranial occlusion. The clinical benefit of adding mechanical thrombectomy to thrombolysis decreased with the increase of lesional volume. Ann Neurol 2018;83:178-185.

Validation of overestimation ratio and TL-SVS as imaging biomarker of cardioembolic stroke and time from onset to MRI.

OBJECTIVE: We aimed to determine in the "THRACE" trial, the clinical and MRI technical parameters associated with the two-layered susceptibility vessel sign (TL-SVS) and the overestimation ratio (overR). MATERIALS AND METHODS: Patients with pre-treatment brain gradient echo (GRE) sequence and an etiological work-up were identified. Two readers reviewed TL-SVS, i.e., a SVS with a linear low-intense signal core surrounded by a higher intensity and measured the overR as the width of SVS divided by the width of the artery. Binomial and ordinal logistic regression respectively tested the association between TL-SVS and quartiles of overR with patient characteristics, cardioembolic stroke (CES), time from onset to imaging, and GRE sequence parameters (inter slice gap, slice thickness, echo time, flip angle, voxel size, and field strength). RESULTS: Among 258 included patients, 102 patients were examined by 3 Tesla MRI and 156 by 1.5 Tesla MRI. Intra- and inter-reader agreements for quartiles of overR and TL-SVS were good to excellent. The median overR was 1.59 (IQR, 1.30 to 1.86). TL-SVS was present in 101 patients (39.2%, 95%CI, 33.1 to 45.1%). In multivariate analysis, only CES was associated with overR quartiles (OR, 1.83; 95%CI, 1.11 to 2.99), and every 60 min increase from onset to MRI time was associated with TL-SVS (OR, 1.72; 95%CI, 1.10 to 2.67). MRI technical parameters were statistically associated with neither overR nor TL-SVS. CONCLUSION: Independent of GRE sequence parameters, an increased overR was associated to CES, while the TL-SVS is independently related to a longer time from onset to MRI. KEY POINTS: • An imaging biomarker would be useful to predict the etiology of stroke in order to adapt secondary prevention of stroke. • The two-layered susceptibility vessel sign and the overestimation ratio are paramagnetic effect derived markers that vary according to the MRI machines and sequence parameters. • Independent of sequence parameters, an increased overestimation ratio was associated to cardioembolic stroke, while the two-layered susceptibility vessel sign is independently related to a longer time from onset to MRI.

Intracranial aneurysms treatment with Barricade coils: Safety and 1-year efficacy in a prospective, single-center series.

BACKGROUND AND PURPOSE: Barricade coils (Blockade/Balt, Montmorency, France) are bare platinum coils, electrically detached existing in different shapes, softnesses, and sizes. This series is analyzing the safety (procedural complications) and efficacy (anatomical results at 1-year) of these coils in a prospective, single-center series. MATERIALS AND METHODS: All patients with aneurysms treated with Barricade coils, without associated treatment (flow diverter, flow disrupter, or surgery) or parent artery occlusion were included. Peri-operative complications were evaluated. Anatomical results at 1-year were analyzed for patients that completed the 1-year digital subtraction angiographic follow-up and were independently evaluated by an expert neuroradiologist. RESULTS: During the study period (October 2013-October 2017), 132 patients (female: 88/132, 66.7%; median age: 50 years) with 141 aneurysms treated with Blockade coils were included. Aneurysm rupture, thromboembolic complication, and technical problems occurred in 9 aneurysms (6.3%), 8 aneurysms (5.6%), and 8 aneurysms (5.6%), respectively. Clinical consequences were variable; morbidity was reported in 5 patients (3.8%) and mortality in 2 patients (1.5%). Post-operatively aneurysm occlusion was complete in 117 aneurysms (83.0%), neck remnant in 16 aneurysms (11.3%), and aneurysm remnant in 8 aneurysms (5.7%). At 1-year aneurysm occlusion was complete in 53 aneurysms (51.5%), neck remnant in 34 aneurysms (33.0%), and aneurysm remnant in 16 aneurysms (15.5%). Retreatment in the year following the initial treatment was reported in 10 aneurysms (9.7%). CONCLUSION: Treatment of ruptured, unruptured, and recanalized aneurysms with Barricade coils is associated with a good safety and 1-year efficacy.

Comparison of two preventive dual antiplatelet regimens for unruptured intracranial aneurysm embolization with flow diverter/disrupter: A matched-cohort study comparing clopidogrel with ticagrelor.

PURPOSE: Standard dual antiplatelet therapy (DAPT) for complex aneurysms treated with flow diversion and flow disruption is acetylsalicylic acid (ASA) plus clopidogrel. However, clopidogrel resistance frequently occurs and can lead to thromboembolic events. Ticagrelor is an alternative not requiring platelet inhibition testing. We compared two DAPT regimens (ASA with clopidogrel or ticagrelor) on morbi-mortality, safety and efficacy of unruptured aneurysm embolization with flow diverter/disrupter. MATERIALS AND METHODS: This retrospective analysis of a 1:1 matched cohort compares patients treated with ASA + clopidogrel (March 2013-December 2015) vs. ASA + ticagrelor (January 2016-March 2017). No platelet inhibition testing was conducted. Patients matched for age (±10 years), type of treatment and aneurysm sac size ( ± 2 mm). Primary outcome measures were morbidity and mortality at 1-month; secondary outcomes were thromboembolic and hemorrhagic complications [on angiography and magnetic resonance imaging (MRI)] and groin complications. Outcomes were compared using bivariate analyses. RESULTS: Ninety patients fulfilled inclusion criteria, of which 80 remained after matching (40 per group). There was no statistical difference in 1-month morbidity between the ticagrelor and clopidogrel groups (2.5% vs. 10%, P = 0.36) and no deaths reported. We observed no significant differences between ticagrelor and clopidogrel groups in terms of angiographic thromboembolic complications (5% vs. 12.5%, P = 0.43), territorial infarction on DWI (2.5% vs. 7.5%, P = 0.61), angiographic (0% vs. 0%, P = 1) and MRI (5% vs 5%, P = 1) hemorrhagic complications, new microbleeds (57.5% vs. 40%, P = 0.12) and groin puncture complications (2.5% vs. 0%, P = 1). At three months, there was no delayed territorial infarction or hemorrhage in either group. CONCLUSIONS: Ticagrelor is safe and effective in replacing clopidogrel as DAPT for unruptured aneurysms.

Outcome After Reperfusion Therapies in Patients With Large Baseline Diffusion-Weighted Imaging Stroke Lesions: A THRACE Trial (Mechanical Thrombectomy After Intravenous Alteplase Versus Alteplase Alone After Stroke) Subgroup Analysis.

BACKGROUND AND PURPOSE: Stroke patients with large diffusion-weighted imaging (DWI) volumes are often excluded from reperfusion because of reckoned futility. In those with DWIvolume >70 mL, included in the THRACE trial (Mechanical Thrombectomy After Intravenous Alteplase Versus Alteplase Alone After Stroke), we report the associations between baseline parameters and outcome. METHODS: We examined 304 patients with anterior circulation stroke and pretreatment magnetic resonance imaging. Variables were extracted from the THRACE database, and DWI volumes were measured semiautomatically. RESULTS: Among 53 patients with DWIvolume >70 mL, 12 had favorable outcome (modified Rankin Scale score, ≤2) at 3 months; they had less coronary disease (0/12 versus 12/38; P=0.046) and less history of smoking (1/10 versus 12/31; P=0.013) than patients with modified Rankin Scale score >2. None of the 8 patients >75 years of age reached modified Rankin Scale score ≤2. Favorable outcome occurred in 12 of 37 M1-occluded patients but in 0 of 16 internal carotid-T/L-occluded patients (P=0.010). Favorable outcome was more frequent (6/13) when DWI lesion was limited to the superficial middle cerebral artery territory than when it extended to the deep middle cerebral artery territory (6/40; P=0.050). CONCLUSIONS: Stroke patients with DWI lesion >70 mL may benefit from reperfusion therapy, especially those with isolated M1 occlusion or ischemia restricted to the superficial middle cerebral artery territory. The benefit of treatment seems questionable for patients with carotid occlusion or lesion extending to the deep middle cerebral artery territory.

Follow-up of intracranial aneurysms treated with stent-assisted coiling: Comparison of contrast-enhanced MRA, time-of-flight MRA, and digital subtraction angiography.

BACKGROUND AND PURPOSE: Data about non-invasive follow-up of aneurysm after stent-assisted coiling is scarce. We aimed to compare time-of-flight (TOF) magnetic resonance angiography (MRA) (3D-TOF-MRA) and contrast-enhanced MRA (CE-MRA) at 3-Tesla, with digital subtraction angiography (DSA) for evaluating aneurysm occlusion and parent artery patency after stent-assisted coiling. MATERIALS AND METHODS: In this retrospective single-center study, patients were included if they had an intracranial aneurysm treated by stent-assisted coiling between March 2008 and June 2015, followed with both MRA sequences (3D-TOF-MRA and CE-MRA) at 3-Tesla and DSA, performed in an interval<48hours. RESULTS: Thirty-five aneurysms were included. Regarding aneurysm occlusion evaluation, agreement with DSA was better for CE-MRA (K=0.53) than 3D-TOF-MRA (K=0.28). Diagnostic accuracies for aneurysm remnant depiction were similar for 3D-TOF-MRA and CE-MRA (P=1). Both 3D-TOF-MRA (K=0.05) and CE-MRA (K=-0.04) were unable to detect pathological vessel compared to DSA, without difference in accuracy (P=0.68). For parent artery occlusion detection, agreement with DSA was substantial for 3D-TOF-MRA (K=0.64) and moderate for CE-MRA (K=0.45), with similar good diagnostic accuracies (P=1). CONCLUSION: After stent-assisted coiling treatment, 3D-TOF-MRA and CE-MRA demonstrated good accuracy to detect aneurysm remnant (but tended to overestimation). Although CE-MRA agreement with DSA was better, there was no statistical difference between 3D-TOF-MRA and CE-MRA accuracies. Both MRAs were unable to provide a precise evaluation of in-stent status but could detect parent vessel occlusion.

Endovascular treatment of intracranial aneurysms with Barricade coils: Feasibility, procedural safety, and immediate postoperative anatomical results.

BACKGROUND AND PURPOSE: The safety of bare platinum coils has been widely described in the literature. This study aimed to report the first series of intracranial aneurysms treated with Barricade bare platinum coils with a comprehensive evaluation of their procedural safety and postprocedural anatomical results. METHODS: Patients with intracranial aneurysms treated between October 2013 and December 2015 by simple coiling or balloon-assisted coiling with Barricade coils (Blockade Medical, Irvine, California, USA) were prospectively included in a database and retrospectively studied. For all included patients, the patient and aneurysm characteristics, procedural complications, technical issues, postoperative anatomical results, and one-month clinical outcome (modified Rankin Scale) were evaluated by an independent interventional neuroradiologist. RESULTS: Eighty-eight patients harboring 97 aneurysms were included. Procedural complications and technical issues were encountered in 17 and 5 patients (19.3 and 5.7%, respectively), but clinical worsening in only 2 patients (2.2%). There was no treatment-related mortality. After one month, morbidity (mRS≥1) was observed in 19 patients (21.8%), 17 related to subarachnoid hemorrhage (SAH) in patients with ruptured aneurysms (19.4%) and 2 related to thromboembolic events in patients with unruptured aneurysms (2.3%). Nine patients initially presenting with a ruptured aneurysm were deceased at 1 month as a consequence of SAH (10.2%). Adequate occlusion was observed postoperatively in 94.8% of the aneurysms (complete occlusion in 81.4% and residual neck in 13.4%). CONCLUSION: Endovascular treatment of intracranial aneurysms with Barricade coils is feasible and the demonstrated overall safety results are within the ranges found in the literature for other coils. Immediate anatomical results are satisfying.

How sustained is 24-hour diffusion-weighted imaging lesion reversal? Serial magnetic resonance imaging in a patient cohort thrombolyzed within 4.5 hours of stroke onset.

BACKGROUND AND PURPOSE: Here, we assessed how sustained is reversal of the acute diffusion lesion (RAD) observed 24 hours after intravenous thrombolysis, and the relationships between RAD fate and early neurological improvement. METHODS: We analyzed 155 consecutive patients thrombolyzed intravenously 152 minutes (median) after stroke onset and who underwent 3 MR sessions: 1 before and 2 after treatment (median times from onset, 25.6 and 54.3 hours, respectively). Using voxel-based analysis of diffusion-weighted imaging (DWI)1, DWI2, and DWI3 lesions on coregistered image data sets, we assessed the outcome of RAD voxels (hyperintense on DWI1 but not on DWI2) as transient or sustained on DWI3, and their relationships with early neurological improvement, defined as ΔNational Institutes of Health Stroke Scale ≥8 or National Institutes of Health Stroke Scale ≤1 at 24 hours. Tmax and apparent diffusion coefficient values were compared between sustained and transient RAD voxels. RESULTS: The median (interquartile range) baseline National Institutes of Health Stroke Scale and DWI1 lesion volume were 11 (7-18) mL and 15.6 (6.0-50.9) mL, respectively. The median (interquartile range) RAD volume on DWI2 was 2.8 (1.1-6.6) mL, of which 70% was sustained on DWI3. Sixteen (10.3%) patients had sustained RAD ≥10 mL. As compared with transient RAD voxels, sustained RAD voxels had nonsignificantly higher baseline apparent diffusion coefficient values (median [interquartile range], 793 [717-887] versus 777 [705-869]×10(-6) mm(2)·s (-1), respectively; P=0.08) and significantly better perfusion (Tmax, mean±SD, 6.3±3.2 versus 7.8±4.0 s; P<0.001). At variance with transient RAD, the volume of sustained RAD was associated with early neurological improvement in multivariate analysis (odds ratio, 1.08; 95% confidence interval, [1.01-1.17], per 1-mL increase; P=0.03). CONCLUSIONS: After thrombolysis, over two-thirds of the DWI lesion reversal captured on 24-hour follow-up MR is sustained. Sustained DWI lesion reversal volume is a strong imaging correlate of early neurological improvement.