Is off-label thrombolysis safe and effective in a real-life primary stroke center? A retrospective analysis of data from a 5-year prospective database.

BACKGROUND: Intravenous thrombolysis (IVT) use for acute ischemic stroke (AIS) varies among countries, partly due to guidelines and product labeling changes. The study aim was to identify the characteristics of patients with AIS treated with off-label IVT and to determine its safety when performed in a primary stroke center (PSC). METHODS: This observational, single-center study included all consecutive patients admitted to Perpignan PSC for AIS and treated with IVT and patients transferred for EVT, between January 1, 2015 and December 31, 2019. Data of patients treated with IVT according to ("in-label group") or outside ("off-label") the initial guidelines and manufacturer's product specification were compared. Safety was assessed using symptomatic intracerebral hemorrhage (SIH) as the main adverse event. RESULTS: Among the 892 patients in the database (834 screened by MRI, 93.5%), 746 were treated by IVT: 185 (24.8%) "in-label" and 561 (75.2%) "off-label". In the "off-label" group, 316 (42.4% of the cohort) had a single criterion for "off-label" use, 197 (26.4%) had two, and 48 (6.4%) had three or more criteria, without any difference in IVT safety pattern among them. SIH rates were comparable between the "off-label" and "in-label" groups (2.7% vs. 1.1%, P=0.21); early neurological deterioration and systematic adverse event due to IVT treatment were similar in the 2 groups. "Off-label" patients had higher in-hospital (8.7% vs. 3.8%, P=0.05) and 3-month mortality rates (12.1% vs 5.4%, P<0.01), but this is explained by confounding factors as they were older (76 vs 67 years, P<0.0001) and more dependent (median modified Rankin scale score 0.4 vs 0.1, P<0.0001) at admission. CONCLUSIONS: "Off-label" thrombolysis for AIS seems to be safe and effective in the routine setting of a primary stroke center.

Endovascular treatment for acute ischemic stroke at a primary stroke center: First results of the Perpignan center.

INTRODUCTION: Converting a high-volume primary stroke center (PSC) into a stroke center that can perform emergency endovascular treatment (EVT) could reduce the time to thrombectomy. We report the first results of a newly established EVT facility at the Perpignan PSC and their comparison with the targets defined by the established guidelines. PATIENTS AND METHOD: For this comprehensive observational study, data of patients with acute ischemic stroke (AIS) due to proximal large vessel occlusion (LVO) and treated by EVT at the Perpignan PSC from December 5, 2019 to September 15, 2020 were extracted from an ongoing prospective database. RESULTS: During the study period, 37 patients underwent EVT at the Perpignan PSC. The median (range) symptom-onset to recanalization time was 262min (100-485min). The median (range) intra-hospital times were: 20min (2-58min) for door-to-imaging, 57min (30-155min) for imaging-to-puncture, 55min (15-180min) for puncture-to-recanalization, and 137min (59-319min) for door-to-recanalization. At 3 months post-AIS, the favorable outcome (modified Ranking Score: 0-2) rate was 50% and the mortality rate was 19.4%. These results are comparable to those of previous clinical trials, and meet the targets defined by the current consensus statements for EVT. DISCUSSION AND CONCLUSION: Our results show the feasibility and safety of EVT in a PSC for patients with AIS due to LVO. The implementation of this strategy may be important for shortening the time to thrombectomy.

Percutaneous thermal ablation of primary and secondary lung tumors: Comparison between microwave and radiofrequency ablation.

PURPOSE: The purpose of this study was to retrospectively compare microwave (MWA) and radiofrequency (RFA) ablation in the percutaneous treatment of primary and secondary lung tumors. MATERIAL AND METHODS: A total of 115 patients with a total of 160 lung tumors (primary, n=41; secondary, n=119) were retrospectively included. There were 56 men and 59 women with a mean age of 67.8±12.7 (SD) years (range: 42-89 years) who underwent either MWA (61 patients; 79 tumors) or RFA (54 patients; 81 tumors). The primary study endpoints were local recurrence during follow-up and the incidence of complications during and following thermal ablation. The MWA and RFA groups were compared in terms of treatment efficacy and complication rates. RESULTS: Demographics were similar in the two groups. Mean tumor diameter was smaller in RFA group (13.1±5.1 [SD] mm; range: 4-27mm) than in MWA group (17.1±8.3 [SD] mm; range: 5-36mm) (P<0.001). Ablation volumes at one month were 24.1±21.7 (SD) cm3 (range: 2-97.8 cm3) in RFA group and 30.2±35.9 (SD) cm3 (range: 1.9-243.8 cm3) in MWA group (P=0.195). During a mean overall follow-up duration of 488±407 (SD) days (range: 30-1508 days), 9/160 tumors (5.6%) developed local recurrence: six (6/79; 7.6%) in the RFA group and three (3/81; 3.7%) in the MWA group (P=0.32). Pneumothoraces were more frequent in the RFA group (32/79; 40.5%) than in the MWA group (20/81; 24.7%) (P=0.049). The mean length of hospital stay was 4.5±3.7 (SD) days (range: 1-25 days) in the RFA group and 4.7±4.6 (SD) days (range: 2-25 days) in the MWA group (P=0.76). CONCLUSIONS: MWA favorably compares with RFA and can be considered as an effective and safe thermal ablation technique for lung tumors, especially in situations where RFA has limited efficacy.

Results of a 1-year quality-improvement process to reduce door-to-needle time in acute ischemic stroke with MRI screening.

OBJECTIVE: To determine the effects of a 1-year quality-improvement (QI) process to reduce door-to-needle (DTN) time in a secondary general hospital in which multimodal MRI screening is used before tissue plasminogen activator (tPA) administration in patients with acute ischemic stroke (AIS). METHODS: The QI process was initiated in January 2015. Patients who received intravenous (iv) tPA<4.5h after AIS onset between 26 February 2015 to 25 February 2016 (during implementation of the QI process; the "2015 cohort") were identified (n=130), and their demographic and clinical characteristics and timing metrics compared with those of patients treated by iv tPA in 2014 (the "2014 cohort", n=135). RESULTS: Of the 130 patients in the 2015 cohort, 120 (92.3%) of them were screened by MRI. The median DTN time was significantly reduced by 30% (from 84min in 2014 to 59min; P<0.003), while the proportion of treated patients with a DTN time≤60min increased from 21% to 52% (P<0.0001). Demographic and baseline characteristics did not significantly differ between cohorts, and the improvement in DTN time was associated with better outcomes after discharge (patients with a 0-2 score on the modified rankin scale: 59% in the 2015 cohort vs 42.4% in the 2014 cohort; P<0.01). During the 1-year QI process, the median DTN time decreased by 15% (from 65min in the first trimester to 55min in the last trimester; P≤0.04) with a non-significant 1.5-fold increase in the proportion of treated patients with a DTN time≤60min (from 41% to 62%; P=0.09). CONCLUSION: It is feasible to deliver tPA to patients with AIS within 60min in a general hospital, using MRI as the routine screening modality, making this QI process to reduce DTN time widely applicable to other secondary general hospitals.

[Arterial thrombolysis and angioplasty in atheromatous basilar artery occlusion]. / Thrombolyse par voie artérielle et angioplastie dans l'occlusion athéromateuse du tronc basilaire.

Basilar occlusions treated with conventional therapy (anticoagulants or antiplatelets) have a poor outcome (80p. cent mortality). This unfavorable outcome may require a treatment within 6 hours by intra-arterial thrombolysis, sometimes followed by percutaneous transluminal angioplasty (PTA) in case of atherothrombotic occlusion due to a tight atherosclerotic stenosis. A 48 year-old patient, presented with left hemiparesis, left multimodal hypoesthesia, paralytic dysarthria. CT-scan showed a spontaneous hyperdensity of the basilar artery and arterial occclusion was confirmed by angiography, which showed an atherothrombotic occlusion involving the proximal part of the vessel. Intra-arterial thrombolysis began five hours after the onset with 0,25mg/kg of Rt-Pa (Actilyse((R))), given by bolus followed by 4 others bolus of 10mg. After a total dose of 60mg, arterial recanalization was obtained showing a tight atherosclerotic stenosis involving the proximal part of the basilar artery. PTA was performed 18 hours later with a ballon inflation at 6 atmospheres during 20 seconds. It allowed to decrease the stenosis from 80p. cent to 60p. cent. The patient recovered and MRI at D20 showed a small right lateral infarct involving the pons. Our study confirms the usefulness of intra-arterial thrombolysis in basilar artery occlusion. Consecutive PTA may be proposed in case of associated atherosclerotic stenosis, and the interest of PTA is further discussed.

[Amyloidoma of the central nervous system: CT and MR aspects]. / Amyloïdome primitif du cerveau: aspect TDM et IRM.

PURPOSE: To report a case of tumor like amyloïd formation (amyloidoma) of the brain with etiologic discussion. MATERIAL: and Methods. A 46-year-old female had a 7 year history of epilepsy. CT scan and MRI revealed two enhancing lesions in the white matter of the right temporal and frontal lobes. RESULTS: Stereotactic biopsy examination showed large amyloid deposits surrounded by sparsely scattered lymphocytes, few matures plasma cells, macrophages and rare foreign body type giant cells. The congophilic amyloid was found in the interstitium as well as within the walls of blood vessels with close connection to the choroid plexus. No significant abnormalities were noted on routine laboratory studies. DISCUSSION: Unlike all other types of amyloid, AL amyloid can produce both systemic amyloidosis and solitary amyloidoma. Amyloidomas are rare and usually found in the lung, skin, lower urinary tract. The location in the brain is extremely rare, with only 16 cases reported in the literature. All this cases as well as our example in the current study to some extent involved deep white matter. The association with choroid plexus is possible. The relatively indolent course of this amyloidomas is noted. Our study showed a presence of monotypic lambda producing plasma cells. Thus this lesion could be the result of monoclonal B cell neoplasm capable of terminal differentiation and the existence of AL amyloid producing low grade B lymphomas of the brain could be discussed.

[Neurotrichinosis: a case report with MRI evaluation]. / Neurotrichinose: à propos d'une observation documentée par IRM.

Neurological complications are rare in trichinosis. A case of trichinosis involving the central nervous system documented by MRI is presented. To our knowledge, only three cases of neurotrichinosis with MRI abnormalities have been already reported. The physiopathological mechanism are discussed (transport of the parasite through the blood-stream, immuno-allergic reaction or eosinophilic neurotoxic effect).

[Preoperative evaluation of translabyrinthine cholesteatomas by MRI]. / Evaluation préopératoire par IRM des cholestéatomes translabyrinthiques.

PURPOSE: Hearing preservation is one of the major goals of surgical resection of invasive cholesteatomas. Patients were prospectively evaluated using a 3D-CISS MR acquisition in order to improve the detection of perilymphatic fistulae. MATERIALS AND METHODS: 16 patients (10 M, 6 F) presenting with a primary (1 case) or a secondary (post-otitis) middle ear cholesteatoma extending to the osseous labyrinth (as defined by HR-CT) were evaluated at MR (1.5 T Vision, Siemens). The 3D-CISS sequence (TR: 12.25 ms, TE: 5.90 ms, flip angle: 70 degrees, slice thickness: 1 mm, matrix: 307 x 512, FOV: 200) allowed detection of invasion of the membranous labyrinth using a 3 level grading scale: 1) normal fluids, 2) focal and 3) diffuse obliteration of labyrinthine fluid. RESULTS: While CT showed a definite osseous labyrinthine fistula, the 3D-CISS sequence depicted either a normal membranous labyrinth (9 cases), a focal obliteration of the basal turn (1 case) or lateral semi-circular canal (3 cases) or a diffuse obliteration of the labyrinthine fluid (3 cases). Diffuse obliteration of the labyrinth fluid and 1 out 3 cases of focal obliteration of the semi-circular canal were found to have perilymphatic fistulae at surgery. None of the normal labyrinths were associated with perilymphatic fistula formation. CONCLUSION: The 3D-CISS sequence allows a comprehensive preoperative evaluation of the membranous labyrinth. Loss of signal from the labyrinthine fluid due to invasion or compression of the membranous structures accounts for the lack of specificity of the technique.

Spinal cord abscess in a heroin addict: case report.

Spinal cord abscesses are extremely rare, even in intravenous drug abusers. They usually have a poor prognosis unless diagnosed and treated promptly. MRI is the best imaging modality for diagnosis and follow-up. We report a 42-year-old man, an active intravenous drug user, HIV negative, who developed subacute tetraplegia from an intramedullary abscess caused by Staphylococcus aureus. Immediate decompressive surgery and antibiotic treatment led to progressive recovery.