Perfusion Imaging to select patients with large ischemic core for mechanical thrombectomy

International audienceBackground and purpose: Patients with acute ischemic stroke, proximal vessel occlusion and a large ischemic core at presentation are commonly not considered for mechanical thrombectomy (MT). We tested the hypothesis that in patients with baseline large infarct cores, identification of remaining penumbral tissue using perfusion imaging would translate to better outcomes after MT.Methods: This was a multicenter, retrospective, core lab adjudicated, cohort study of adult patients with proximal vessel occlusion, a large ischemic core volume (diffusion weighted imaging volume ≥70 mL), with pre-treatment magnetic resonance imaging perfusion, treated with MT (2015 to 2018) or medical care alone (controls; before 2015). Primary outcome measure was 3-month favorable outcome (defined as a modified Rankin Scale of 0-3). Core perfusion mismatch ratio (CPMR) was defined as the volume of critically hypo-perfused tissue (Tmax >6 seconds) divided by the core volume. Multivariable logistic regression models were used to determine factors that were independently associated with clinical outcomes. Outputs are displayed as adjusted odds ratio (aOR) and 95% confidence interval (CI).Results: A total of 172 patients were included (MT n=130; Control n=42; mean age 69.0±15.4 years; 36% females). Mean core-volume and CPMR were 102.3±36.7 and 1.8±0.7 mL, respectively. As hypothesized, receiving MT was associated with increased probability of favorable outcome and functional independence, as CPMR increased, a difference becoming statistically significant above a mismatch-ratio of 1.72. Similarly, receiving MT was also associated with favorable outcome in the subgroup of 74 patients with CPMR >1.7 (aOR, 8.12; 95% CI, 1.24 to 53.11; P=0.028). Overall (prior to stratification by CPMR) 73 (42.4%) patients had a favorable outcome at 3 months, with no difference amongst groups.Conclusion: s In patients currently deemed ineligible for MT due to large infarct ischemic cores at baseline, CPMR identifies a subgroup strongly benefiting from MT. Prospective studies are warranted

Endovascular therapy in patients with a large ischemic volume at presentation: An aggregate patient-level analysis.

INTRODUCTION Recently, four randomized controlled trials (RCTs) have demonstrated the benefits of mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) caused by anterior large vessel occlusion (LVO) and a large ischemic core at baseline (LIC). The purpose of this study was to investigate the features influencing the clinical outcome and the benefits of mechanical thrombectomy in this subgroup. METHODS We conducted a multicenter retrospective aggregate cohort study of patients with AIS-LVO and a LIC, assessed with quantitative core volume measures, treated with MT between 2012 and 2019. The data were queried through four registries, including patients with core volumes ≥50cc. Multivariable logistic regression models were employed to determine factors independently associated with clinical outcomes in patients with successful recanalization (modified-Thrombolysis-in-Cerebral-Infarction-score, mTICI=2b-3) and unsuccessful recanalization group (mTICI=0-2a). The primary endpoint was a favorable functional outcome at day-90, defined as a modified Rankin scale (mRS) of 0-3, accounting for the inherent severity of AIS with baseline LIC. Secondary outcomes included functional independence (mRS 0-2) at day-90, mortality, and symptomatic Intracranial Hemorrhage (sICH). RESULTS A total of 460 patients were included (mean age 66±14.2 years; 39.6 % females). The mean baseline NIHSS was 20±5.2, and the core volume was 103.2±54.6 ml. Overall, 39.8 % (183/460) of patients achieved a favorable outcome at day-90 (mRS 0-3). Successful recanalization was significantly associated with a more frequent favorable outcome (aOR, 4.79; 95 %CI, 2.73-8.38; P<0.01) and functional independence (P<0.01). This benefit remained significant in older patients and in patients with cores above 100cc. At 90 days, 147/460 patients (32 %) were deceased, with successful recanalization significantly associated with less frequent mortality (OR, 0.34; 95 %CI, 0.22-0.53; P<0.01). The rate of sICH was 17.4 % and did not differ significantly between groups. CONCLUSIONS In this large, pooled-cohort study of AIS-LVO patients with infarct cores over 50cc at baseline, we demonstrated that successful recanalization was associated with a better functional outcome, lower mortality, and similar rates of symptomatic intracranial hemorrhage for a wide spectrum of patients

Sudden coma onset following simultaneous bilateral carotid occlusion

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Cytotoxic lesion of the corpus callosum as presenting neuroradiological manifestation of COVID-2019 infection

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Cicaflow étude animale sur l'endothélialisation des stents à diversion de flux: analyse histologique, en tomographie par cohérence optique, et angiographique chez le lapin

International audienceObjectifComparer différents stents à diversion flux (flow-diverters) avec des régimes d'anti-agrégation plaquettaire différents, et analyser le processus d'endothélialisation de ces dispositifs, et les risques thromboemboliques associés. Comprendre le processus de cicatrisation et son support, est indispensable pour assurer une sécurité dans le traitement des anévrismes intracrâniens avec ces dispositifs, et dans notre étude, nous avons utilisé des stents flow-diverters actuellement utilisés en pratique clinique et ayant des caractéristiques différentes en termes de coating, certains ayant des recouvrements à visée anti-thrombotique. Cependant, aucune étude n'a étudié l'impact de ces traitements de surface sur l'endothélialisation des dispositifs qui est indispensable à la cicatrisation des anévrismes.MéthodeDans un premier temps, 3 stents à diversion de flux de différents laboratoires avec des caractéristiques (et des revêtements) différents ont été mis en place dans l'aorte de 9 lapins en alternant l'ordre d'implantation dans le sens cranio-caudal. Puis, les lapins ont été répartis parmi un des 3 régimes d'anti-agrégation plaquettaire suivant: absence d'antiagrégant plaquettaire, simple anti-agrégation plaquettaire par aspirine, ou double anti-agrégation plaquettaire par aspirine et ticagrelor. Chacun des groupes de lapins a reçu une combinaison de stents (mis en place dans le sens cranio-caudal), et un traitement antiagrégant plaquettaire différent. L'animal et le processus d'endothélialisation du dispositif ont été évalués précocement après mise en place du dispositif par des contrôles radiologiques et biologiques. L'OCT est un des éléments clés qui a été utilisé pour monitorer cette étude, en plus des prélèvements histologiques et des analyses en microscopie électronique à balayage, et microscopie biphotonique.RésultatsL'étude CICALFOW est terminée, et l'analyse des résultats touche à sa fin (article en cours de rédaction).Ce projet nous a permi d'effectuer des analyses qui ne sont pas réalisables chez l’être humain afin d’évaluer la réponse biologique à l'implantation de stents à diversion de flux, ce qui n'a encore jamais été fait de façon indépendante in vivo. L'analyse de la prolifération tissulaire sur le dispositif et sa thrombogénicité, apporte des connaissances supplémentaires et une meilleure compréhension sur les principes du traitement des anévrysmes cérébraux par stents à diversion de flux, permettant d'opter et de développer les dispositifs les plus fiables pour l'Homme. Ce travail évalue également de façon annexe pour la première fois l'utilisation du ticagrélor (brilique) chez le lapin pour des dispositifs endovasculaires utilisés en NRI, et la pertinence de son utilisation en remplacement du plavix pour l'ensemble des études animales à venir

Non-ischemic cerebral enhancing lesions after thrombectomy: a multicentric retrospective French national registry

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Preclinical in vitro and in vivo results of the new silk vista flow diverter with P8RI coating

International audienceBackground Flow diverting stents (FDS) have transformed the treatment of intracranial aneurysms; however, their metallic structure associated with their intra-luminal positioning hamper angiographic and clinical outcomes. Therefore, there is a need to develop FDS with optimized surfaces that reduce thrombogenicity while promoting the healing process and endothelialization. Methods P8RI, a peptide mimicking the CD31 protein, was previously developed and grafted onto Silk Vista (SV) FDS. P8RI-SV and bare-SV were used in vitro in a blood loop model to test their hemocompatibility using human whole blood and in vivo using the rabbit elastase model for optical coherence tomography (OCT) comparisons of neointimal formation at day 5 and day 28. Results After blood loop incubation, P8RI-SV showed significant reduction in fibrin binding (p=0.004) and platelet adhesion (p=0.041) compared with bare-SV. Similarly, derivative markers measured in blood, thromboxane B2 (platelet activation) and Thrombin-Antithrombin III complexes (coagulation activation), were also significantly reduced in the P8RI-SV group (both p=0.002). In vivo, complete or near-complete occlusion was reached in all aneurysms (n=6) at day 28. Excellent rate of stent-coverage ratio was obtained at day 5 (89.3% (79.1%–98.7%)) comparable to the observation at day 28 (91.8% (79.1%–100%); p=0.44). These rates were significantly higher compared with bare-SV at day 5 (77.8% (58.3%–86.8%); p&lt;0.001) and at day 28 (67.7% (52.6%–88.9%); p&lt;0.0001). Conclusion In vitro results confirm enhanced hemocompatibility with a significant anti-thrombotic effect of the P8RI-SV. In vivo results provide evidence of rapid neo-intimal growth reaching near-complete tissue healing as early as day 5 in a rabbit model

Neurophysiological monitoring during endovascular treatment of brain arteriovenous malformations: A meta-analysis

Background: Treatment of brain arteriovenous malformations (b-AVM) carries a risk of iatrogenic injury to eloquent brain regions. Intraoperative neuro-monitoring (IONM) has increasingly been used to monitor spontaneous or evoked neural activity during neurosurgery, but its use is not as well characterized in the endovascular treatment (EVT) of b-AVMs. We aimed to provide a systematic review and meta-analysis of studies reporting any neurological deficit after b-AVM embolization with IONM, with or without provocative test (PT), and no-IONM. Methods: This systematic review followed the PRISMA guidelines. Medline, EMBASE, and Scopus were searched from conception until March 1, 2022 for studies evaluating EVT with IONM and PT. Primary outcome was the rate of postoperative neurological deficits in EVT with IONM versus no-IONM, while secondary outcome was the subanalysis of IONM with or without PT. Meta-analysis was performed using the Mantel-Haenszel method and random effects modeling. Results: Six studies reached synthesis. Out of a total of 192 EVT, 14 events occurred. Results demonstrated a nonsignificant trend favoring IONM compared to no-IONM to prevent neurological deficits (OR 0.09, 95% CI 0-4.68). Among the EVT with IONM, PT was done in 411 branches with 10 events (0.2%) despite a negative PT. There was a nonsignificant trend favoring IONM plus PT compared to IONM without PT (OR 0.16, 95% CI 0.02-1.07). Conclusions: Our study suggests that b-AVM EVT with IONM plus PT might reduce rates of postprocedural neurological deficits compared with EVT without IONM. Further studies are needed to confirm these results