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

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

Mechanical thrombectomy in basilar artery occlusions: impact of first-line strategy as a function of the occlusion level.

BACKGROUND: Retrospective studies suggest the superiority of first-line contact aspiration (CA) thrombectomy over stent-retriever (SR) in basilar artery occlusions (BAO). We aimed to investigate the impact of first-line mechanical thrombectomy per the occlusion level, considering differences in stroke etiology prevalence between proximal and distal BAO. METHODS: A retrospective, multicentric analysis of the Endovascular Treatment in Ischemic Stroke Registry (ETIS) included consecutive BAO patients treated from January 2016 to May 2022. Patients were categorized into SR (±aspiration) and CA alone groups. Occlusion levels were determined through digital subtraction angiography. Favorable clinical outcome was defined as 90-day modified Rankin Scale (mRS) 0-3. RESULTS: A total of 380 patients were analyzed (251 CA alone, 129 SR±aspiration). Globally, first-line SR showed lower recanalization rates (89.1% vs 94.8%, OR=0.29, 95% CI 0.16 to 0.53; p<0.001) and worse clinical outcomes (mRS 0-3: 46.0% vs 52.2%, OR=0.62, 95% CI 0.44 to 0.87; p=0.006) compared with CA. In proximal occlusions, SR was significantly associated with poorer clinical outcomes (mRS 0-3: 20.9% vs 37.1%; OR=0.40, 95% CI 0.19 to 0.83; p=0.014) despite similar recanalization rates. Conversely, in distal occlusions there was no difference in clinical outcomes although recanalization rates were higher with CA (modified Thrombolysis in Cerebral Infarction score (mTICI 2b/3): 97.7% vs 91.7%; OR=0.17, 95% CI 0.05 to 0.66; p=0.01). CONCLUSIONS: In our BAO population, CA demonstrated better angiographic outcomes in middle and distal occlusions and better clinical outcomes in proximal occlusions. This translated into better angiographic and clinical results in the global study population. Clinical results were particularly influenced by the negative impact of SR on 90-day mRS, independently of recanalization rates in proximal BAO.

Secondary Neurologic Deterioration After Moderate Traumatic Brain Injury: Development of a Multivariable Prediction Model and Proposition of a Simple Triage Score.

BACKGROUND: Identifying patients at risk of secondary neurologic deterioration (SND) after moderate traumatic brain injury (moTBI) is a challenge, as such patients will need specific care. No simple scoring system has been evaluated to date. This study aimed to determine clinical and radiological factors associated with SND after moTBI and to propose a triage score. METHODS: All adults admitted in our academic trauma center between January 2016 and January 2019 for moTBI (Glasgow Coma Scale [GCS] score, 9-13) were eligible. SND during the first week was defined either by a decrease in GCS score of >2 points from the admission GCS in the absence of pharmacologic sedation or by a deterioration in neurologic status associated with an intervention, such as mechanical ventilation, sedation, osmotherapy, transfer to the intensive care unit (ICU), or neurosurgical intervention (for intracranial mass lesions or depressed skull fracture). Clinical, biological, and radiological independent predictors of SND were identified by logistic regression (LR). An internal validation was performed using a bootstrap technique. A weighted score was defined based on beta (ß) coefficients of the LR. RESULTS: A total of 142 patients were included. Forty-six patients (32%) showed SND, and 14-day mortality rate was 18.4%. Independent variables associated with SND were age above 60 years (odds ratio [OR], 3.45 [95% confidence interval {CI}, 1.45-8.48]; P = .005), brain frontal contusion (OR, 3.22 [95% CI, 1.31-8.49]; P = .01), prehospital or admission arterial hypotension (OR, 4.86 [95% CI, 2.03-12.60]; P = .006), and a Marshall computed tomography (CT) score of 6 (OR, 3.25 [95% CI, 1.31-8.20]; P = .01). The SND score was defined with a range from 0 to 10. The score included the following variables: age >60 years (3 points), prehospital or admission arterial hypotension (3 points), frontal contusion (2 points), and Marshall CT score of 6 (2 points). The score was able to detect patients at risk of SND, with an area under the receiver operating characteristic curve (AUC) of 0.73 (95% CI, 0.65-0.82). A score of 3 had a sensitivity of 85%, a specificity of 50%, a VPN of 87%, and a VPP of 44 % to predict SND. CONCLUSIONS: In this study, we demonstrate that moTBI patients have a significant risk of SND. A simple weighted score at hospital admission could be able to detect patients at risk of SND. The use of the score may enable optimization of care resources for these patients.

Energy consumption in MRI: Determinants and management options.

BACKGROUND: Energy consumption awareness is a known concern, and radiology departments have energy-intensive consuming machines. The means of energy consumption management in MRI scanners have yet to be evaluated. PURPOSE: To measure the MRI energy consumption and to evaluate the means to reduce it. MATERIALS AND METHODS: Data was retrieved for two MRI scanners through the hospital's automated energy consumption measurement software. After correlation with picture archiving and communication system (PACS) files, they were segmented by machine and mode (as follows: stand-by, idle and active) and analyzed. Active mode data for a specific brain MRI protocol have been isolated, and equivalent low energy consuming protocol was made. Both were performed on phantom and compared. Same protocol was performed on a phantom using 3.0T 16 and 32 head channels coils. Multiples sequences were acquired on phantom to evaluate power consumption. RESULTS: Stand-by mode accounted for 60 % of machine time and 40 % of energy consumption, active mode accounted for 20 % machine time and 40 % energy consumption, idle mode for 20 % imachine time and 20 % consumption. DWI and TOF sequences were the most consuming in our brain-MRI protocol. The low energy consuming protocol allowed a saving of approximately 10 % of energy consumption, which amounted for 0.20€ for each examination. This difference was mainly due to an energy consumption reduction of the DWI sequence. There were no difference in consumption between a 3.0T 16 and 32 channels head coils. Sequence's active power and duration (especially considering slice thickness) have to be taken into account when trying to optimize energy consumption. CONCLUSION: There are two key factors to consider when trying to reduce MRI scan energy consumption. Stand-by mode energy consumption has to be taken into account when choosing an MRI scan, as it can't be changed further on. Active mode energy consumption is dependent of the MRI protocols used, and can be reduced with sequences adaptation, which must take into account sequence's active power and duration, on top of image quality.

Rescue intracranial permanent stenting for refractory occlusion following thrombectomy: a propensity matched analysis.

BACKGROUND: Rescue intracranial stenting (RIS) can be used in refractory large vessel occlusion (LVO) after mechanical thrombectomy (MT). We aimed to assess the safety and efficacy of RIS versus a propensity matched sample of patients with persistent LVO. METHODS: We retrospectively analysed a multicenter retrospective pooled cohort of patients with anterior LVO (2015-2021) treated with MT, and identified patients with at least three passes and a modified Thrombolysis In Cerebral Infarction (mTICI) score of 0 to 2a. Propensity score matching was used to account for determinants of outcome in patients with or without RIS. The study outcomes included 3 months modified Rankin Scale (mRS) and symptomatic hemorrhagic transformation (HT). RESULTS: 420 patients with a refractory anterior occlusion were included, of which 101 were treated with RIS (mean age 69 years). Favorable outcome (mRS 0-2) was more frequent in patients with a patent stent at day 1 (53% vs 6%, P<0.001), which was independently associated with an early dual antiplatelet regimen (P<0.05). In the propensity matched sample, patients treated with RIS versus without RIS had similar rates of favorable outcomes (36.8% vs 30.3%, P=0.606). Patients with RIS showed a favorable shift in the overall mRS distributions (common adjusted OR 0.74, 95% CI 0.60 to 0.91, P=0.006). Symptomatic HT was marginally more frequent in the RIS group (9% vs 3%, P=0.07), and there was no difference in 3-month mortality. CONCLUSION: In selected patients with a refractory intracranial occlusion despite at least three thrombectomy passes, RIS may be associated with an overall shift towards more favorable clinical outcome, and no significant increase in the odds of symptomatic HT or death.

Assessment of using ultrasonography to teach abdominal and cervical anatomy in French medical curricula.

PURPOSE: The objective of this work was to assess, in a quantitative and qualitative way, the teaching of cervical and abdominal anatomy via ultrasound for medical students. METHODS: For several years, tutorials on the study of anatomy through use of ultrasound on the living organism have been given at the Medical School of Brest. These sessions have focused on cervical anatomy and abdominal anatomy. Students were invited to quantitatively assess these lessons by taking two tests containing questions on both cervical and abdominal anatomy and ultrasound technique: a pre-test administered at the beginning of the year and a post-test at the end of the year. In addition, a qualitative assessment was carried out at the end of the year. Ten statements were presented, and students were asked to indicate their agreement or disagreement to a four-point Likert scale. RESULTS: One hundred and twelve students answered all the questions on the pre-test with an average of 13.4 correct answers out of 20. Forty-eight students answered all the questions on the post-test with an average of 14.6/20. Twenty-six students who benefited from the courses gave positive feedback about the workshops on the qualitative assessment at the end of the year (median scores > = 3/4). CONCLUSION: The results of this work suggest that the use of ultrasound makes a positive contribution to the teaching of anatomy. The students interviewed think this type of tutorial should be an integral part of the anatomy curriculum at our university. In addition, this type of instruction can serve to introduce the use of ultrasound itself in a practical learning setting.

Endovascular Management of Brain Arteriovenous Malformations.

Due to the risk of cerebral hemorrhage, and its related morbidity-mortality, brain arteriovenous malformations (bAVMs) are a rare and potentially life-threatening disease. Despite this, there is only one randomized controlled trial on bAVM management, A Randomized trial of Unruptured Brain Arteriovenous malformations (ARUBA). The results of the ARUBA trial favor a noninterventional approach in the case of an unruptured bAVM; however, implementation of these findings is challenging in daily practice. Instead, management of bAVM relies on multidisciplinary discussions that lead to patient-specific strategies based on patient preferences, local expertise, and experience in referral centers. Considering the diverse patterns of presentation and numerous treatment modalities, implementing standardized guidelines in this context proves challenging, notwithstanding the recommendations or expert opinions offered. Endovascular treatment (EVT) of bAVM can be curative, or can serve as an adjunct treatment prior to surgery or radiosurgery ("pre-EVT"). EVT practice is in constant evolution (i.e., venous approach, combination with surgery during the same anesthesia, etc.). Liquid embolic agents such as ethylene vinyl alcohol (EVOH) copolymer and cyanoacrylates (CYA), and their method of injection to increase bAVM occlusion have also benefited from technical evolutions such as the use of adjunctive flow arrest techniques (mini balloons, pressure cooker technique, and multiple catheters). Further research is necessary to evaluate the advantages and disadvantages of EVT for bAVM.

Angioplasty, stenting, or both - rescue maneuvers and reperfusion after endovascular therapy for intracranial atherosclerosis-related occlusion.

PURPOSE: Data concerning reperfusion strategies of intracranial atherosclerosis-related occlusion (ICARO) and clinico-angiographic outcomes remain scarce, particularly in Caucasians. We aim to compare the reperfusion rate and functional outcome between reperfusion strategies in the setting of the ICARO. METHODS: Retrospective analysis of prospectively maintained endovascular thrombectomy (EVT) registries at three high-volume stroke centers were retrospectively analyzed for consecutive ICARO patients from January 2015 to December 2019. We defined ICARO as any fixed high-degree (> 70%) focal narrowing or stenosis of any degree with a perpetual tendency for reocclusion. We categorized reperfusion strategies into four groups: EVT [group 1], balloon angioplasty [(BAp), group 2], placement of self-expandable stents [(SES), group 3], and BAp combined with implantation of SES; or direct placement of balloon mounted stents (BMS) [(BAp-SES/BMS), group 4]. We evaluated the association with the successful reperfusion [mTICI 2b - 3] and favorable outcome [mRS 0-2] with logistic regression analysis. RESULTS: Out of 2550 EVT, 124 patients (median age, 70 (61-80) years; 76 men) with ICARO and 130 reperfusion attempts [36 EVT, 38 BAp, 17 SES, and 39 BAp + SES/BMS] were analyzed. SES implantation showed the highest frequency of post-procedural symptomatic intracranial hemorrhage [(18%, 3/17), p = .03]; however, we observed no significant differences in the mortality rate. Overall, we achieved successful reperfusion in 71% (92/130) and favorable outcomes in 42% (52/124) of the patients. BAp + SES/BMS was the only independent predictor of the final successful reperfusion [aOR, 4.488 (95% CI, 1.364-14.773); p = .01], which was significantly associated with the 90-day favorable outcome [aOR, 10.837 (95% CI, 3.609-32.541); p = < .001] after adjustment for confounding variables between the reperfusion strategies. CONCLUSION: Among patients with ICARO, the rescue angioplasty stenting effectively contributed to higher odds of successful reperfusion with no increased risk for intracranial hemorrhage.

Frontline thrombectomy strategy and outcome in acute basilar artery occlusion.

BACKGROUND: Novel thrombectomy strategies emanate expeditiously day-by-day counting on access system, clot retriever device, proximity to and integration with the thrombus, and microcatheter disengagement. Nonetheless, the relationship between native thrombectomy strategies and revascularization success remains to be evaluated in basilar artery occlusion (BAO). PURPOSE: To compare the safety and efficacy profile of key frontline thrombectomy strategies in BAO. METHODS: Retrospective analyses of prospectively maintained stroke registries at two comprehensive stroke centers were performed between January 2015 and December 2019. Patients with BAO selected after MR imaging were categorized into three groups based on the frontline thrombectomy strategy (contact aspiration (CA), stent retriever (SR), or combined (SR+CA)). Patients who experienced failure of clot retrieval followed by an interchanging strategy were categorized as a fourth (switch) group. Clinicoradiological features and procedural variables were compared. The primary outcome measure was the rate of complete revascularization (modified Thrombolysis in Cerebral Infarction (mTICI) grade 2c-3). Favorable outcome was defined as a 90 day modified Rankin Scale score of 0-2. RESULTS: Of 1823 patients, we included 128 (33 underwent CA, 35 SR, 35 SR +CA, and 25 switch techniques). Complete revascularization was achieved in 83/140 (59%) primarily analyzed patients. SR +CA was associated with higher odds of complete revascularization (adjusted OR 3.04, 95% CI 1.077 to 8.593, p=0.04) which was an independent predictor of favorable outcome (adjusted OR 2.73. 95% CI 1.152 to 6.458, p=0.02). No significant differences were observed for symptomatic intracranial hemorrhage, functional outcome, or mortality rate. CONCLUSION: Among BAO patients, the combined technique effectively contributed to complete revascularization that showed a 90 day favorable outcome with an equivalent complication rate after thrombectomy.

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

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

Complete recanalization predicts favorable outcome in patients with distal M2-M3 middle cerebral artery occlusions following endovascular thrombectomy.

BACKGROUND: - scanty articles illustrate the prognostic factors for favorable outcome after endovascular thrombectomy (EVT) in distal vessel occlusion (DMVO). Moreover, the current literature is diversified; conglomerating both primary, secondary, and anterior, posterior circulations embolic strokes in the same shell. PURPOSE: to identify the association between complete reperfusion and favorable outcome following EVT for DMVO in the middle cerebral artery (MCA) territory. METHODS: -we performed a retrospective analysis of prospectively maintained EVT registries at two comprehensive stroke centers between January 2015 and December 2019 for consecutive stroke patients with MCA-DMVO. DMVO was defined as an occlusion of distal M2 and M3 segments of the MCA. Only patients with primary isolated occlusions were included. A multivariate logistic regression was utilized to identify clinical and procedural-related factors associated with the 90-day favorable clinical outcome [defined as modified Rankin score (mRS) 0-2] after EVT. RESULTS: -Out of 1823 within the registries; 66 patients (median age was 72 (60-78) and 59% were males) with primary isolated DMVO of the MCA were eligible for inclusion in the current study. Complete reperfusion was achieved in 56% (37/66) of the patients with no difference among the reperfusion strategies while the favorable outcome was observed in 68% (45/66). In the multivariate analysis, final complete reperfusion [modified Thrombolysis In Cerebral Infarction (mTICI) score 2c-3] was significantly associated with favorable outcome [aOR=7.69; (95% CI 1.73-34.17); p=.01], while higher baseline NIHSS score [aOR=0.82; (95% CI 0.69-0.98); p=.03] and increased imaging to puncture interval [aOR=0.99; (95% CI 0.98, 1.00); p=.01] decreased the probability of the favorable outcome. CONCLUSION: according to our results, complete reperfusion was the most significant predictor of the favorable outcome, while higher baseline NIHSS and longer imaging to puncture interval decreased the probability of the favorable outcome.

Negative susceptibility vessel sign might be predictive of complete reperfusion in patients with acute basilar artery occlusion managed with thrombectomy.

OBJECTIVES: Negative susceptibility vessel sign (SVS) on pre-thrombectomy MRI has been linked to fibrin-rich thrombus and difficult retrieval in anterior ischemic stroke. However, its impact in posterior circulation-large vessel occlusion stroke (PC-LVOS) has not yet been elucidated. We aim to investigate the relationship of SVS parameters with stroke subtypes and their influence on angiographic and functional outcomes. METHODS: Prospective thrombectomy registries at two-comprehensive stroke centers were retrospectively reviewed between January 2015 and December 2019 for consecutive MRI-selected patients with PC-LVOS. Two groups were assigned by two independent readers, based on the presence or absence of the SVS (SVS +, SVS -) on MRI-GRE sequence. Multivariate logistic regression analysis was utilized to study primarily the impact of the SVS on the rate of complete recanalization (defined as mTICI 2c/3) at the final series following endovascular thrombectomy (EVT) and whether or not it might influence the efficacy of the frontline EVT strategy. Secondarily, we studied whether the absence of the SVS was predictive of the rate of 90-day functional independence (defined as mRS score < 2). Lastly, both qualitative (SVS +, SVS-) and quantitative (SVS length and diameter) parameters of the SVS were analyzed in association with the puncture to recanalization interval and various stroke etiological subtypes based on TOAST criteria. RESULTS: Among 1823 patients, 116 were qualified for final analysis (median age, 68 (59-75) years; male, 65%); SVS was detected in 62.9% (73/116) of cases. SVS length was an independent predictor of procedural duration (p = .01) whilst two-layered SVS was inversely associated with the atherosclerosis etiological subtype (aOR = 0.27, 95% CI 0.08-0.89; p = .03). Successful recanalization was achieved in 82% (60/73) vs. 86% (37/43), p = .80 of patients with SVS (+, -) respectively. Only in SVS (+), stentriever (RR 0.59 (0.4-0.88), p = .009), and contact-aspiration (RR 0.82 (0.7-0.96), p = .01) achieved a lower rate of successful recanalization compared to combined technique. SVS (-) was significantly associated with a higher rate of mTICI 2c/3 (aOR = 4.444; 95% CI 1.466-13.473; p = .008) and showed an indirect effect of 9% towards functional independence mediated by mTICI 2c/3. CONCLUSION: SVS parameters in PC-LVOS might predict stroke subtype and indirectly influence the functional outcome by virtue of complete recanalization. KEY POINTS: • Negative susceptibility vessel sign (SVS) in patients with basilar occlusion independently predict complete recanalization that indirectly instigated a 3-month favorable outcome following thrombectomy. • The longer the SVS, the higher likelihood of large artery atherosclerosis and the longer the thrombectomy procedure. • Two-layered SVS might be negatively associated with the presence of atherosclerosis, yet already-known limitations of TOAST classification and the absence of pathological analysis should be taken into consideration.

Outcomes Following Mechanical Thrombectomy in Different Etiological Subtypes of Acute Basilar Artery Occlusion : Stroke Etiology and Outcome after EVT in BAO.

BACKGROUND AND PURPOSE: Vertebrobasilar occlusion stroke (VBOS) is innately associated with high morbimortality despite advances in endovascular thrombectomy (EVT). Nonetheless, notable outcome dissimilarities exist between angiographically categorized stroke subtypes. We aim to evaluate potential differences concerning clinical angiographic outcomes among etiological subtypes of VBOS based on the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. METHODS: We retrospectively reviewed prospective EVT databases at two tertiary care stroke centers for consecutive patients with VBOS who had preinterventional MRI and underwent EVT from January 2015 to December 2019. We identified three groups: large artery atherosclerosis (LAA), cardioembolic stroke (CES), and embolic stroke of undetermined source (ESUS). The primary endpoints were the rates of poor outcome (identified as 90-day modified Rankin scale score of 3-6) and mortality, while the secondary endpoint included the rates of incomplete reperfusion (identified as modified treatment in cerebral infarction scale mTICI 0-2b), and periprocedural symptomatic intracranial hemorrhage. We evaluated the association between the etiology and clinical angiographic outcomes through stepwise logistic regression analysis. RESULTS: Out of 1823 patients, 139 (91 men; median age, 69 (61-76) years) with VBOS were qualified for the final analysis with incidence as follows: LAA (41%, n = 57), CES (35%, n = 48), and ESUS (24%, n = 34). Overall, incomplete reperfusion was realized in 41% (57/139) of the patients, a poor outcome in 65% (90/139), and mortality in 40% (55/139). Longer puncture to reperfusion interval (aOR 1.0182 [95% CI: 1.008-1.029]; p < 0.001) and utilization of combined aspiration-retriever technique (aOR 0.1998 [95% CI: 0.066-0.604]; p = 0.004) were associated with a greater likelihood of incomplete reperfusion (mTICI 0-2b) irrespective of the stroke etiology. After adjustment for confounding factors in the regression analysis, ESUS was an independent predictor of poor outcome (aOR 5.315 [95% CI: 1.646-17.163]; p = 0.005) and mortality (aOR 4.667 [95% CI: 1.883-11.564]; p < 0.001) at 90 days following EVT. CONCLUSION: The functional outcome following EVT for VBOS might depend on stroke etiology. According to our results, ESUS seems to be associated with the worst outcome, which needs further investigation to tailor the appropriate therapeutic plan.

Radiotherapy Target Volume Definition in Newly Diagnosed High-Grade Glioma Using 18F-FET PET Imaging and Multiparametric MRI: An Inter Observer Agreement Study.

Background: The aim of this prospective monocentric study was to assess the inter-observer agreement for tumor volume delineations by multiparametric MRI and 18-F-FET-PET/CT in newly diagnosed, untreated high-grade glioma (HGG) patients. Methods: Thirty patients HGG underwent O-(2-[18F]-fluoroethyl)-l-tyrosine(18F-FET) positron emission tomography (PET), and multiparametric MRI with computation of rCBV map and K2 map. Three nuclear physicians and three radiologists with different levels of experience delineated the 18-F-FET-PET/CT and 6 MRI sequences, respectively. Spatial similarity (Dice and Jaccard: DSC and JSC) and overlap (Overlap: OV) coefficients were calculated between the readers for each sequence. Results: DSC, JSC, and OV were high for 18F-FET PET/CT, T1-GD, and T2-FLAIR (>0.67). The Spearman correlation coefficient between readers was ≥0.6 for these sequences. Cross-comparison of similarity and overlap parameters showed significant differences for DSC and JSC between 18F-FET PET/CT and T2-FLAIR and for JSC between 18F-FET PET/CT and T1-GD with higher values for 18F-FET PET/CT. No significant difference was found between T1-GD and T2-FLAIR. rCBV, K2, b1000, and ADC showed correlation coefficients between readers <0.6. Conclusion: The interobserver agreements for tumor volume delineations were high for 18-F-FET-PET/CT, T1-GD, and T2-FLAIR. The DWI (b1000, ADC), rCBV, and K2-based sequences, as performed, did not seem sufficiently reproducible to be used in daily practice.

Model-Based Iterative Reconstruction (MBIR) for ASPECT Scoring in Acute Stroke Patients Selection: Comparison to rCBV and Follow-Up Imaging.

BACKGROUND: To compare a model-based iterative reconstruction (MBIR) versus a hybrid iterative reconstruction (HIR) for initial and final Alberta Stroke Program Early Ct Score (ASPECT) scoring in acute ischemic stroke (AIS). We hypothesized that MBIR designed for brain computed tomography (CT) could perform better than HIR for ASPECT scoring. METHODS: Among patients who had undergone CT perfusion for AIS between April 2018 and October 2019 with a follow-up imaging within 7 days, we designed a cohort of representative ASPECTS. Two readers assessed regional-cerebral-blood-volume-ASPECT (rCBV-ASPECTS) on the initial exam and final-ASPECTS on the follow-up non-contrast-CT (NCCT) in consensus. Four readers performed independently MBIR and HIR ASPECT scoring on baseline NCCT. RESULTS: In total, 294 hemispheres from 147 participants (average age of 69.59 ± 15.63 SD) were analyzed. Overall raters' agreement between rCBV-map and MBIR and HIR ranged from moderate to moderate (κ = 0.54 to κ = 0.57) with HIR and moderate to substantial (κ = 0.52 to κ = 0.74) with MBIR. Overall raters' agreement between follow-up imaging and HIR/MBIR ranged from moderate to moderate (κ = 0.55 to κ = 0.59) with HIR and moderate to almost perfect (κ = 0.48 to κ = 0.82) with MBIR. CONCLUSIONS: ASPECT scoring with MBIR more closely matched with initial and final infarct extent than classical HIR NCCT reconstruction.

Adenoid cystic carcinoma of jugular foramen.

Adenoid cystic carcinoma is a slowly growing malignant tumor with high local recurrence, perineural and vascular invasion. This tumor might arise from the glands of upper respiratory tract and oral cavity (eg, salivary or serous or mucous). Here we report the case of a 65-year-old woman who was referred to our unit for left retro-auricular radiating pain with trigger points and frontal headache since 6 months. There was no involvement of cranial nerves. Imaging screening using MRI, Positron emission tomography with 2-[fluorine-18] fluoro-2-deoxy-D-glucose, Gallium-68 DOTA-Phe1-Tyr3-Octreotide (68Ga DOTATOC) Positron emission tomography-CT suggested a suspicion of schwannoma or paraganglioma of the jugular foramen. However, the CT-guided biopsy revealed presence of adenoid cystic carcinoma. These warrants performing mandatory histological analysis combined with imaging screening suspicion of schwannoma or paraganglioma.

Safety and Efficacy of Cangrelor Among Three Antiplatelet Regimens During Stent-Assisted Endovascular Treatment of Unruptured Intracranial Aneurysm: A Single-Center Retrospective Study.

Introduction: Thromboembolic events represent the most frequent complications of endovascular treatment of unruptured intracranial aneurysm using stent-assisted coilling or flow diverter stents. Dual antiplatelet therapy has become the standard to prevent these but remains unstandardized. We present here a single center experience of 3 standardized antiplatelet regimens during brain aneurysm treatment, while emphasizing the use of the Cangrelor. Method: We retrospectively reviewed data from patients treated using stent-assisted coilling or flow diverter stents from 2016 to 2021. We collected and compared safety and efficacy data within 6 months of three groups of patients corresponding to three antiplatelet standardized regimens: group T with Ticagrelor, with preprocedural preparation; group E with Eptifibatide, injected during procedure; group C with Cangrelor, injected during procedure. Results: Data of 112 patients were analyzed and 76 belonged to group T, 21 to group E, and 15 to group C. Eleven events over the 14 recorded were adjudicated to be related to antiplatelets, their repartition did not differ between the 3 groups (p = 0.43). All symptomatic events (N = 8) were not distributed significantly differently between the 3 groups (p = 0.11) and asymptomatic events were also balanced (p = 1.00). Of these, 6 subjects had a change in the mRS score at 3-6 months. Thrombo-embolic events represented the most encountered events in the sample: 2 acute ischemic strokes were recorded in group E and 1 in group T; 1 transient ischemic stroke was noted in group E; 4 silent infarcts were found on control MRI (2 belonged to group T, 1 to group E and 1 to group C). Among 3 intracranial bleeding events, 1 was symptomatic in group C, 2 were asymptomatic in group T. On the control evaluation performed at 6 months, there was no significant difference on aneurysmal occlusion (p = 0.67). Conclusion: This single-center retrospective study compared 3 antiplatelet regimens, finding no significant difference in the safety and efficacy in the context of endovascular treatments of unruptured aneurysm using stent or flow diverters. This study adds data for the Cangrelor use and suggests its usefulness in the field of neuro-endovascular intervention. Randomized controlled studies are warranted to confirm these results.

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.