Preventive treatment of unruptured intracranial aneurysms in adult patients with sickle cell anemia: A cohort study.

BACKGROUND AND PURPOSE: Intracranial aneurysms are frequent in patients with sickle cell anemia, while subarachnoid hemorrhage is a major cause of death and disability in young adult patients. Several characteristics, such as younger age and smaller size at rupture, may incline therapeutic decision towards exclusion treatments. Clinical guidelines on treatment of unruptured intracranial aneurysms in this population are still missing. We aimed to assess the safety and efficacy of the treatment of unruptured intracranial aneurysm in patients with sickle cell anemia, using an adapted hematological preparation regimen. PATIENTS AND METHODS: Adult patients with sickle cell anemia and treated unruptured aneurysms by endovascular therapy or neurosurgery were included in this retrospective cohort study. Treatment decision was reached after multi-disciplinary assessment. A pre-operative blood transfusion protocol was undertaken targeting a HbS below 30%. Demographic data, hematological preparation parameters and clinical and radiological outcomes were documented. RESULTS AND CONCLUSIONS: Twenty-five procedures were performed in 18 patients encompassing 19 aneurysms treated by embolization and 6 by surgery. Median age at treatment was 34 years-old and median aneurysm dome size was 4.4 mm. Immediate aneurysm exclusion rate was 85.7% after endovascular therapy and 100% after neurosurgery. Median follow-up was 6 months, with all patients being asymptomatic at last follow-up. Two transitory ischemic neurological deficits, as well as four cases of iodine-induced encephalopathy were identified after embolization. No complication occurred after surgery. Endovascular therapy by coiling and neurosurgical treatment of unruptured intracranial aneurysms appears to be safe in patients with sickle cell anemia and should be considered given the specific hemorrhagic risk observed in this population. A rigorous hematological preparation, associated with a dedicated peri­operative protocol and an adequate therapeutic strategy are essential prerequisites.

CTA-Based Patient-Tailored Femoral or Radial Frontline Access Reduces the Rate of Catheterization Failure in Chronic Subdural Hematoma Embolization.

BACKGROUND AND PURPOSE: Chronic subdural hematoma embolization, an apparently simple procedure, can prove to be challenging because of the advanced age of the target population. The aim of this study was to compare 2 arterial-access strategies, femoral versus patient-tailored CTA-based frontline access selection, in chronic subdural hematoma embolization procedures. MATERIALS AND METHODS: This was a monocentric retrospective study. From the March 15, 2018, to the February 14, 2019 (period 1), frontline femoral access was used. Between February 15, 2019, and March 30, 2020 (period 2), the choice of the frontline access, femoral or radial, was based on the CTA recommended as part of the preoperative work-up during both above-mentioned periods. The primary end point was the rate of catheterization failure. The secondary end points were the rate of access site conversion and fluoroscopy duration. RESULTS: During the study period, 124 patients (with 143 chronic subdural hematomas) underwent an embolization procedure (mean age, 74 [SD, 13] years). Forty-eight chronic subdural hematomas (43 patients) were included during period 1 and were compared with 95 chronic subdural hematomas (81 patients) during period 2. During the first period, 5/48 (10%) chronic subdural hematoma embolizations were aborted due to failed catheterization, significantly more than during period 2 (1/95, 1%; P = .009). The rates of femoral-to-radial (P = .55) and total conversion (P = .86) did not differ between the 2 periods. No significant difference was found regarding the duration of fluoroscopy (P = .62). CONCLUSIONS: A CTA-based patient-tailored choice of frontline arterial access reduces the rate of catheterization failure in chronic subdural hematoma embolization procedures.

Atypical Deep Cerebral Vein Thrombosis with Hemorrhagic Venous Infarction in a Patient Positive for COVID-19.

There is growing evidence that Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) has a neurotropic and neuroinvasive potential. In particular, neurologic complications associated with the infection by SARS-CoV-2 include strokes that may result from a dysregulated inflammatory response to the infection. We report an atypical deep cerebral vein thrombosis complicated with hemorrhagic venous infarction in a patient positive for SARS-CoV-2 with no risk factors for thrombosis.

Safe short circuit in cataract surgery: Incidence and risk factors for intraoperative medical action.

Cataract surgery has become the most frequent surgical procedure performed every year in Western countries. Perioperative patient circuit has to be adapted to the important medical needs and progress. Hence, a secure short circuit (SSC) for surgeries of the anterior segment of the eye under topical anaesthesia was created. Patients included in the circuit are selected first by surgeons and answer a medical questionnaire, they do not have any preoperative evaluation by anaesthesiologist, are monitored during surgery by the surgical team and in case of problem an intraoperative medical action (IMA) can be performed. We conducted a retrospective observational incidence study of the occurrence of the IMA, followed by a case control study. The primary outcome was to identify risk factors of IMA among the patients' medical history. Out of 2744 screened patients, 1592 patients were included during the period of November 2015 to November 2017. The rate of IMA was 5%, 81% of them presenting with intraoperative high blood pressure (HBP). In the case control study part, stepwise regression analysis revealed that a history of HBP and insulin-dependent diabetes (IDD) was significantly correlated with IMA (respectively, adjusted odds ratio 1.7, P=0.005 and 2.6, P=0.002). The low incidence of IMA showed that the SSC is a safe tool thanks to a selection and an optimised and secure pathway. A history of HBP and IDD was significantly associated with the occurrence of IMA. Therefore, an optimisation of the perioperative period would be beneficial in these cases.

Outcomes of Acute Stroke Patients Requiring Mechanical Ventilation: Study Protocol for the SPICE Multicenter Prospective Observational Study.

BACKGROUND: Care pathways and long-term outcomes of acute stroke patients requiring mechanical ventilation have not been thoroughly studied. METHODS AND RESULTS: Stroke Prognosis in Intensive Care (SPICE) is a prospective multicenter cohort study which will be conducted in 34 intensive care units (ICUs) in the Paris, France area. Patients will be eligible if they meet all of the following inclusion criteria: (1) age of 18 years or older; (2) acute stroke (i.e., ischemic stroke, intracranial hemorrhage, or subarachnoid hemorrhage) diagnosed on neuroimaging; (3) ICU admission within 7 days before or after stroke onset; and (4) need for mechanical ventilation for a duration of at least 24 h. Patients will be excluded if they meet any of the following: (1) stroke of traumatic origin; (2) refusal to participate; and (3) privation of liberty by administrative or judicial decision. The primary endpoint is poor functional outcome at 1 year, defined by a score of 4 to 6 on the modified Rankin scale (mRS), indicating severe disability or death. Main secondary endpoints will include decisions to withhold or withdraw care, mRS scores at 3 and 6 months, and health-related quality of life at 1 year. CONCLUSIONS: The SPICE multicenter study will investigate 1-year outcomes, ethical issues, as well as care pathways of acute stroke patients requiring invasive ventilation in the ICU. Gathered data will delineate human resources and facilities needs for adequate management. The identification of prognostic factors at the acute phase will help to identify patients who may benefit from prolonged intensive care and rehabilitation. TRIAL REGISTRATION: NCT03335995.

Should posterior cerebral artery occlusions be recanalized? Insights from the Trevo Registry.

BACKGROUND AND PURPOSE: The purpose of this study was to evaluate the safety and effectiveness of mechanical thrombectomy (MT) in patients with acute ischaemic stroke related to isolated and primary posterior cerebral artery (PCA) occlusions amongst the patients enrolled in the multicentre post-market Trevo Registry. METHOD: Amongst the 2008 patients enrolled in the Trevo Registry with acute ischaemic stroke due to large vessel occlusion treated by MT, 22 patients (1.1%) [10 females (45.5%), mean age 66.2 ± 14.3 years (range 28-91)] had a PCA occlusion [17 P1 (77.3%) and five P2 occlusions (22.7%)]. Recanalization after the first Trevo (Stryker, Fremont, CA, USA) pass and at the end of the procedure was rated using the modified Thrombolysis in Cerebral Infarction (mTICI) score. Procedure-related complications (i.e. groin puncture complication, perforation, symptomatic haemorrhage, embolus in a new territory) were also recorded. The modified Rankin Scale at 90 days was assessed. RESULTS: Median National Institutes of Health Stroke Scale at admission was 14 (interquartile range 8-16). Stroke aetiology was cardio-embolic in 68.2% of cases. Half of the patients (11/22) received intravenous tissue plasminogen activator. 54.5% of the patients were treated under general anaesthesia. Reperfusion (i.e. mTICI 2b or 3) after first pass was obtained in 65% of cases. Final mTICI 2b-3 reperfusion was obtained in all cases. Only one (4.5%) procedure-related complication was recorded (puncture site) that resolved after surgery. At 90-day follow-up, modified Rankin Scale 0-2 was obtained in 59% of the patients and 9.1% died within the first 3 months after MT. CONCLUSION: Mechanical thrombectomy for PCA occlusions seems to be safe (<5% procedure-related complications) and effective. Larger repository datasets are needed.

Contribution of endobronchial ultrasound elastography to the characterization of mediastinal lymphadenopathy: A single-center, prospective, observational study.

BACKGROUND: Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a reliable technique providing high diagnostic yield in mediastinal lymphadenopathy. However, mediastinoscopy is sometimes necessary to eliminate false-negative results. Elastography is a recent technique that can be combined with EBUS to evaluate the elasticity and consequently the nature of a tissue. The primary objective was to evaluate the diagnostic performance of EBUS-TBNA combined with elastography for the assessment of mediastinal lymph nodes. METHODS: Single-center, prospective study in patients with mediastinal lymphadenopathy. EBUS-TBNA combined with elastography was performed in each patient. Several elastographic parameters were studied: colorimetric score, average elasticity, elasticity ratio, percentage of hard areas. The final diagnosis was that obtained by TBNA cytology, histology of a surgical biopsy, when performed, or follow-up CT and PET-CT at 6 months. RESULTS: Overall, 110 lymph nodes were examined in 87 patients: 44 were malignant according to TBNA. These nodes had significantly higher elasticity ratio, percentage of hard areas and colorimetric score and significantly lower average elasticity compared to benign nodes (P<0.001). With a negative predictive value of 100%, the cut-offs defined by receiver operating characteristic curves were 1.4 for elasticity ratio, 84.8 for average elasticity, 32.6 for percentage of hard areas and 3 for colorimetric score. No adverse events were observed. CONCLUSION: Endobronchial ultrasound elastography is a non-invasive technique that can contribute to prediction of the nature of lymph nodes by distinguishing malignant from benign nodes. Although EBUS cannot replace histological examination, elastography can provide reliable complementary information when combined with EBUS.

Clinical Impact of Flat Panel Volume CT Angiography in Evaluating the Accurate Intraoperative Deployment of Flow-Diverter Stents.

BACKGROUND AND PURPOSE: The deployment of flow-diverter stents may be difficult to analyse on regular DSA. The purpose of our study was to investigate the clinical impact of stent-dedicated flat panel volume CT angiography to evaluate intraoperatively the satisfactory deployment of flow-diverter stents. MATERIALS AND METHODS: From January 2009 to April 2015, 83 consecutive patients (mean age, 51 years; 62 women) were treated in our institution with flow-diverter stents. Eighty-seven aneurysms (82 unruptured, 5 ruptured; 77 anterior, 10 posterior circulation) were treated in these 83 patients (4 patients had 2 aneurysms, both treated by means of flow-diverter stents). One patient was treated for a traumatic carotid cavernous fistula. In 80% of the cases (68/85) a flat panel volume CT angiography was performed in the angiographic suite just after the flow-diverter stent deployment. Stent visualization was assessed by 2 independent reviewers. The clinical impact of stent malapposition was evaluated. RESULTS: Flow-diverter stent visualization was satisfactory in 73.5% of the cases. In 2 cases (2.9%) the flat panel volume CT angiography prompted the operator to perform an additional intrastent angioplasty for a condition that was previously underestimated. Four patients (4.7%) experienced acute thromboembolic complications; 3 others had delayed thromboembolic complications. Only 1 of these patients had thromboembolic complications (acute or delayed) related to stent misdeployment, which was easily managed intraoperatively with no clinical consequence. CONCLUSIONS: Flat panel volume CT angiography is an interesting tool to depict flow-diverter stent misdeployment and may encourage the operator to perform intrastent angioplasty (2.9% of the cases in our experience) to reduce the risks of thromboembolic complications.

Relation between acute and long-term cognitive decline after surgery: Influence of metabolic syndrome.

INTRODUCTION: The relationship between persistent postoperative cognitive decline and the more common acute variety remains unknown; using data acquired in preclinical studies of postoperative cognitive decline we attempted to characterize this relationship. METHODS: Low capacity runner (LCR) rats, which have all the features of the metabolic syndrome, were compared postoperatively with high capacity runner (HCR) rats for memory, assessed by trace fear conditioning (TFC) on the 7th postoperative day, and learning and memory (probe trial [PT]) assessed by the Morris water-maze (MWM) at 3 months postoperatively. Rate of learning (AL) data from the MWM test, were estimated by non-linear mixed effects modeling. The individual rat's TFC result at postoperative day (POD) 7 was correlated with its AL and PT from the MWM data sets at postoperative day POD 90. RESULTS: A single exponential decay model best described AL in the MWM with LCR and surgery (LCR-SURG) being the only significant covariates; first order AL rate constant was 0.07 s(-1) in LCR-SURG and 0.16s(-1) in the remaining groups (p<0.05). TFC was significantly correlated with both AL (R=0.74; p<0.0001) and PT (R=0.49; p<0.01). CONCLUSION: Severity of memory decline at 1 week after surgery presaged long-lasting deteriorations in learning and memory.

[Inflammation and acute brain injuries in intensive care]. / Inflammation et lésions cérébrales aiguës en anesthésie réanimation.

Patients with acute brain injuries or susceptibility to post-surgery stroke are a major therapeutic challenge for intensive care and anaesthesiology medicine. The control of systemic stress involved in brain damage is necessary to reduce the frequency and severity of secondary brain lesions. Inflammation is known to be directly involved in acute brain lesions. The brain is a major participant in inflammation control through activation or inhibition effects. The exact mechanisms involved in deleterious effects following acute brain injuries due to inflammation are still unknown. This non-exhaustive study will expose the principal processes involved in inflammatory brain disease and explain the consequences of peripheral inflammation for the brain. Neuroprotection strategies in acute neuroinflammation will be reported with a focus on anaesthetic agents and the inflammation cascade.

IL-9/IL-9 receptor signaling selectively protects cortical neurons against developmental apoptosis.

In mammals, programmed cell death (PCD) is a central event during brain development. Trophic factors have been shown to prevent PCD in postmitotic neurons. Similarly, cytokines have neurotrophic effects involving regulation of neuronal survival. Nevertheless, neuronal PCD is only partially understood and host determinants are incompletely defined. The present study provides evidence that the cytokine interleukin-9 (IL-9) and its receptor specifically control PCD of neurons in the murine newborn neocortex. IL-9 antiapoptotic action appeared to be time-restricted to early postnatal stages as both ligand and receptor transcripts were mostly expressed in neocortex between postnatal days 0 and 10. This period corresponds to the physiological peak of apoptosis for postmitotic neurons in mouse neocortex. In vivo studies showed that IL-9/IL-9 receptor pathway inhibits apoptosis in the newborn neocortex. Furthermore, in vitro studies demonstrated that IL-9 and its receptor are mainly expressed in neurons. IL-9 effects were mediated by the activation of the JAK/STAT (janus kinase/signal transducer and activator of transcription) pathway, whereas nuclear factor-kappaB (NF-kappaB) or Erk pathways were not involved in mediating IL-9-induced inhibition of cell death. Finally, IL-9 reduced the expression of the mitochondrial pro-apoptotic factor Bax whereas Bcl-2 level was not significantly affected. Together, these data suggest that IL-9/IL-9 receptor signaling pathway represents a novel endogenous antiapoptotic mechanism for cortical neurons by controlling JAK/STAT and Bax levels.

Does the brain become heavier or lighter after trauma?

An uncontrolled rise in intracranial pressure is probably the most common cause of death in traumatic brain-injured patients. The intracranial pressure rise is often due to cerebral oedema. Diffusion-weighted imaging has been extensively used to study cerebral oedema formation after trauma in experimental studies. Nevertheless, this technology is difficult to perform at the acute phase, especially in unstable head trauma patients. For these reasons, a safe examination allowing us to better understand the pathophysiology of cerebral oedema formation in such patients would be of great interest. Radiological attenuation is linearly correlated with estimated specific gravity in human tissue. This property gives the opportunity to measure in vivo the volume, weight and specific gravity of any tissue by computed tomography. We recently developed a software package (BrainView) for Windows workstations, providing semi-automatic tools for brain analysis from DICOM images obtained from cerebral computed tomography. In this review, we will discuss the results of the in vivo analysis of brain weight, volume and specific gravity and consider the use of this software as a new technology to improve our knowledge of cerebral oedema formation after trauma and to evaluate the severity of traumatic brain-injured patients.