Predictive factors of functional independence after optimal reperfusion in anterior circulation ischaemic stroke with indication for intravenous thrombolysis plus mechanical thrombectomy.

BACKGROUND AND PURPOSE: Intravenous thrombolysis plus mechanical thrombectomy (IVT + MT) is the best current management of acute stroke due to large-vessel occlusion and results in optimal reperfusion for most patients. Nevertheless, some of these patients do not subsequently achieve functional independence. The aim was to identify baseline factors associated with 3-month independence after optimal reperfusion and to validate a prediction model. METHODS: All consecutive patients with intracranial anterior large-vessel occlusion, with indication for IVT + MT and achieving optimal reperfusion (defined as modified Treatment in Cerebral Ischaemia score 2b-3), from the THRACE trial and the ETIS registry, were included in order to identify a prediction model. The primary outcome was 3-month independence [modified Rankin Scale (mRS) score ≤ 2]. Multivariate inferences invoked forward logistic regression, multiple imputation and bootstrap resampling. Predictive performance was assessed by c-statistic. Model validation was conducted on patients from the ASTER trial. RESULTS: Amongst 139 patients (mean age 65.5 years; 54.3% female), predictors of 3-month mRS ≤ 2 (n = 82) were younger age [odds ratio 0.62 per 10-year increase; 95% confidence interval (CI) 0.53-0.72] and higher Alberta Stroke Program Early Computed Tomography Score (ASPECTS) (odds ratio 1.65 per 1-point increase; 95% CI 1.47-1.86) with c-statistic 0.77. Model validation (n = 104/181 patients with 3-month mRS ≤ 2) demonstrated a moderate discrimination (c-statistic 0.74; 95% CI 0.66-0.81) combining age and ASPECTS. The validation model was improved by the adjunction of three candidate variables that were found to be predictors. Addition of baseline National Institutes of Health Stroke Scale (NIHSS) score, history of vascular risk factor and onset-to-reperfusion time significantly improved discrimination (c-statistic 0.85; 95% CI 0.83-0.87). CONCLUSIONS: After optimal reperfusion, younger age, higher ASPECTS, lower NIHSS score, shorter onset-to-reperfusion time and absence of vascular risk factor were predictive of independence and could help to guide patient management.

The ophthalmic artery: a new variant involving two branches from the supracavernous internal carotid artery.

PURPOSE: We report an extremely rare, double ophthalmic artery configuration. METHODS: We present 2D- and 3D-angiographic features of an anomalous origin of the ophthalmic artery. RESULTS: The double ophthalmic artery was the result of the persistence of the primitive dorsal ophthalmic artery combined with the presence of a second orbital artery originating from the supracavernous internal carotid artery, passing through the superior orbital fissure and into the orbit to furnish the muscular, lacrimal and ethmoidal arteries and the medial long posterior ciliary artery. CONCLUSIONS: A heretofore undocumented instance of ophthalmic artery duplication is presented. Knowledge of such variations is important for the planning of endovascular treatments and the comprehension of unusual angiographic images. Such fine arterial variants may very well be frequent, but difficult to demonstrate on simple 2D angiographies. Multiplanar reconstructions of 3D angiography data make it possible to diagnose rare, but embryologically predictable arterial variants.

Thrombectomy outcomes for acute stroke patients with anterior circulation tandem lesions: a clinical registry and an update of a systematic review with meta-analysis.

BACKGROUND AND PURPOSE: Although mechanical thrombectomy (MT) appears to be superior in stroke patients with extracranial carotid disease (ECD) compared to thrombolysis alone, the impact of emergent carotid stenting during MT remains unclear. The MT outcomes were assessed in anterior stroke patients with ECD, especially when combined with carotid stenting. METHODS: A retrospective analysis of our registry was performed and an update of a systematic review and meta-analysis of MT studies with or without stenting for anterior circulation stroke with ECD published between November 2010 and April 2017 was conducted. RESULTS: In our registry, 46 patients with ECD underwent MT. In the meta-analysis including 13 primary studies plus our prospective registry data (590 patients in total), the successful reperfusion rate (modified thrombolysis in cerebral infarction score ≥2b) reached 75% [95% confidence interval (CI) 69%-81%]. The rate of symptomatic intracranial haemorrhage (sICH) was 8% (95% CI 6%-11%), 90-day favourable outcome was achieved in 50% (95% CI 42%-59%) and mortality rate was 16% (95% CI 11%-22%). When using carotid stenting, rates of successful reperfusion, sICH, 90-day favourable outcome and mortality were 80% (95% CI 73%-87%), 7% (95% CI 4%-12%), 53% (95% CI 43%-62%) and 14% (95% CI 9%-19%), respectively. CONCLUSIONS: Our data report an association between acute stenting and successful reperfusion rates in stroke patients with tandem lesion treated with MT. Further studies are warranted to determine the intracranial bleeding risk after MT and stenting according to the antiplatelet therapy.

FLAIR Vascular Hyperintensities as a Surrogate of Collaterals in Acute Stroke: DWI Matters.

BACKGROUND AND PURPOSE: FLAIR vascular hyperintensities are thought to represent leptomeningeal collaterals in acute ischemic stroke. However, whether all-FLAIR vascular hyperintensities or FLAIR vascular hyperintensities-DWI mismatch, ie, FLAIR vascular hyperintensities beyond the DWI lesion, best reflects collaterals remains debated. We aimed to compare the value of FLAIR vascular hyperintensities-DWI mismatch versus all-FLAIR vascular hyperintensities for collateral assessment using PWI-derived collateral flow maps as a reference. MATERIALS AND METHODS: We retrospectively reviewed the registries of 6 large stroke centers and included all patients with acute stroke with anterior circulation large-vessel occlusion who underwent MR imaging with PWI before thrombectomy. Collateral status was graded from 1 to 4 on PWI-derived collateral flow maps and dichotomized into good (grades 3-4) and poor (grades 1-2). The extent of all-FLAIR vascular hyperintensities and FLAIR vascular hyperintensities-DWI mismatch was assessed on the 7 cortical ASPECTS regions, ranging from 0 (absence) to 7 (extensive), and associations with good collaterals were compared using receiver operating characteristic curves. RESULTS: Of the 209 included patients, 133 (64%) and 76 (36%) had good and poor collaterals, respectively. All-FLAIR vascular hyperintensity extent was similar between collateral groups (P = .76). Conversely, FLAIR vascular hyperintensities-DWI mismatch extent was significantly higher in patients with good compared with poor collaterals (P < .001). The area under the curve was 0.80 (95% CI, 0.74-0.87) for FLAIR vascular hyperintensities-DWI mismatch and 0.52 (95% CI, 0.44-0.60) for all-FLAIR vascular hyperintensities (P < .001 for the comparison), to predict good collaterals. Variables independently associated with good collaterals were smaller DWI lesion volume (P < .001) and larger FLAIR vascular hyperintensities-DWI mismatch (P = .02). CONCLUSIONS: In acute ischemic stroke with large-vessel occlusion, the extent of FLAIR vascular hyperintensities does not reliably reflect collateral status unless one accounts for DWI.

[Treatment of arterial and venous brain ischemia. Experts' recommendations: stroke management in the intensive care unit]. / Traitement de l'ischémie cérébrale artérielle et veineuse. Recommandations formalisées d'experts: Prise en charge de l'AVC par le réanimateur.

With thrombolysis, intravenous alteplase (0.9 mg/kg body weight, maximum 90 mg), with 10% of the dose given as a bolus followed by a 60-minute infusion, is recommended within 4.5 hours of onset of ischemic stroke. When indicated, intravenous thrombolysis must be initiated as soon as possible. It is possible to use intravenous alteplase in patients with seizures at stroke onset, if the neurological deficit is related to acute cerebral ischemia. Intravenous alteplase can be discussed for use on a case-by-case basis, according to risk of bleeding, in selected patients under 18 years and over 80 years of age, although for the current European recommendations this would be an off-label use. In hospitals with a stroke unit, intravenous thrombolysis is prescribed by a neurologist (current French labelling) or a physician having the French certification for neurovascular diseases (outside the current French labelling). The patient must be monitored in the stroke unit or in case of multiple organ failure in an intensive and critical care unit. In hospitals without a stroke unit, thrombolysis must be decided by the neurologist from the corresponding stroke unit via telemedicine. It is recommended to perform brain imaging 24 hours after thromboysis. Intra-arterial thrombolysis can be contemplated on a case-by-case basis after multidisciplinary discussion within a 6-hour time window for patients with acute middle cerebral artery or carotid occlusions, and within a larger time window for patients with basilar artery occlusion, because of their very poor spontaneous prognosis. Mechanical thrombectomy can also be contemplated in the same situations. With antiplatelet agents, it is recommended that patients receive aspirin (160 mg-325 mg) within 48 hours of ischemic stroke onset. When thrombolysis is performed or contemplated, it is recommended to delay the initiation of aspirin or other antithrombotic drugs for 24 hours. The use of antiplatelet agents that inhibit the glycoprotein IIb/IIIa receptor is not recommended. Urgent anticoagulation using heparin, low-molecular-weight heparins or danaparoid with the goal to treat ischemic stroke patients is not recommended. Secondary prevention by anticoagulation can be used, immediately or within the first days, after minor ischemic stroke or TIA in patients with a high risk for cardioembolism, if uncontrolled hypertension is absent. In patients with large infarcts and a high risk for cardioembolism, the timing for initiating anticoagulation must be decided on a case-by-case basis. In patients with anticoagulation who had an ischemic stroke, the decision to temporarily stop or maintain anticoagulation must be made on a case-by-case basis, depending on thromboembolic risk, level of anticoagulation at stroke onset and estimated risk of hemorrhagic transformation. It is not recommended to use neuroprotective agents in ischemic stroke patients. Patients with cerebral venous thrombosis must be treated with therapeutic doses of heparin, even in case of concomitant intracranial hemorrhage related to cerebral venous thrombosis. If the patient's status worsens despite adequate anticoagulation, thrombolysis may be used in selected cases. The optimal administration route (local or intravenous), thrombolytic agent (urokinase or alteplase) and dose are unknown. There is currently no recommendation with regard to local thrombolytic therapy in patients with dural sinus thrombosis. Urgent blood transfusions are recommended to reduce hemoglobin S to <30% in patients with sickle cell disease and acute ischemic stroke.

Flow Diversion in the Treatment of Intracranial Aneurysms: A Pragmatic Randomized Care Trial.

BACKGROUND AND PURPOSE: Flow diversion is a recent endovascular treatment for intracranial aneurysms. We compared the safety and efficacy of flow diversion with the alternative standard management options. MATERIALS AND METHODS: A parallel group, prerandomized, controlled, open-label pragmatic trial was conducted in 3 Canadian centers. The trial included all patients considered for flow diversion. A Web-based platform 1:1 randomly allocated patients to flow diversion or 1 of 4 alternative standard management options (coiling with/without stent placement, parent vessel occlusion, surgical clipping, or observation) as prespecified by clinical judgment. Patients ineligible for alternative standard management options were treated with flow diversion in a registry. The primary safety outcome was death or dependency (mRS > 2) at 3 months. The composite primary efficacy outcome included the core lab-determined angiographic presence of a residual aneurysm, aneurysm rupture, progressive mass effect during follow-up, or death or dependency (mRS > 2) at 3-12 months. RESULTS: Between May 2011 and November 2020, three hundred twenty-three patients were recruited: Two hundred seventy-eight patients (86%) had treatment randomly allocated (139 to flow diversion and 139 to alternative standard management options), and 45 (14%) received flow diversion in the registry. Patients in the randomized trial frequently had unruptured (83%), large (52% ≥10 mm) carotid (64%) aneurysms. Death or dependency at 3 months occurred in 16/138 patients who underwent flow diversion and 12/137 patients receiving alternative standard management options (relative risk, 1.33; 95% CI, 0.65-2.69; P = .439). A poor primary efficacy outcome was found in 30.9% (43/139) with flow diversion and 45.6% (62/136) of patients receiving alternative standard management options, with an absolute risk difference of 14.7% (95% CI, 3.3%-26.0%; relative risk, 0.68; 95% CI, 0.50-0.92; P = .014). CONCLUSIONS: For patients with mostly unruptured, large, anterior circulation (carotid) aneurysms, flow diversion was more effective than the alternative standard management option in terms of angiographic outcome.

Clot Burden Score and Collateral Status and Their Impact on Functional Outcome in Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Collateral status and thrombus length have been independently associated with functional outcome in patients with acute ischemic stroke. It has been suggested that thrombus length would influence functional outcome via interaction with the collateral circulation. We investigated the individual and combined effects of thrombus length assessed by the clot burden score and collateral status assessed by a FLAIR vascular hyperintensity-ASPECTS rating system on functional outcome (mRS). MATERIALS AND METHODS: Patients with anterior circulation acute ischemic stroke due to large-vessel occlusion from the ASTER and THRACE trials treated with endovascular thrombectomy were pooled. The clot burden score and FLAIR vascular hyperintensity score were determined on MR imaging obtained before endovascular thrombectomy. Favorable outcome was defined as an mRS score of 0-2 at 90 days. Association of the clot burden score and the FLAIR vascular hyperintensity score with favorable outcome (individual effect and interaction) was examined using logistic regression models. RESULTS: Of the 326 patients treated by endovascular thrombectomy with both the clot burden score and FLAIR vascular hyperintensity assessment, favorable outcome was observed in 165 (51%). The rate of favorable outcome increased with clot burden score (smaller clots) and FLAIR vascular hyperintensity (better collaterals) values. The association between clot burden score and functional outcome was significantly modified by the FLAIR vascular hyperintensity score, and this association was stronger in patients with good collaterals, with an adjusted OR = 6.15 (95% CI, 1.03-36.81). CONCLUSIONS: The association between the clot burden score and functional outcome varied for different collateral scores. The FLAIR vascular hyperintensity score might be a valuable prognostic factor, especially when contrast-based vascular imaging is not available.

Dynamic susceptibility contrast-enhanced MRI evaluation of cerebral intraventricular tumors: preliminary results.

INTRODUCTION: The aims of the present study were to determine the perfusion characteristics of several types of intraventricular tumors and to evaluate the usefulness of dynamic contrast-enhanced MRI in making the differential diagnosis. METHODS: A total of 28 patients with intraventricular tumors (five meningiomas, five papillomas, three ependymomas, four subependymomas, seven central neurocytomas, two subependymal giant cell astrocytomas and two metastases) underwent conventional and dynamic susceptibility contrast-enhanced MRI. Cerebral blood volume (CBV) maps were obtained and the relative CBV (rCBV) calculated for each tumor. Mean rCBV(max) values were compared across the different types of tumors (ANOVA, P=0.05). RESULTS: Intraventricular tumors presented with three different patterns of vascularization: highly vascularized tumors (mean rCBV(max)>3), including papillomas, meningiomas and renal carcinoma metastases; poorly vascularized tumors (mean rCBV(max)<2), including ependymomas and subependymomas; and intermediately vascularized tumors (mean rCBV(max)>2 but<3), including central neurocytomas and lung metastases. There was a significant difference between the highly vascularized (papillomas, meningiomas) and poorly vascularized (subependymomas) tumors. In cases of suspected meningioma, papilloma or neurocytoma, low rCBV values (<3) point to a diagnosis of neurocytoma rather than either of the other tumor types. CONCLUSION: Susceptibility contrast-enhanced MRI can provide additional information on the vascularization of intraventricular cerebral tumors and may help in making the differential diagnosis.

[Imaging of cranial gunshot traumas]. / Imagerie des traumatismes crâniens par arme à feu.

Cranial traumas from gunshot wounds are characterised by the impact of a high velocity projectile. There are therefore serious, life threatening traumas. CT Scan is essential in the emergency setting for initial evaluation of traumatic bone and parenchymatous injuries to determine the indication for neurosurgery and appropriate medical management. In case of survival, CT Scan and MRI can be used to monitor progress and any possible complications, in particular vascular or infectious complications which are specific to this type of injury.

Functional outcome 1 year after aneurysmal subarachnoid hemorrhage due to ruptured intracranial aneurysm in elderly patients.

BACKGROUND: Population aging raises questions about extending treatment indications in elderly patients with aneurysmal subarachnoid hemorrhage (aSAH). We therefore assessed functional status 1 year after treatment. METHODS: This study involved 310 patients, aged over 70 years, with ruptured brain aneurysm, enrolled between 2008 and 2014 in a prospective multicentre trial (FASHE study: NCT00692744) but considered unsuitable for randomisation and therefore analysed in the observational arms of the study: endovascular occlusion (EV), microsurgical exclusion (MS) and conservative treatment. The aims were to assess independence, cognition, autonomy and quality of life (QOL) at 1 year post-treatment, using questionnaires (MMSE, ADLI, IADL, EORTC-QLQ-C30) filled in by independent nurses after discharge. RESULTS: The 310 patients received the following treatments: 208 underwent EV (67.1%), 54 MS (17.4%) and 48 were conservatively managed (15.5%). At 1 year, independence rates for patients admitted with good clinical status (WFNS I-III) were, according to the aneurysm exclusion procedure (EV, MS or conservative), 58.9%, 50% and 12.1% respectively. MMSE score was pathological in 26 of the 112 EV patients (23.2%), 10 of the 25 MS patients (40%) and 4 of the 9 patients treated conservatively (44%), without any statistically significant difference [Pearson's Chi2 test, F ratio=4.29; P=0.11]. Regarding QoL, overall score was similar between the EV and MS cohorts, but significantly lower with conservative treatment. CONCLUSION: Elderly patients in good clinical condition with aSAH should be treated regardless of associated comorbidities. Curative treatment (EV or MS) reduced mortality without increasing dependence, in comparison with conservative treatment.

Posterior reversible encephalopathy syndrome: a case of unusual diffusion-weighted MR images.

Posterior reversible encephalopathy (PRES) represents an uncommon entity related to multiple pathologies, the most common of which is hypertensive crisis. PRES is classically characterized as symmetrical parieto-occipital edema, but may affect other areas of the brain. Diffusion-weighted magnetic resonance imaging (DWI) is important for differentiating between vasogenic and cytotoxic edema. We present here the case of a 43-year-old woman, known to suffer from arterial hypertension and severe renal failure, who developed PRES with restricted apparent diffusion coefficients (ADC) in various cerebral areas, suggesting irreversible tissue damage. Nevertheless, follow-up cranial MRI revealed complete remission, indicating that restricted diffusion does not always lead to cell death in this pathology. The underlying pathophysiological mechanism is not well understood. Such reversibility of diffusion anomalies has already been reported with transient ischemia, vasospasm after subarachnoid hemorrhage and epilepsy but, to our knowledge, never before in PRES.

[Impact of PACS implementation in a university center on radiology practice profile]. / Changements des pratiques radiologiques induites par l'implantation d'un réseau images en milieu hospitalo-universitaire.

PURPOSE: To determine the impact of a joint PACS implementation at a university medical center and cancer center on the radiology practice profile. Materials and methods. In 5 radiology sections, patients, selected based on identifiable acute or chronic diseases, underwent US, CT or MRI. Data were collected on datasheets from each provider with regards to clinical history, availability of prior examinations, description of patient management during the different phases of the examination, duration of examinations, and satisfaction. Data obtained prior to PACS implementation and 6-12 months and 30-36 months after implementation were compared. RESULTS: A total of 1098 datasheets were collected. Hard copy readings rapidly decreased. Comparison with prior examinations improved (+20.6% to 25.6%) as well as frequency of post-processing (+29%). The time required for image management was much more reduced for technologists (-75%) than for physicians (-23%). PACS implementation only temporarily improved the availability of radiology reports and the distribution of work between senior and junior radiologists. User satisfaction, initially high, progressively decreased due to saturation of the archival capabilities. CONCLUSION: PACS implementation in a large university center improves the efficiency of image acquisition but does not solve some of the inefficiencies of hospital organization.

Two-Layered Susceptibility Vessel Sign and High Overestimation Ratio on MRI Are Predictive of Cardioembolic Stroke.

In a prospective study among patients in the THRombectomie des Artères Cerebrales trial, we analyzed the diagnostic accuracy of 2 imaging biomarkers, the 2-layered susceptibility vessel sign and a high overestimation ratio, obtained on pretreatment brain T2* sequences, to identify cardioembolic stroke etiology (107/260 patients). In combination, these 2 biomarkers, on 1.5T or 3T systems (159 and 101 patients, respectively), demonstrated high specificity (0.77 at 1.5T and 1 at 3T) and their simultaneous presence is highly associated with cardioembolism.

Susceptibility-Weighted Angiography for the Follow-Up of Brain Arteriovenous Malformations Treated with Stereotactic Radiosurgery.

The criterion standard for assessing brain AVM obliteration postradiosurgery is DSA. To explore the value of susceptibility-weighted angiography, we followed 26 patients with brain AVMs treated by radiosurgery using susceptibility-weighted angiography and DSA. Studies were evaluated by 2 independent readers for residual nidi. Susceptibility-weighted angiography demonstrated good intermodality (κ = 0.71) and interobserver (κ = 0.64) agreement, and good sensitivity (85.7%) and specificity (85.7%). Susceptibility-weighted angiography is a useful radiation- and contrast material-free technique to follow-up brain AVM obliteration postradiosurgery.

[A survey of the management of unruptured intracranial aneurysms as practised by French neuroradiological and neurosurgical teams]. / Prise en charge des anévrismes intracrâniens non rompus. Enquête de pratique des équipes neurochirurgicales et neuroradiologiques françaises.

BACKGROUND: The lack of consensus in the management of unruptured intracranial aneurysms (UIA) has resulted in a variety of different clinical practices. The aim of this study is to analyze these different practices. METHODS: A questionnaire concerning the management of UIA was mailed out to French neurosurgeons (NS) and neuroradiologists (NR). Eighteen responses from 17 teams of NS and 23 responses from 19 teams of NR were included in our analysis. RESULTS: In making a therapeutic decision, about three-quarters of both NR and NS take into account the age of the patient and all of our responders except one consider the aneurysm's morphology, especially its size and neck structure. Pinpointing the location of the aneurysm is an important factor for 61% of NR and 40% of NS. Information concerning the risk of aneurysm rupture and the risks of treatment is routinely given to the patient orally and, sometimes, in writing. The follow-up of UIA treated by NR usually consists of one X-ray angiography and several MR angiographic (MRA) films taken over a period of at least five years and, sometimes, for the rest of the patient's life (22%). The follow-up after surgical treatment mainly comprises X-ray angiography for a limited period of time-usually from five to ten years. The follow-up of untreated aneurysms is usually by either MRA or angioCT. For most NR, the duration of follow-up is long and, sometimes, unlimited. For NS, the duration is more difficult to pinpoint: the response was indeterminate in 28 and 33% gave no response at all. If the first screening tests negative, 44% of NS and 61% of NR propose a repeat screening. CONCLUSION: Given the differences in the management of UIA as revealed by this survey, a multidisciplinary approach that combines the various clinical practices may be the best way forward.

[MRI imaging of the neural pituitary]. / Imagerie par résonance magnétique nucléaire de la neurohypohyse.

The main illness of the neural pituitary is diabetes insipidus (DI). MRI is essential if DI occurs during childhood, in order to highlight malignant germinoma prognosis of which remains excellent if the diagnosis is made as early as possible. In adults, primary intracranial tumours causing DI include craniopharyngioma, or pineal tumours. Infiltrative histiocytosis is another frequent aetiology. One third of previously considered idiopathic DI is in fact auto-immune. Early MRI findings advocate for such a diagnosis. Finally, meticulous analysis of the neural pituitary imaging may avoid several pitfalls and help the analysis of adenopituitary abnormalities.

["Benign" intracranial hypertension: neuroradiology and endovascular treatments]. / Hypertension intracrânienne "bénigne": imagerie et thérapeutiques endovasculaires.

Neuroimaging is useful in benign intracranial hypertension (BIH), contributing to its diagnosis criteria and ruling out other causes of intracranial hypertension. CT and/or MR results may be normal or may show small ventricles, an empty sella, or more frequently optic nerve sheath dilatation. Diffusion as well as perfusion MR studies show conflicting results. Venous sinus imaging plays a growing role in BIH evaluation, because impaired cranial venous outflow is a common factor in the pathogenesis of BIH and venous sinus stenosis is frequently observed in this condition. Angiography is not the gold standard for this evaluation: angio-MR (with dynamic sequences) clearly demonstrates venous sinus stenosis (mostly located in the transverse sinus). We believe that this investigation must be carried out in every case of BIH. For medically refractory cases of BIH with associated sinus venous stenosis, sinus pressure recording may be necessary, sometimes leading to endovascular treatment of the stenosis (stenting). The results are promising, but long-term follow-up of these patients is needed.

A randomized controlled study assessing outcome, cognition, autonomy and quality of life in over 70-year-old patients after aneurysmal subarachnoid hemorrhage.

BACKGROUND: Current aging of the population with good physiological status and the increasing incidence of subarachnoid hemorrhage (SAH) in elderly patients has enhanced the benefit of treatment in terms of independence and long-term quality of life (QoL). METHODS: From November 1, 2008 to October 30, 2012, 351 patients aged 70 years or older with aneurysmal SAH underwent adapted treatment: endovascular coiling (EV) for 228 (65%) patients, microsurgical clipping (MS) for 75 (29.3%) or conservative treatment for 48 (13.7%). Forty-one of these were randomized to EV (n=20) or to MS (n=21). The objectives were to determine the proportion of patients with modified Rankin Scale score≤2 (independence) at 1 year, and, secondarily, to compare cognitive function on the Mini-Mental State Examination (MMSE), autonomy on the Activities of Daily Living Index (ADLI) and Instrumental Activities of Daily Living scale (IADL), and QoL, in the prospective and randomized arms, at 1 year. RESULTS: At 1 year, with 1 loss to follow-up in the EV arm, 11 patients (55%) were independent after EV occlusion and 8 (38.1%) after MS exclusion, without significant difference (P=0.29). Mortality was higher after MS during the first 2 postoperative months, and thereafter the difference between MS and EV ceased to be significant. Cognitive function and autonomy scores were similar in both arms. CONCLUSION: In elderly patients treated for aneurysmal SAH, approximately 50% were independent at 1 year, with conserved cognition and autonomy. EV and MS are valid procedures in this population, with similar results at 1 year in terms of independence, cognition, autonomy, and QoL.

Giant cystic widening of Virchow-Robin spaces: an anatomofunctional study.

We describe 2 patients with unusual white matter cystic dilations, which could correspond to widening of the perivascular spaces. They underwent morphologic MR imaging with tractography, functional MR imaging (fMRI), and neuropsychological evaluation. fMRI examination showed no functional reorganization of cortical areas. Tractography showed an apparent decrease of white matter tract vectors into the regions of concern. Findings of the neuropsychological examination were normal. It seems that even an extensive cystic dilation of white matter does not deteriorate brain function.

[Carotid Stenting in France after the EVA 3S and SPACE publications]. / Stenting carotidien en France après les publications d'EVA 3S et de SPACE?

Angioplasty of stenoses of the carotid bifurcation is a revascularization procedure that is used successfully in many patients. With more than 10 years of experience now, the feasibility of carotid stenting has been demonstrated. Its distribution is highly variable depending on the country, with a mean penetration rate in Europe of 15% of the number of carotid revascularizations. However, the complication rate is highly variable from one series to another and depends on the type of patient treated and the operator's learning curve. The results of the first two randomized studies comparing endarterectomy and carotid stenting, EVA 3S in France and SPACE in Germany, have just been published. The conclusions of these studies only relate to symptomatic patients, who make up a small proportion of revascularized patients. At 30 days, the French study concluded that surgery was better, and the German study showed no advantage to stenting. The analysis of these results compared to other publications should make it possible to best define the current indications for carotid stenting.