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

Mechanical thrombectomy outcomes with or without intravenous thrombolysis: insight from the ASTER randomized trial (Contact Aspiration versus Stent Retriever for Successful Revascularization)

L’administration de la thrombolyse intra-veineuse (TIV) avant la thrombectomie mécanique (TM) est recommandée dans les 4h30 suivant l’apparition des symptômes. Nous avons comparé l’évolution clinique, la récupération neurologique, la recanalisation et les complications selon l’administration ou non de la TIV avant la TM. Matériels et méthodes Nous avons réalisé une analyse post-hoc de l’essai ASTER (Contact Aspiration versus Stent Retriever for Successful Revascularization). Le critère de jugement principal était l’évolution clinique favorable à 3 mois défini un score de Rankin modifié inférieur ou égal à 2. Les critères de jugement secondaires étaient la recanalisation favorable après stratégie première et en fin de procédure, le nombre de passage du dispositif de TM, et la modification du score National Institutes of Health Stroke Scale (NIHSS) à 24 heures. Nous avons également analysé les complications avec notamment la mortalité à 3 mois et la survenue de toute hémorragie cérébrale. Résultats Les données des 381 patients inclus dans ASTER ont été analysées : 250 patients dans le groupe TIV+TM et 131 patients dans le groupe TM seule. Nous n’avons pas trouvé de différence significative entre les deux groupes en terme d’évolution clinique favorable à 3 mois, de succès de recanalisation, d’amélioration du score NIHSS à 24 heures et de complications hémorragiques. La mortalité à 3 mois était significativement plus faible dans le groupe TIV+TM par rapport au groupe TM seule (risque ratio ajusté, 0.59; IC95%, 0.39 to 0.88). Chez les patients sans anticoagulants avant l’AVC, nous avons mis en évidence une meilleure évolution clinique à 3 mois (risque ratio ajusté, 1.38; IC95%, 1.02 to 1.89), un taux de recanalisation après stratégie première plus important (risque ratio ajusté, 1.26; 95%CI, 1.05 to 1.50), une mortalité plus faible dans le groupe TIV+TM (risque ratio ajusté, 0.58; 95%CI, 0.36 to 0.93) sans majoration des complications hémorragiques. Conclusion Nos résultats montrent que les patients traités par TIV+TM dans l’essai ASTER ont un taux de mortalité à 3 mois significativement plus faible par rapport à ceux traités par TM seule. Dans une sous-population sans anticoagulants avant l’AVC, nous avons mis en évidence que l’association TIV et TM permet d’améliorer le pronostic clinique, la recanalisation et de diminuer la mortalité.Intravenous thrombolysis (IVT) within 4,5 hours of symptom onset, is currently recommended prior to mechanical thrombectomy (MT). We compared functional outcome, neurological recovery, reperfusion and adverse events according to the use or not of IVT prior to MT. Methods: This is a post-hoc analysis of the ASTER trial (Contact Aspiration versus Stent Retriever for Successful Revascularization). The primary outcome was favorable 90-day functional outcome defined as a modified Rankin Scale (mRS) of 2 or less. Secondary outcomes were successful reperfusion following all procedures and after the first-line procedure, number of device passes and change in National Institutes of Health Stroke Scale (NIHSS) score at 24 hours. Safety outcomes included 90-day mortality and any symptomatic intracerebral hemorrhage. Results: Three hundred and eighty-one patients were included, 250 of whom received IVT prior to MT (IVT+MT group). There were no significant differences between IVT+MT and MT alone groups in 90-day favorable functional outcome, in successful reperfusion rate (modified Thrombolysis In Cerebral Infarction 2b or 3), in NIHSS score improvement at 24 hours or in hemorrhagic complication rate. 90-day mortality rate in the IVT+MT group was lower than after MT alone (fully-adjusted RR, 0.59; 95%CI, 0.39 to 0.88). In a subgroup of patients without anticoagulant medication before stroke onset, a better functional outcome (fully-adjusted RR, 1.38; 95%CI, 1.02 to 1.89), a higher successful recanalization rate after first line strategy (fully-adjusted RR, 1.26; 95%CI, 1.05 to 1.50), a lower mortality rate (fully-adjusted RR, 0.58; 95%CI, 0.36 to 0.93) and a comparable hemorrhagic complication risk were observed. Conclusion Our results show that IVT+MT patients in the ASTER trial have lower 90-day mortality compared with those receiving MT alone. In a selected population of patients without pre-stroke anticoagulation, we demonstrated that IVT associated with MT might improve functional outcome and recanalization while reducing mortality rates

Acta Neurol Scand.

Background and Purpose : The influence of chronic treatment by antiplatelet drug (APD) at stroke onset on the outcomes of patients with acute ischemic stroke (AIS) treated with combined intravenous thrombolysis (IVT) and endovascular therapy (EVT) is unclear. We investigated whether prior APD use influences the risk of symptomatic intracranial hemorrhage (sICH) and functional outcome in AIS patients treated with combined reperfusion therapy. Methods : A single-center retrospective analysis of AIS patients with proximal intracranial occlusion who underwent IVT and EVT between January 2015 and May 2017. The main outcomes were the incidence of sICH using the Heidelberg Bleeding Classification and patients’ functional status at 90 days, as defined by the modified Rankin scale (mRS). Outcomes were evaluated according to daily exposure to APD, and associations were assessed using multivariate logistic regression analysis. Results : This study included 204 patients: 71 (34.8%) were taking APD before AIS. Patients with chronic treatment by APD at stroke onset had a higher rate of sICH (26.7% vs. 3.7%; p2) at 90 days (69% vs. 36.8%; p < .001). Prior APD use was associated with an increased likelihood of sICH (OR 9.8; 95%CI [3.6–31.3], p < .05) and of functional dependence at 90 days (OR 5.72; 95%CI [2.09–1.72], p < .001), independent of confounders on multivariate analysis. Conclusions : Chronic treatment by APD at stroke onset in AIS patients with proximal intracranial occlusion treated using IVT and EVT increases the risk of sICH and worsens the functional prognosis. Further investigation to refine acute revascularization strategies in this population might be required

Safety and efficacy of the Silk flow diverter: Insight from the DIVERSION prospective cohort study

BACKGROUND AND PURPOSE Flow diverters are considered as an essential tool in the stent-based treatment of complex intracranial aneurysms. We report here a subgroup analysis of the nationwide prospective DIVERSION study to investigate the safety and efficacy of the Silk flow diverter at 12 months follow-up. METHODS We performed a subgroup analysis of patients included in the DIVERSION, a national prospective cohort study including all flow diverters placement between 2012 and 2014 in France, and treated with the Silk. The primary outcome was the morbi-mortality at 12 months, including death, morbidity event and aneurysm retreatment within 12 months post-treatment. All reported serious events were adjudicated by an independent Data Safety and Monitoring Board. Satisfactory occlusion was defined as 3 or 4 on Kamran's scale by an independent imaging core laboratory during follow-up. RESULTS A total of 102 procedures involving 101 patients (mean age±standard deviation, 54.3±13.5 years) harbouring 118 aneurysms (113/118 located in the anterior circulation; mean size 8.2±7.1mm) were included. During the 12-month follow-up, 34 (33.3%) procedures experienced at least one morbi-mortality event: 3 deaths, 27 morbidity events and 4 retreatments. Overall, 1/3 deaths and 10/27 morbidity events were related to the device and/or the procedure, leading to a specific survival rate and a specific free-morbidity survival rate at 12 months of 98.98% [95% confidence interval, 92.98%-99.86%] and 89.73% [95%CI, 81.71%-94.36%], respectively. The rate of permanent-related neurological deficit was 5.9% within 12 months. One year follow-up imaging showed satisfactory occlusion in 82.2% of cases. CONCLUSION Flow diversion with the Silk device has a reasonable safety and effectiveness profile for the endovascular treatment of intracranial aneurysms

Bifurcation geometry remodelling of vessels in de novo and growing intracranial aneurysms: a multicenter study

International audienceBackground Geometrical parameters, including arterial bifurcation angle, tortuosity, and arterial diameters, have been associated with the pathophysiology of intracranial aneurysm (IA) formation. The aim of this study was to investigate whether these parameters were present before or if they resulted from IA formation and growth. Methods Patients from nine academic centers were retrospectively identified if they presented with a de novo IA or a significant IA growth on subsequent imaging. For each patient, geometrical parameters were extracted using a semi-automated algorithm and compared between bifurcations with IA formation or growth (aneurysmal group), and their contralateral side without IA (control group). These parameters were compared at two different times using univariable models, multivariable models, and a sensitivity analysis with paired comparison. Results 46 patients were included with 21 de novo IAs (46%) and 25 significant IA growths (54%). The initial angle was not different between the aneurysmal and control groups (129.7±42.1 vs 119.8±34.3; p=0.264) but was significantly wider at the final stage (140.4±40.9 vs 121.5±34.1; p=0.032), with a more important widening of the aneurysmal angle (10.8±15.8 vs 1.78±7.38; p=0.001). Variations in other parameters were not significant. These results were confirmed by paired comparisons. Conclusion Our study suggests that wider bifurcation angles that have long been deemed causal factors for IA formation or growth may be secondary to IA formation at pathologic bifurcation sites. This finding has implications for our understanding of IA formation pathophysiology

Safety and outcomes of mechanical thrombectomy for acute stroke related to infective endocarditis: A case–control study

International audienceBackground and purpose Successful reperfusion can be achieved in more than two-thirds of patients with usual large-vessel occlusion stroke causes treated with mechanical thrombectomy. However, the safety and outcomes after mechanical thrombectomy in the setting of large-vessel occlusion related to infective endocarditis is not known. In this study, we investigated the impact of mechanical thrombectomy in infective endocarditis patients on angiographic and clinical outcomes. Methods This was a multicenter study from five comprehensive stroke centers. We compared the outcomes of mechanical thrombectomy treated stroke patients due to infective endocarditis with patients presenting atrial fibrillation. Clinical outcomes included 90-day modified Rankin Scale, symptomatic intracerebral hemorrhage, and mortality. Results Between June 2013 and March 2019, 28 patients presenting large-vessel occlusion stroke due to IE were included. These cases were matched with 84 large-vessel occlusion stroke related to atrial fibrillation. Successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b/3) was obtained in 85.7%. Symptomatic intracranial hemorrhage, favorable outcome and mortality rates were respectively 8.0%, 25.9%, and 25.9%. In the case–control analysis, we demonstrated no difference in terms of successful reperfusion, procedural complication, symptomatic intracranial hemorrhage, and mortality rates. Three-month favorable outcome was less often achieved in the infective endocarditis group. Conclusions Mechanical thrombectomy of infective endocarditis patients presents similar safety and angiographic results compared to patients suffering from atrial fibrillation

Validation of an automatic tool for the rapid measurement of brain atrophy and white matter hyperintensity: QyScore®

International audienceObjectivesQyScore® is an imaging analysis tool certified in Europe (CE marked) and the US (FDA cleared) for the automatic volumetry of grey and white matter (GM and WM respectively), hippocampus (HP), amygdala (AM), and white matter hyperintensity (WMH). Here we compare QyScore® performances with the consensus of expert neuroradiologists.MethodsDice similarity coefficient (DSC) and the relative volume difference (RVD) for GM, WM volumes were calculated on 50 3DT1 images. DSC and the F1 metrics were calculated for WMH on 130 3DT1 and FLAIR images. For each index, we identified thresholds of reliability based on current literature review results. We hypothesized that DSC/F1 scores obtained using QyScore® markers would be higher than the threshold. In contrast, RVD scores would be lower. Regression analysis and Bland–Altman plots were obtained to evaluate QyScore® performance in comparison to the consensus of three expert neuroradiologists.ResultsThe lower bound of the DSC/F1 confidence intervals was higher than the threshold for the GM, WM, HP, AM, and WMH, and the higher bounds of the RVD confidence interval were below the threshold for the WM, GM, HP, and AM. QyScore®, compared with the consensus of three expert neuroradiologists, provides reliable performance for the automatic segmentation of the GM and WM volumes, and HP and AM volumes, as well as WMH volumes.ConclusionsQyScore® represents a reliable medical device in comparison with the consensus of expert neuroradiologists. Therefore, QyScore® could be implemented in clinical trials and clinical routine to support the diagnosis and longitudinal monitoring of neurological diseases.Key Points• QyScore® provides reliable automatic segmentation of brain structures in comparison with the consensus of three expert neuroradiologists.• QyScore® automatic segmentation could be performed on MRI images using different vendors and protocols of acquisition. In addition, the fast segmentation process saves time over manual and semi-automatic methods.• QyScore® could be implemented in clinical trials and clinical routine to support the diagnosis and longitudinal monitoring of neurological diseases

Influence of prior intravenous thrombolysis on outcome after failed mechanical thrombectomy: ETIS registry analysis

International audienceBackground : Despite constant improvements in recent years, sufficient reperfusion after mechanical thrombectomy (MT) is not reached in up to 15% of patients with large vessel occlusion stroke (LVOS). The outcome of patients with unsuccessful reperfusion after MT especially after intravenous thrombolysis (IVT) use is not known. We investigated the influence of initial IVT in this particular group of patients with failed intracranial recanalization. Methods We conducted a retrospective analysis of the Endovascular Treatment in Ischemic Stroke (ETIS) registry from January 2015 to December 2019. Patients presenting with LVOS of the anterior circulation and final modified Thrombolysis in Cerebral Infarction score (mTICI) of 0, 1 or 2a were included. Posterior circulation, isolated cervical carotid occlusions and successful reperfusions (mTICI 2b, 2c or 3) were excluded. The primary endpoint was favorable outcome (modified Rankin Scale score of 0–2) after 3 months. Secondary endpoints were safety outcomes including mortality, any intracranial hemorrhage (ICH), parenchymal hematoma (PH) and symptomatic intracranial hemorrhage (sICH) rates. Results Among 5076 patients with LVOS treated with MT, 524 patients with insufficient recanalization met inclusion criteria, of which 242 received IVT and 282 did not. Functional outcome was improved in the MT+IVT group compared with the MT alone group, although the difference did not reach statistical significance (23.0% vs 12.9%; adjusted OR=1.82; 95% CI 0.98 to 3.38; p=0.058). However, 3 month mRS shift analysis showed a significant benefit of IVT (adjusted OR=1.68; 95% CI 1.56 to 6.54). ICH and sICH rates were similar in both groups, although PH rate was higher in the MT+IVT group (adjusted OR=3.20; 95% CI 1.56 to 6.54). Conclusions : Among patients with LVOS in the anterior circulation and unsuccessful MT, IVT was associated with improved functional outcome even after unsuccessful MT. Despite recent trials questioning the place of IVT in the LVOS reperfusion strategy, these findings emphasize a subgroup of patients still benefiting from IVT

A multicenter preliminary study of cangrelor following thrombectomy failure for refractory proximal intracranial occlusions

International audienceBACKGROUND AND PURPOSE: Rescue endovascular and pharmacologic approaches are increasingly being adopted after recanalization failure of acute large-vessel occlusion strokes with mechanical thrombectomy, with encouraging results. The safety and efficacy of glycoprotein IIb/IIIa inhibitors in ischemic stroke have been investigated, though cangrelor, a recent intravenous P2Y12-receptor inhibitor with a rapid onset/offset of action and a short half-life, may be a valuable option. We compared the safety and efficacy of cangrelor with those of glycoprotein IIb/IIIa inhibitors for refractory occlusions. MATERIALS AND METHODS: We performed a retrospective analysis of the ongoing prospective, multicenter, observational Endovascular Treatment in Ischemic Stroke Registry in France between May 2012 and February 2020. Refractory intracranial occlusions of the anterior and posterior circulation were included and defined as recanalization failure of large-vessel occlusion stroke, perioperative target artery reocclusion, or high risk of early reocclusion related to an arterial wall lesion. The primary end point was a favorable outcome, defined as a 90-day mRS of 0-2. Secondary end points were reperfusion, intracranial hemorrhage, and procedural complications. RESULTS: Among 69 patients, 15 were treated with cangrelor, and 54, with glycoprotein IIb/IIIa inhibitors. The favorable outcome (adjusted OR = 2.22; 95% CI, 0.42-11.75; P =.348) and mortality (adjusted OR = 0.44; 95% CI, 0.06-3.16; P =.411) rates were similar in both groups. There was no difference in the rates of any intracranial hemorrhage (adjusted OR = 0.40; 95% CI, 0.08-2.09; P =.280), symptomatic intracranial hemorrhage (6.7% versus 0.0%, P =.058), or procedural complications (6.7% versus 20.4%, P =.215). Reperfusion rates were higher in the cangrelor group, though the difference did not reach statistical significance (93.3% versus 75.0% for modified TICI 2b-3; adjusted OR =10.88; 95% CI, 0.96-123.84; P =.054). CONCLUSIONS: Cangrelor seems to be as safe as glycoprotein IIb/IIIa inhibitors for managing refractory intracranial occlusion and leads to satisfactory brain reperfusion. Cangrelor is a promising agent in this setting, and additional studies are warranted to confirm our findings

Hydrocephalus in children with ruptured cerebral arteriovenous malformation

International audienceObjective: Hydrocephalus is a strong determinant of poor neurological outcome after intracerebral hemorrhage (ICH). In children, ruptured brain arteriovenous malformations (bAVMs) are the dominant cause of ICH. In a large prospective cohort of pediatric patients with ruptured bAVMs, the authors analyzed the rates and predictive factors of hydrocephalus requiring acute external ventricular drainage (EVD) or ventriculoperitoneal shunt (VPS).Methods: The authors performed a single-center retrospective analysis of the data from a prospectively maintained database of children admitted for a ruptured bAVM since 2002. Admission clinical and imaging predictors of EVD and VPS placement were analyzed using univariate and multivariate statistical models.Results: Among 114 patients (mean age 9.8 years) with 125 distinct ICHs due to ruptured bAVM, EVD and VPS were placed for 55/125 (44%) hemorrhagic events and 5/114 patients (4.4%), respectively. A multivariate nominal logistic regression model identified low initial Glasgow Coma Scale (iGCS) score, hydrocephalus on initial CT scan, the presence of intraventicular hemorrhage (IVH), and higher modified Graeb Scale (mGS) score as strongly associated with subsequent need for EVD (all p < 0.001). All children who needed a VPS had initial hydrocephalus requiring EVD and tended to have higher mGS scores.Conclusions: In a large cohort of pediatric patients with ruptured bAVM, almost half of the patients required EVD and 4.4% required permanent VPS. Use of a low iGCS score and a semiquantitative mGS score as indicators of the IVH burden may be helpful for decision making in the emergency setting and thus improve treatment