Impact of the COVID-19 outbreak on acute stroke pathways - insights from the Alsace region in France.

BACKGROUND AND PURPOSE: To date, no study has attempted to quantify the impact of the COVID-19 outbreak on the incidence and treatment of acute stroke. METHODS: This was a retrospective review of acute stroke pathway parameters in all three stroke units in the Alsace region during the first month of the outbreak (1-31 March 2020), using the similar period from 2019 as a comparator. A secondary detailed analysis of all stroke alerts and stroke unit admissions was performed in the centre with the largest case volume. RESULTS: Compared to the same period in 2019, in March 2020 there were 39.6% fewer stroke alerts and 33.3% fewer acute revascularization treatments [40.9% less intravenous thrombolysis (IVT) and 27.6% less mechanical thrombectomy (MT)]. No marked variation was observed in the number of stroke unit admissions (-0.6%). The proportion of patients with acute revascularization treatments (IVT or MT) out of the total number of stroke unit admissions was significantly lower in March 2020 (21.3%) compared to 2019 (31.8%), P = 0.034. There were no significant differences in time delays or severity of clinical symptoms for patients treated by IVT or MT, nor in the distribution of final diagnosis amongst stroke alerts and stroke unit admissions. CONCLUSION: These results suggest that the overall incidence of stroke remained the same, but fewer patients presented within the therapeutic time window. Increased public awareness and corrective measures are needed to mitigate the deleterious effects of the COVID-19 outbreak on acute stroke care.

Postprocedural Antiplatelet Treatment after Emergent Carotid Stenting in Tandem Lesions Stroke: Impact on Stent Patency beyond Day 1.

BACKGROUND AND PURPOSE: Postprocedural dual-antiplatelet therapy is frequently withheld after emergent carotid stent placement during stroke thrombectomy. We aimed to assess whether antiplatelet regimen variations increase the risk of stent thrombosis beyond postprocedural day 1. MATERIALS AND METHODS: Retrospective review was undertaken of all consecutive thrombectomies for acute stroke with tandem lesions in the anterior circulation performed in a single comprehensive stroke center between January 9, 2011 and March 30, 2020. Patients were included if carotid stent patency was confirmed at day 1 postprocedure. The group of patients with continuous dual-antiplatelet therapy from day 1 was compared with the group of patients with absent/discontinued dual-antiplatelet therapy. RESULTS: Of a total of 109 tandem lesion thrombectomies, 96 patients had patent carotid stents at the end of the procedure. The early postprocedural stent thrombosis rate during the first 24 hours was 14/96 (14.5%). Of 82 patients with patent stents at day 1, in 28 (34.1%), dual-antiplatelet therapy was either not initiated at day 1 or was discontinued thereafter. After exclusion of cases without further controls of stent patency, there was no significant difference in the rate of subacute/late stent thrombosis between the 2 groups: 1/50 (2%) in patients with continuous dual-antiplatelet therapy versus 0/22 (0%) in patients with absent/discontinued dual-antiplatelet therapy (P = 1.000). In total, we observed 88 patient days without any antiplatelet treatment and 471 patient days with single antiplatelet treatment. CONCLUSIONS: Discontinuation of dual-antiplatelet therapy was not associated with an increased risk of stent thrombosis beyond postprocedural day 1. Further studies are warranted to better assess the additional benefit and optimal duration of dual-antiplatelet therapy after tandem lesion stroke thrombectomy.

A combined single-stage procedure to treat brain AVM.

Complete resection of brain arteriovenous malformation (AVM) is a surgical challenge, mainly due to risk of intraoperative rupture. The objective of this feasibility study was to analyze complete resection rate at 3 months and clinical outcome at 6 months after treatment of brain AVM by combined single-stage embolization and surgical resection. A retrospective observational study from July 2015 to February 2019 was conducted at the Department of Neurosurgery of Strasbourg University Hospital, France. Decision to treat was taken on the basis of history of AVM rupture, symptomatic AVM, or morphologic risk factors for rupture. Complete resection rate was assessed on postoperative cerebral subtraction angiography at 3 months and clinical outcome at 6 months was evaluated on the modified Rankin Scale (mRS). In the 16 patients treated for symptomatic brain AVM, the rate of complete resection was 75%, resection with residual shunt 18.7%, and incomplete resection with residual nidus 6.3%. Good clinical outcome (mRS=0 or 1) was achieved in 81.3% of patients at 6 months. The transfusion rate was 7.1%. There were procedural complications in 12.5% of patients but no intraoperative ruptures. This combined single-stage procedure allows extensive preoperative embolization of the AVM, facilitating surgical microdissection by identifying the dissection plane and perforating arteries and allowing the operator to work in close contact with the nidus without fear of intraoperative rupture.

Stroke Thrombectomy in Patients with COVID-19: Initial Experience in 13 Cases.

We performed a retrospective review in both comprehensive stroke units of a region affected early by the coronavirus disease 2019 (COVID-19) pandemic, between March 1 and April 26, 2020, including patients with COVID-19 who underwent mechanical thrombectomy for ischemic stroke. We identified 13 cases, representing 38.2% of 34 thrombectomies performed during this period. We observed increased mortality and a high incidence of thrombotic complications during hospitalization. Given the high rate of infected patients, systematic use of full personal protection measures seems justified.

Predictors and Clinical Impact of Delayed Stent Thrombosis after Thrombectomy for Acute Stroke with Tandem Lesions.

BACKGROUND AND PURPOSE: There are very few published data on the patency of carotid stents implanted during thrombectomies for tandem lesions in the anterior circulation. We aimed to communicate our experience of stenting in the acute setting with systematic follow-up of stent patency and discuss predictors and clinical repercussions of delayed stent thrombosis. MATERIALS AND METHODS: We performed a retrospective study of stroke thrombectomies in a single center between January 2009 and April 2018. Patient files were reviewed to extract patient characteristics, procedural details, imaging studies, and clinical information. Predictors of delayed stent thrombosis and clinical outcome at discharge were analyzed using univariate and multivariate analyses. RESULTS: We identified 81 patients treated for tandem lesions: 63 (77.7%) atheromas, 17 (20.9%) dissections, and 1 (1.2%) carotid web. TICI 2b-3 recanalization was achieved in 70 (86.4%) cases. Thirty-five patients (43.2%) were independent (mRS score ≤ 2) at discharge. Among 73 patients with intracranial recanalization and patent stents at the end of the procedure, delayed stent thrombosis was observed in 14 (19.1%). Among 59 patients with patent stents, 44 had further imaging controls (median, 105 days; range, 2-2407 days) and 1 (1.6%) had 50% in-stent stenosis with no retreatment. Stent occlusion rates were 11/39 (28.2%) for periprocedural aspirin treatment versus 3/34 (8.8%) for aspirin and clopidogrel (P = .04). Delayed stent thrombosis was independently associated with higher admission NIHSS scores (OR, 1.1; 95% CI, 1.01-1.28), diabetes (OR, 6.07; 95% CI, 1.2-30.6), and the presence of in-stent thrombus on the final angiographic run (OR, 6.2; 95% CI, 1.4-27.97). Delayed stent thrombosis (OR, 19.78; 95% CI, 2.78-296.83), higher admission NIHSS scores (OR, 1.27, 95% CI, 1.12-1.51), and symptomatic hemorrhagic transformation (OR, 23.65; 95% CI, 1.85-3478.94) were independent predictors of unfavorable clinical outcome at discharge. CONCLUSIONS: We observed a non-negligible rate of delayed stent thrombosis with significant negative impact on clinical outcome. Future studies should systematically measure and report stent patency rates.

Trisacryl gelatin microspheres for therapeutic embolization, I: development and in vitro evaluation.

PURPOSE: To develop a precisely calibrated, perfectly spherical, stainable, soft, and implantable but nonresorbable particulate embolization material. METHODS: Calibrated particles with a trisacryl gelatin polymer core and hydrophilic surface characteristics were obtained by reversed emulsion synthesis followed by application of a wet-sieving technique. Particles were suspended in saline, bottled, and sterilized. Quality control included analysis of particle diameters before and after sieving and of suspension sterility and apyrogenicity. Particles were subsequently tested to ascertain their compatibility with commercially available microcatheters. RESULTS: The resulting embolization material consisted of spherical, stainable microspheres of medical grade with diameters ranging from 130 microns to 1200 microns. Sieving the suspension produced particle groups of homogeneous size (accuracy, +/- 20-100 microns). At injection, the particles showed no tendency to build aggregates or to obstruct the microcatheters. CONCLUSION: Precisely calibrated and easy-to-use microspheres were obtained that satisfied the biomedical requirements for implantation as an embolization material.

Trisacryl gelatin microspheres for therapeutic embolization, II: preliminary clinical evaluation in tumors and arteriovenous malformations.

PURPOSE: To evaluate an embolic agent that is precisely calibrated, perfectly spherical in shape, and soft but nonresorbable for use in the embolization of vascular disease of the head, neck, and spine in humans. METHODS: We used supple, hydrophilic, and calibrated trisacryl gelatin microspheres 200, 400, 600, 800 and 1000 microns in diameter for superselective embolization in 105 patients (27 tumors, 14 facial arteriovenous malformations [AVMs], 37 spinal cord AVMs, 21 cerebral AVMs, and 6 miscellaneous diseases). We used particles in 200 to 600 microns in diameter for tumors and for facial AVMs, particles 400 to 600 microns in diameter for spinal cord AVMs, and particles over 1000 micros in diameter for cerebral AVMs. RESULTS: Delivery of the embolic material was easy: microspheres did not aggregate and catheters did not become obstructed by particles. It was possible to control the embolization through precise accounting of the amount of microspheres and matching of the particle size to the size of the pathologic vascular network. CONCLUSION: The microspheres are easy to use and allow precise control of the embolization procedure. Their physical characteristics make them a safe embolic agent.

Posterior lumbar epidural fat as a functional structure? Histologic specificities.

STUDY DESIGN: A topographic and histologic study was done to describe the location of the lumbar epidural fat and to find potential tissular specificities. OBJECTIVES: To search for possible histologic characteristics of posterior lumbar epidural fat, which so far has been described as semifluid tissue, and to determine whether posterior lumbar epidural fat is not a simple incidental tissue. SUMMARY OF BACKGROUND DATA: The lumbar epidural fat on two fetuses was studied. In adults, subcutaneous fat and posterior lumbar epidural fat were taken from seven corpses. The authors obtained 13 posterior lumbar epidural fat pads (two at L1-L2, three at L2-L3, six at L3-L4, and two at L4-L5) and four subcutaneous fat pads. METHODS: The authors studied abdominal axial histologic sections in two fetuses, histologic multiplanar sections in seven adults, and semithin sections in four adults of posterior lumbar epidural fat and subcutaneous fat. RESULTS: Fetal distribution of epidural fat was circumferential. Adult epidural fat distribution was limited to the posterior part of the vertebral canal and located at the disc level. Fascicles of connective tissue were less numerous and thinner in posterior lumbar epidural fat than in subcutaneous fat. Organized sliding spaces were found in the posterior epidural fat ped. CONCLUSIONS: Posterior lumbar epidural fat is not a simple incidental tissue and shows specific histologic features: sliding spaces and rarefaction of connective tissue that could explain semifluid features of the tissue. These characteristics suggest a functional role of posterior epidural fat in the lumbar spinal unit.

[Value and limitations of coronary artery imaging with the MRI navigator technique. Comparison with coronary angiography results in 37 patients]. / Intérêt et limites actuelles de l'imagerie des artères coronaires avec la technique d'IRM du navigateur. Comparaison avec les données coronaro-angiographiques chez 37 patients.

The introduction of a non-invasive method of imaging the coronary arteries would be a great advance in daily cardiological practice. The authors report their experience of imaging the coronary arteries with 1 Tesla MRI using the "navigator technique". Twenty-five sections 1.2 mm thick, focused on the proximal left coronary artery, were acquired with a 512 matrix, without injecting contrast during normal respiration with a tolerance on the portion of the right diaphragmatic cupola of 5 mm. Analysis of the coronary segments included in the field of view was performed on native sections after curve reconstruction and on targetedMIP series. A comparison of the results with respect to conventional coronary angiography showed a relatively limited visualisation of the proximal coronary segments because, in addition to the impossibility of carrying out the investigation in 24% of cases (faulty cardiac or respiratory synchronisation, poor signal/noise ratio), only 93% of the left main coronary and 75% of the proximal left anterior descending arteries could be visualised. In the analyzable segments, the diagnostic performances were modest with a global sensitivity of 60.8% and specificity of 91%. With the exception of the left main coronary artery, the sensitivities observed did not make MRI of the coronary arteries a rival to conventional coronary angiography. These limited performances may be explained by the lack of rapidity of the sequences of acquisition compared to the rapid motion of the structures under investigation whose dimensions are 5 to 10 times smaller than their amplitude of excursion. Technical developments are regularly accomplished in this domain, especially 3rd generation sequences in apnoea with injection of contrast media. At present, despite some results reported in the literature, angio-MRI of the coronary arteries cannot be used reliably to guide clinical decisions in coronary artery disease with the exception of some situations like congenital abnormalities of the coronary arteries, non-invasive follow-up of coronary aneurysms or analysis of the left main coronary artery.

[Posterior epidural adipose tissue and the narrow lumbar canal: replacement tissue or cause of impingement?]. / Graisse épidurale postérieure et canal lombaire étroit: tissu de remplissage ou acteur du conflit?

The role played by the epidural fat has been reported in lipomatosis induced by exogenous glucocorticoids and in severe obesity with lipomatosis. The role played by the "normal" posterior epidural fat (PEF) in lumbar canal stenosis (LCS) is less well known. The purpose of this study was to determine the part taken by PEF in LCS patients without endocrine disease, corticosteroid therapy or obesity. For this, we tried to specify the amount and distribution of PEF among the soft tissues in the vertebral canal, to demonstrate the involvement of PEF in dural sac compression, to describe the radiological features observed in cases of LCS and to look for associated morphological factors. The records of 30 LCS patients without exogenous or endogenous lipomatosis and in whom the essential pathogenic factor in 40 levels was PEF were reviewed retrospectively. At disc level, PEF was evaluated in the lower part of the mobile segment by means of CT or MRI axial sections cut through one or two spaces between L2-L3 and L4-L5. Measurements were made in 25 men (80%) and 6 women (20%) aged from 33 to 83 years (mean: 58 years). Most patients were suffering from lumbar pain, radiculopathy and/or neurogenic intermittent claudication. The data measured were: antero-posterior (AP) diameter of the dural sac, AP diameter of the bony lumbar canal (BLC), interligamentous distance (ILD) opposite the articular facets, and surface of PEF. The soft elements present on the midline--anterior epidural space (AES) and posterior epidural (PEF)--were expressed as percentage of the AP diameter of the bony lumbar canal.(ABSTRACT TRUNCATED AT 250 WORDS)

[Histologic characteristics of posterior lumbar epidural fatty tissue]. / Caractéristiques histologiques de la graisse épidurale lombaire postérieure.

The aim of this study was to describe the histological specificities of posterior lumbar epidural fat (PLEF) considered a "semi-fluid" tissue. We performed axial histological sections of posterior lumbar epidural fat through the abdomen of two foetuses, as well as histological sections on several planes in 11 adults. For comparison, we simultaneously cut sections in subcutaneous fat of adults (SCF). In the foetuses the epidural fat was arranged around the dural sac and extended along the entire lumbar spine, whereas in adults the epidural fat was discontinuous and the fat pads were located at intervertebral disc level, in a trianglular space with posterior apex, limited by the ligamenta flava laterally and by dural sac anteriorly. The PLEF was a homogeneous tissue in both size and shape and consisted of regular adipocytes and little connective tissue. In contrast, the SCF was made of adipocytes which varied in size and shape and were accompanied by numerous connective fibers (fibrous cones) subdividing the hypodermis into lobules. But the main specificity of the PLEF was the oriented empty spaces or slits found and observed in all samples with a special arrangement. These slits subdivided the fat into several layers enabling them to slide and could be regarded as "sliding spaces". They were never observed in the SCF samples. PLEF, therefore, is not a simple filling tissue. Its histological features (homogeneity, scarcity of connective tissue and oriented slits) explain the "semi-fluid" characteristic and confirm the specialization of this fat tissue. Its location at the level of the mobile segment of the lumbar spine suggests that it plays a role of sliding structure between the posterior surface of the thecal sac and the anterior surface of the vertebral arch.

[A diagnostic strategy in persistent hyperparathyroidism]. / Strategia diagnostica nell'iperparatiroidismo persistente.

BACKGROUND: Primary operations for hyperparathyroidism performed by experienced surgeons has a success rate of about 95% without any preoperative localization. After unsuccessful cervicotomy, localization studies must be performed in order to define the surgical approach. The objective of our retrospective studies was to determine the accuracy of non invasive and invasive localization studies in patients with persistent hyperparathyroidism. METHODS: The present reoperative series involved 7 patients with persistent hyperparathyroidism. Six patients came from a series of 140 operated on at the department of Prof. J. Marescaux from 1991 to 1993 (success rate of 95.7% in cervical exploration). Patient n. 7 came from another department. RESULTS: After negative initial cervicotomy, non invasive localization procedure are undertaken, but with a high incidence of false-positive results (9% to 75%). Among available invasive techniques, it has been chosen to sample blood from large veins in the neck and mediastinum for Parathyroid Hormone (1-84 PTH) determination and to realise angiography for locating parathyroid adenomas as well as for vein mapping. Their combination permitted to localize all lesions. CONCLUSIONS: The specificity of serum concentration of 1-84 PTH determination by catheterization of cervical and mediastinal veins (100%) combined to the sensitivity of angiography (82%) allowed to obtain good result in parathyroid localization in persistent hyperparathyroidism.

[Ureteral endometriosis. Role of medical imaging]. / Endométriose urétérale. Rôle de l'imagerie médicale.

Three cases of ureteral endometriosis are reviewed. Computed tomography and magnetic resonance imaging show the mass which causes ureteral obstruction. The role of imaging modalities is discussed.

[Contribution of the cervical scanner with injection in the diagnosis of vertebral artery dissection]. / Apport du scanner cervical avec injection dans le diagnostic de la dissection de l'artère vertébrale.

Vertebral artery dissection is the first diagnosis that must be suspected by a 40 years old patient with posterior fossa ischemic signs. CT data from six cases of spontaneous or post-traumatic vertebral artery dissections are reviewed. Cervical CT is performed after contrast medium injection from C7 to C0 with 1.5 mm thick slices and a 2 mm gap or with a spiral mod including millimetric reconstruction. The enhancement of the vascular wall, the hypodense hematoma surrounding a stenotic and eccentric lumen, and the enlargement of the artery are typical for a vertebral artery dissection. CT findings were correlated with angiography that is still considered to be the gold standard for this diagnosis. Among noninvasive technics including MRI, duplex scanning and CT, the latter appears very accurate to diagnose vertebral artery dissection.

[Primary leiomyosarcoma of the femoral vein. Therapeutic aspects]. / Léiomyosarcome primitif de la veine fémorale--aspects thérapeutiques.

Leiomyosarcomas are exceptional in peripheral veins. Clinical signs are not specific, secondary to effects of the tumoural mass. Computed tomography and MRI give a precise topographic diagnosis. Pathology examination on biopsy or surgical specimens establishes the histological diagnosis. Therapeutic management must take into account local tumour recurrence and metastasis. Surgical exeresis should be wider than the tumour's pseudocapsule to include micrometastases neighbouring the primary tumour. Post-operative radiotherapy (55 to 70 Gy) and chemotherapy should follow. With this management scheme, local disease is controlled in 85% of the cases with a 5-year follow-up. Local or metastatic extension usually occurs within the first 3 years. Management of venous sarcomas thus requires a multidisciplinary cooperation between the surgeon, the radiotherapists and the chemotherapist.

[Endovascular treatment of hemorrhagic renal angiomyolipoma with platinum microcoils]. / Traitement endovasculaire d'un angiomyolipome rénal hémorragique par microcoil de platine.

Haemorrhage is the major complication of renal angiomyolipoma and is classically treated surgically, but embolization constitutes an alternative treatment. Improvement of catheters and embolization materials now allows highly selective embolization. The authors present a case in which the use of a variable stiffness catheter and platinum microcoils allowed highly selective embolization of a haemorrhagic renal angiomyolipoma while preserving the functional renal parenchyma.

[Giant cell tumor of the C2 colonized by an aneurismal bone cyst. Report of case]. / Tumeur à cellules géantes de C2 colonisée par un kyste anévrismal. À propos d'un cas.

Giant cell tumor is colonized by aneurismal bone cyst in only 15% of cases and cervical localisation accounts for less than 1% of giant cell tumors. We are reporting a rare case of a C2 hypervascularized giant cell tumor colonized by an aneurismal bone cyst treated with an effective preoperative Onyx embolization followed by a full tumor resection. The patient experienced a moderate cervical spine injury 2 months prior admission followed by a progressive stiff neck and cervicalgia. CT and MRI identified a lytic lesion of the body and lateral masses of the C2 with encasement of both vertebral arteries. The angiography showed a hypervascularization of the lesion from the vertebral and external carotid arteries as well as a thrombosis of the V3 segment of the right vertebral artery at the C1 level. A posterior occipito-C3/C4 fixation and a tumor biopsy were performed. Histopathological examination concluded to a giant cell tumor colonized by an aneurismal bone cyst. Three weeks later, the patient developed a right upper extremity deficit. The MRI showed an increased C1-C2 stenosis and an increase of the hypervascularization. Three sessions of embolization by the onyx were performed. During surgery a near total tumor devascularisation was observed and a complete resection of the tumor was achieved through an anterolateral approach. Reconstruction consisted of a cementoplasty of the C2 body and odontoïd process with an anterior C3-prosthesis plate. The postoperative course was uneventful.

Is preoperative embolization a prerequisite for spinal metastases surgical management?

BACKGROUND: Preoperative embolization decreases the intraoperative risk of hemorrhage in spinal decompression surgery of hypervascular metastases such as renal cell carcinoma. There is no consensus concerning embolization in other metastases. The purpose of this study was to compare the intraoperative amount of blood loss in embolized versus non-embolized patients, seeking for differences depending on the primary tumor and the extent of surgery. PATIENTS AND METHODS: Ninety-three patients, average age 60.5 years, were operated. The origins of metastases were: 28 breast cancer (30.1%), 19 pulmonary carcinoma (20.4%), 16 renal cell carcinoma (17.2%), 30 other cancers (32.3%). Surgical procedures were: 52 thoracolumbar laminectomies with instrumentation, 29 thoracolumbar corpectomies or vertebrectomies, 12 cervical corpectomies. A preoperative microsphere embolization was performed in 35 patients. Blood loss was evaluated by: blood volume in surgical aspiration devices, number of transfused packed red blood cells units and hemoglobin variation during surgery. RESULTS: Renal metastases were systematically embolized. In the breast group, there was no significant difference (P>0.05) in blood loss between embolization versus non-embolization. In the pulmonary group and in other metastases, no difference was found either. The extent of surgery (corpectomy/vertebrectomy versus thoracolumbar instrumentation and cervical corpectomy) increased bleeding: breast 1775ml versus 778ml and 600ml respectively (P=0.048), pulmonary 2500ml versus 430ml and 180ml (P=0.020), renal 3346ml versus 1175ml and 780ml (P=0.036) and others 1550ml versus 474ml and 400ml (P=0.020). CONCLUSIONS: Embolization decreases the risk of hemorrhage in highly vascularized metastases such as renal cell carcinoma. A benefit of embolization was not found for metastases of breast or pulmonary tumors. As far as other metastases, thyroid carcinoma should be analyzed on a greater cohort. The extent of surgery remains an important risk factor for intraoperative bleeding. A preoperative angiogram should be carried out in all types of metastases prior to a thoracolumbar corpectomy or vertebrectomy to perform an embolization if the tumor is hypervascular. LEVEL OF EVIDENCE: Level IV, retrospective study.