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Patients with pre-stroke disability, defined as a modified Rankin Scale (mRS) ≥3, were excluded from most trials of endovascular thrombectomy (EVT) for acute stroke. We sought to evaluate the prognostic factors associated with favorable outcome in stroke patients with known disability undergoing EVT, and the impact of successful reperfusion.Consecutive acute stroke patients with pre-stroke disability, undergoing EVT, were retrospectively collected between 2016 to 2019 from a Canadian cohort and a multicenter French cohort (Endovascular Treatment in Ischemic Stroke registry-ETIS). Favorable outcome was defined as an mRS equal to pre-stroke mRS. Patients achieving successful reperfusion (defined as a modified Thrombolysis in Cerebral Infarction score of 2b/3) were compared with patients without successful reperfusion to determine if successful EVT was associated with better functional outcomes.Among 6220 patients treated with EVT, 280 (4.5%) patients with a pre-stroke mRS ≥3 were included. Sixty-one patients (21.8%) had a favorable outcome and 146 (52.1%) died at 3 months. Patients with successful reperfusion had a higher proportion of favorable 90-day mRS (27.6% versus 19.6%, p = 0.025) and a lower mortality (48.3% versus 69.6%, p = 0.008) than patients without successful reperfusion. After adjusting for baseline prognostic factors, successful reperfusion defined by TICI ≥2b was associated with favorable functional outcome (OR 3.16 CI95% [1.11-11.5]; p 0.048).In patients with pre-stroke disability, successful reperfusion is associated with a greater proportion of favorable outcome and lower mortality.

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 ± 7.1 mm) 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.

Background and purpose Choice of anesthesia type on outcome for mechanical thrombectomy (MT) in acute ischemic stroke remains controversial. The goal of our research was to study the impact of anesthesia strategy on the delay, angiographic and neurological outcome of MT performed under general anesthesia (GA) vs. conscious sedation (CS). Methods This prospective, single-center observational study included patients with anterior circulation large vessel occlusion (ACLVO) strokes treated with MT within 6 hours of symptom onset. All time metrics were evaluated. Angiographic and clinical outcomes were assessed by recanalization rate (mTICI) and 3-month functional independence (mRs). Complications and mortality rate were recorded as safety outcomes. Results In total, 303 consecutive thrombectomies were performed, 86.8% under GA. NIHSS was higher in GA, with median of 19.0 for GA and 16.5 for CS (P = 0.049). Median time from arrival in hospital (door) to groin puncture was 83 min (IQR = 45.0–109.5) for GA compared to 72 min (IQR = 35.0–85.3) for CS, P = 0.170). Median time from arrival in the angiosuite to groin puncture was 20 min (IQR = 15.0–29.0) for GA compared to 15 min (IQR = 10.0–20.0) for CS, P = 0.017). There were no significant differences in recanalization time metrics, successful revascularization rate, functional independence and mortality rate at three months. Conclusions GA induced a 5 to 10 minutes delay for groin puncture, without impact on recanalization time metrics, or neurological outcome at 3 months. Our results demonstrate that a well-organized workflow is associated with reasonable delay in performing GA for MT, without effect on outcome compared to sedation.

Background and purpose Flow disruption with the WEB device is an innovative technique for the endovascular treatment of wide neck bifurcation aneurysms. Good clinical practice trials have shown high safety of this treatment with good efficacy. Technical developments (single layer devices and smaller microcatheters) facilitate the treatment, potentially leading to enlargement of indications. This series is collecting aneurysms in “atypical” locations for WEB treatment and analyzing safety and efficacy of this treatment. Materials and methods In each participating center, patients with aneurysms treated with WEB were prospectively included in a local database. Patients treated for aneurysms in “atypical” locations were extracted. Patient and aneurysm characteristics, intraoperative complications, and anatomical results at the end of the procedure and at last follow-up were collected and analyzed. Results Five French neurointerventional centers included 20 patients with 20 aneurysms in “atypical” locations for WEB treatment treated with WEB. Aneurysm locations were ICA carotid-ophthalmic in 9 aneurysms (45.0%), ICA posterior communicating in 4 (20.0%), Pericallosal artery in 5 (25.0%), and basilar artery between P1 and superior cerebellar artery in 2 (10.0%). There were no complications (thromboembolic or intraoperative rupture) in this series. At follow-up (mean: 7.4 months), adequate occlusion was obtained in 100.0% of aneurysms. Conclusions This series confirms that it is possible to enlarge indications of WEB treatment to “atypical” locations with good safety and efficacy. These data have to be confirmed in large prospective series.

Background To compare efficacy and safety of mechanical thrombectomy (MT) depending on mono versus biplane angioroom (AR), radiation exposure, contrast dose, procedure duration for acute ischemic stroke with large vessel occlusion (AISLVO) according to procedural factors. To realize a systematic literature review on the single/biplane comparison. Materials and methods Between January 2014 and May 2017, 906 consecutive patients from 3 countries with all available data underwent a MT in four centers: – 330 on a single-plane (SP); – 576 on a biplane; – data were retrospectively analyzed. Efficacy and safety characteristics, radiation dose, contrast load and fluoroscopy duration were analyzed and compared depending on clinical and procedural factors of the AR. Results After multivariate analysis, only contrast load (50% lower) and scopy duration (19% lower) remained significantly lower on biplane versus monoplane. There was no difference concerning procedure duration, radiation doses, rate of successful recanalization, outcome and complication between MP and biplane, Philips and Siemens after multivariate analyses. Among other factors, general anaesthesia was associated with higher DAP, Kerma, contrast load. Performing an angiogram before MT was associated with increased procedure duration (15% increase), DAP (33% increase), contrast load (125% increase) on univariate analyses. Conclusion Both AR seem to be equivalent in terms of safety and effectiveness for MT. Biplane equipment drastically reduces contrast load. The decision to realize an angiogram before a MT should be clinically motivated because of increased radiation, contrast doses and procedure duration.

Background Aneurysm recanalization concomitant to endo-saccular device (WEB) compaction has been reported. Association of compaction and aneurysm remnant is still discussed in literature. Effect of WEB oversizing on compaction and recanalization rates remains unknown. Objective To assess the association of WEB compaction and risk of aneurysmal remnant. To assess the association of oversized WEB with complete aneurysmal occlusion, peri-procedural complication, WEB compaction. Methods We retrospectively included all patients treated with the WEB in our center between March 2012 and August 2018 from a prospectively maintained registry. Review Board approval was obtained. From February 2015 to August 2018, we used the oversizing technique (increase of the WEB width of 1 mm compared to aneurysmal width). First we analyzed the association between compaction and occlusion rates. We then compared patients before and after this technical shift, as long as patients with and without “ > 1 oversized WEB” (oversizing >1 mm) for peri-procedural complication, device compaction, complete and adequate occlusion, at 3 to 6 months, 12 to 18 months and after 24 months follow-up (FU). Statistical analyses were performed. Results We treated 78 aneurysms in 77 patients. In case of compaction, patients had a lower rate of adequate (91% vs 52%, P = 0.005) and complete occlusion (36% vs. 16% P = 0.05). The oversizing technique led to improved rates of no-compaction (36 vs. 18%), complete occlusion (28 vs. 13%) at last follow-up despite no statistical significance. For “ > 1 oversized WEB”, per-procedure complication rate was 3 times higher despite being non-statistically significant (P = 0.07). At last follow-up, no-compaction risk was improved (48 vs. 21%, P = 0.02) but complete and adequate final occlusion rates were not different. Conclusion WEB compaction is associated with increased rates of aneurysm remnants. WEB oversizing may improve the complete occlusion rate whereas decreasing WEB compaction. A too much oversizing may lead to increase the risk of per-procedure complication whereas no additional effect on aneurysmal occlusion. Rate of adequate occlusions remains acceptable.

Objectif Evaluer l’exposition aux rayons X et d’autres aspects techniques et cliniques lors de thrombectomies pour AVC ischemique suivant le type de salle d’angiographie utilisee. Determiner s’il existe une salle d’angiographie plus performante pour cette procedure. Methodes Etude unicentrique avec analyse retrospective de donnees acquises prospectivement. Entre decembre 2013 et octobre 2016, 397 patients ont ete traites par thrombectomie, 50 au sein de notre salle single-plane (MP), 24 dans la biplane avant module clarity (BP) (systeme de reduction de dose [SRD] Philips) et 317 avec module clarity (BPC). Les types d’occlusion, duree de procedure (min), type de traitement, taux de recanalisation et complications, dose de rayons X (mGy⋅cm2), quantite de contraste (mL), duree de scopie (min) et type de salle ont ete analyses en fonction de la salle d’angiographie et d’autres aspects cliniques et techniques. Resultats Une reduction significative de la dose moyenne delivree a ete mise en evidence pour les patients du groupe BPC (93 090 mGy⋅cm2) versus BP (142 158 mGy⋅cm2) (p = 10−3, ratio : 1,53) et BPC versus MP (138 228⋅mGy.cm2) (p = 0,002, ratio : 1,49). La quantite moyenne de contraste etait inferieure dans le groupe BP (et BPC) versus MP (125/148 mL ; 16 % de diminution, p = 0,042). L’utilisation de l’aspiration permettait de diminuer la quantite de contraste et la duree de la procedure (p Conclusion Le type de salle d’angiographie n’impacte pas la reussite d’une thrombectomie, cependant l’utilisation d’un SRD permet de diminuer l’irradiation de cette procedure, restant peu irradiante comparee aux autres interventions en neuroradiologie.

Objectif Evaluer l’influence de la visualisation des thrombus en T2* (SVS) sur la recanalisation, le bon pronostic clinique a 3 mois et l’etiologie de l’accident vasculaire cerebral des patients traites par thrombectomie mecanique. Materiels et methodes Cette etude observationnelle portait sur une base de donnee prospective des infarctus cerebraux traites par thrombectomie mecanique recueillant des donnees cliniques et radiologiques. Les criteres d’inclusion etaient : avoir un infarctus cerebral diagnostique sur une IRM avec une sequence T2*, traite par thrombectomie mecanique avec ou sans thrombolyse intra veineuse. La visualisation (SVS+) ou non (SVS−) du thrombus en T2* etait realisee independamment par deux observateurs. La recanalisation etait evaluee en de fin de procedure par le score TICI. L’handicap residuel (evalue par le score mRS), et l’etiologie de l’infarctus etaient etablis a distance par un neurologue. Resultats Sur 180 patients, un SVS+ etait retrouve chez 137 (76 %) patients et SVS− dans 43 (24 %) cas. Le coefficient de variabilite inter-observateur etait de k = 0,609 avec un IC 95 % [0,485–0,732]. La recanalisation TICI2b/3 etait significativement associee a la presence du SVS+ avec un OR = 3,11, IC 95 % [1,29–7,57], p = 0,01 apres analyse multivariee. L’association entre SVS+ et mRS 0–2 n’etait pas significative, OR = 0,59, [0,27–1,28], p = 0,15. Comme pour le SVS et la cause cardioembolique OR = 1,81, IC 95 % [0,77–4,34], p = 0,18. La TIV, n’etait pas significativement associee a une recanalisation satisfaisante ou un bon pronostic a 3 mois en multivariee. Conclusion La presence ou l’absence du SVS est un biomarqueur, fiable et accessible, predictif d’une meilleure recanalisation lors de la thrombectomie mecanique independamment du traitement par TIV.

Summary Background and purpose To evaluate the safety and efficacy of onyx for embolization of brain arteriovenous malformations (BAVM). Methods A prospective, multicenter study was conducted in France to evaluate embolization of BAVM with onyx. From May 2003 to March 2005, 50 patients (26 females, 24 males; mean age: 34.8 years, range: 16–64 years) were included. Clinical presentation was haemorrhage in 22 patients (44.0%), seizures in 16 patients (32.0%), headaches in six patients (12.0%) and progressive neurological deficit in two cases (4.0%). Four patients were asymptomatic (8.0%). Results One hundred and forty-nine sessions of embolization were performed: one to eight sessions/patient with a mean of 3.0 sessions. One hundred and sixteen sessions (77.9%) were performed with onyx, 20 sessions (13.4%) with glue and 13 sessions (8.7%) with onyx and glue. Symptomatic acute postembolization haemorrhage (APEH) was observed in four cases (8.0% per patient). At 1 month, morbidity and mortality related to the treatment were of 8% and 2%, respectively. Complete BAVM occlusion was obtained in 8.3% of cases. In the remaining cases, occlusion rate was between 99 and 80% in 56.3% of patients, 79 and 60% in 16.7%, and less than 60 in 18.7%. In case of incomplete occlusion, complementary treatment was performed by radiosurgery. Conclusion Onyx is suitable for BAVM embolization with acceptable morbidity and mortality.

Resume Les auteurs rapportent le cas d’une forme cerebrale d’adrenoleucodystrophie (ALD), decouverte chez un adulte jeune a l’occasion d’un bilan realise pour hemianopsie laterale homonyme. La forme cerebrale de l’adulte represente environ 3 % des cas decrits d’ALD. L’observation decrit la presentation clinique, l’imagerie IRM conventionnelle et spectroscopique ainsi que son interet dans la prise en charge du patient.

Imaging of stroke has evolved with the development of stroke units and the CE approval of intravenous thrombolysis in the first three hours after stroke onset. The goal of imaging in the acute phase of stroke is: to make the diagnosis of stroke; to rule out other diagnosis (above all hemorrhagic strokes); to precise the location of the arterial occlusion; to assess the level of hypoperfusion; to evaluate the viability and reversibility of brain lesions; to understand the origin of the stroke by evaluating cervical arteries. Constraints of imaging in the acute phase of stroke are: the need to be performed as fast as possible to not delay IV thrombolysis (time is brain); machines must be available 24 hours a day, 7 days a week as close as possible to the stroke unit. The aim of imaging are: in routine practice to evaluate the likely benefits (provided by penumbra imaging) and risks of IV thrombolysis; in term of “evidence based medicine” to better evaluate new specific stroke therapies in randomized studies (IV thrombolysis between 3 to 4 hours, use of anti GpIIbIIIa, intra-arterial mechanical or chemical thrombolysis…). Magnetic resonance imaging is considered the goal standard of stroke imaging allowing to evaluate in a “one stop shopping” the level of arterial occlusion, hypoperfusion and brain viability. However, stroke management is a regional issue and performing MR in extreme emergency is almost impossible in all stroke units outside or even within university hospitals 24 hours a day. CT-perfusion and CT angiography are therefore an accurate alternative tool for acute stroke imaging. Multislice CT is indeed available in almost all stroke units. The examination is very time-saving and clinically relevant to make the decision for IV thrombolysis.

Introduction Le flow diverter (FD), dispositif medical onereux de classe III, est une endoprothese pour embolisation arterielle indiquee en neuroradiologie interventionnelle dans les anevrismes intracrâniens non rompus, sacciformes ou fusiformes, dont le diametre du sac anevrismal est superieur a 15 mm et inaccessibles aux therapeutiques actuelles (traitement endovasculaire avec microspires ou utilisation d’un ballon ou traitement chirurgical) du fait de ses caracteristiques morphologiques. La famille des FD est constituee de plusieurs specialites (SURPASS®, SILK®, P64®, DERIVO®) dont PIPELINE FLEX® reference au CHU de Toulouse. Les FD sont inscrits sur la liste des produits et prestations remboursables (LPPR) pour cette seule indication, ce qui nous a amene a evaluer le respect de l’indication remboursee, les differentes indications hors LPPR et leur justification bibliographique dans la litterature internationale. Materiels et methode Le logiciel de tracabilite Xplore a ete utilise pour exporter les donnees liees au code produit du FD pour les patients hospitalises en Imagerie entre le 01/07/2015 et le 30/06/2016. Puis ces donnees ont ete completees a l’aide du dossier patient papier afin de connaitre precisement le contexte de l’indication LPPR ou hors LPPR. Pour completer cette etude retrospective, une recherche bibliographique a ete effectuee pour toutes les indications hors LPPR retrouvees afin de justifier l’utilisation du FD. Resultats et discussion Pour 33 patients au total traites par PIPELINE FLEX®, on retient seulement 4 cas d’indications LPPR (12,1 %), les 29 autres cas concernent des embolisations d’anevrismes de taille inferieure ou egale a 15 mm, soit pres de 9 cas sur 10. Parmi elles, les embolisations des anevrismes deja traites ayant une recanalisation non rompue du sac anevrismal mesurant plus de 7 mm de diametre et non accessible a un traitement conservateur, sont concernees dans 17 % des cas. Il s’agit d’une indication supplementaire au texte LPPR, retrouve dans l’avis de la CNEDIMTS du 24 mars 2015. Il est retrouve dans la litterature internationale 13 references en faveur de l’embolisation des anevrismes intracrâniens de taille inferieure ou egale a 15 mm, dont 7 publications qui concernent les specialites PIPELINE FLEX® et SILK®, et 2 references en faveur des anevrismes de bifurcation. Toutes les references bibliographiques ont ete validees par les medecins prescripteurs. Conclusion Dans le cadre du contrat de bon usage des medicaments, produits et prestations, la prescription du FD hors indication remboursable, concernant pres de 90 % des cas, necessite une justification bibliographique qui sera presentee prochainement a la commission des medicaments et dispositifs medicaux steriles de l’etablissement, afin d’obtenir une validation par une instance decisionnelle locale.

Objectifs pedagogiques Connaitre la technique et les principales indications de la radiochirurgie. Definir le role de l’imageur avant le traitement par des protocols adaptes aux indications, pendant le traitement, apres le traitement par une surveillance et un suivi. Messages a retenir L’imageur participe activement au fonctionnement et au traitement radiochirurgical en fournissant une imagerie (scanner, IRM, angiographie) adaptee aux protocoles etablis en fonction des indications reconnues : neurinomes, meningiomes, malformation arterioveineuse, metastases, nevralgie faciale, spinale.