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1. Head or Neck First? Speed and Rates of Reperfusion in Thrombectomy for Tandem Large Vessel Occlusion Strokes

Author

Serge Bracard, Mikael Mazighi, René Anxionnat, Salvatore Mangiafico, Panagiotis Papanagiotou, Christian Taschner, Christophe Cognard, Alessandra Biondi, Monika Killer, Bertrand Lapergue, Benjamin Gory, Diogo C Haussen, Markus Holtmannspötter, Maria Boutchakova, Marios Psychogios, Michel Piotin, Adnan H. Siddiqui, Jonathan A. Grossberg, Marc-Antoine Labeyrie, Franziska Dorn, Francis Turjman, Raul G Nogueira, Alejandro M Spiotta, Marc Ribó, Sebastian Eiden, Henrik Steglich-Arnholm, Sébastien Richard, Julien Labreuche, Emory University [Atlanta, GA], Hospices Civils de Lyon (HCL), Hôpital de la Fondation Ophtalmologique Adolphe de Rothschild [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Evaluation des technologies de santé et des pratiques médicales - ULR 2694 (METRICS), Université de Lille-Centre Hospitalier Régional Universitaire [Lille] (CHRU Lille), Rigshospitalet [Copenhagen], Copenhagen University Hospital, Universitäts Klinikum Freiburg = University Medical Center Freiburg (Uniklinik), Klinikum Bremen-Mitte, State University of New York (SUNY), Hôpital Foch [Suresnes], University-Hospital Munich-Großhadern [München], Service Neuroradiologie Diagnostique et Thérapeutique [CHU Toulouse], Pôle imagerie médicale [CHU Toulouse], Centre Hospitalier Universitaire de Toulouse (CHU Toulouse)-Centre Hospitalier Universitaire de Toulouse (CHU Toulouse), Paracelsus Medizinische Privatuniversität = Paracelsus Medical University (PMU), Azienda Ospedaliero-Universitaria Careggi [Firenze] (AOUC), Vall d'Hebron University Hospital [Barcelona], University Medical Center Göttingen (UMG), Medical University of South Carolina [Charleston] (MUSC), Service de Neuroradiologie [CHU Lariboisière], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpital Lariboisière-Fernand-Widal [APHP], Laboratoire de Recherche Vasculaire Translationnelle (LVTS (UMR_S_1148 / U1148)), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité)-Université Sorbonne Paris Nord, Centre Hospitalier Régional Universitaire de Besançon (CHRU Besançon), Service de neurologie [CHRU Nancy], Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy), Défaillance Cardiovasculaire Aiguë et Chronique (DCAC), Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lorraine (UL), Imagerie Adaptative Diagnostique et Interventionnelle (IADI), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lorraine (UL), Département de neuroradiologie diagnostique et thérapeutique [CHRU Nancy], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU), Freiburg University Medical Center, Neuroradiologie Diagnostique et Thérapeutique [Toulouse], Université Toulouse III - Paul Sabatier (UT3), Université Fédérale Toulouse Midi-Pyrénées-Université Fédérale Toulouse Midi-Pyrénées-CHU Toulouse [Toulouse]-Hôpital Purpan [Toulouse], CHU Toulouse [Toulouse], Azienda Ospedaliero-Universitaria Careggi (AOU Careggi), and Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP)-Université Sorbonne Paris Nord

Subjects
medicine.medical_specialty, medicine.medical_treatment, [SDV.IB.MN]Life Sciences [q-bio]/Bioengineering/Nuclear medicine, 030204 cardiovascular system & hematology, Revascularization, Lesion, 03 medical and health sciences, 0302 clinical medicine, medicine.artery, Angioplasty, medicine, [INFO.INFO-IM]Computer Science [cs]/Medical Imaging, Stroke, Original Paper, Cerebral infarction, business.industry, Stent, Thrombolysis, medicine.disease, 3. Good health, Surgery, Neurology (clinical), medicine.symptom, Internal carotid artery, Cardiology and Cardiovascular Medicine, business, 030217 neurology & neurosurgery, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology
Abstract

Background: We aim to evaluate the speed and rates of reperfusion in tandem large vessel occlusion acute stroke patients undergoing upfront cervical lesion treatment (Neck-First: angioplasty and/or stent before thrombectomy) as compared to direct intracranial occlusion therapy (Head-First) in a large international multicenter cohort. Methods: The Thrombectomy In TANdem Lesions (TITAN) collaboration pooled individual data of prospectively collected thrombectomy international databases for all consecutive anterior circulation tandem patients who underwent emergent thrombectomy. The co-primary outcome measures were rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b/3) and time from groin puncture to successful reperfusion. Results: In total, 289 patients with tandem atherosclerotic etiology were included in the analysis (182 Neck-First and 107 Head-First patients). Except for differences in the Alberta Stroke Program Early CT Score (ASPECTS; median 8 [range 7–10] Neck-First vs. 7 [range 6–8] Head-First; p < 0.001) and cervical internal carotid artery (ICA) lesion severity (complete occlusion in 35% of the Neck-First vs. 57% of the Head-First patients; p < 0.001), patient characteristics were well balanced. After adjustments, there was no difference in successful reperfusion rates between the study groups (odds ratio associated with Neck-First: 1.18 [95% confidence interval, 0.60–2.17]). The time to successful reperfusion from groin puncture was significantly shorter in the Head-First group after adjustments (median 56 min [range 39–90] vs. 70 [range 50–102]; p = 0.001). No significant differences in the rates of full reperfusion, symptomatic hemorrhage, 90-day independence, or mortality were observed. Sensitivity analysis excluding patients with complete cervical ICA occlusion yielded similar results. Conclusions: The upfront approach of the intracranial lesion in patients with tandem large vessel occlusion strokes leads to similar reperfusion rates but faster reperfusion as compared to initial cervical revascularization followed by mechanical thrombectomy. Controlled studies are warranted.

Published
2020
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2. Periprocedural Heparin During Endovascular Treatment of Tandem Lesions in Patients with Acute Ischemic Stroke: A Propensity Score Analysis from TITAN Registry

Author

François, Zhu, Michel, Piotin, Henrik, Steglich-Arnholm, Julien, Labreuche, Markus, Holtmannspötter, Christian, Taschner, Sebastian, Eiden, Diogo C, Haussen, Raul G, Nogueira, Panagiotis, Papanagiotou, Maria, Boutchakova, Adnan H, Siddiqui, Bertrand, Lapergue, Franziska, Dorn, Christophe, Cognard, Monika, Killer-Oberpfalzer, Salvatore, Mangiafico, Marc, Ribo, Marios N, Psychogios, Alejandro, Spiotta, Mohammad, Anadani, Marc-Antoine, Labeyrie, Mikael, Mazighi, Alessandra, Biondi, Sébastien, Richard, René, Anxionnat, Serge, Bracard, Francis, Turjman, Benjamin, Gory, Jean-Christophe, Lacour, Département de neuroradiologie diagnostique et thérapeutique [CHRU Nancy], Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy), Imagerie Adaptative Diagnostique et Interventionnelle (IADI), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lorraine (UL), Hôpital Rothschild [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Rigshospitalet [Copenhagen], Copenhagen University Hospital, Evaluation des technologies de santé et des pratiques médicales - ULR 2694 (METRICS), Université de Lille-Centre Hospitalier Régional Universitaire [Lille] (CHRU Lille), Freiburg University Medical Center, Emory University School of Medicine, Emory University [Atlanta, GA], Klinikum Bremen-Mitte, University at Buffalo [SUNY] (SUNY Buffalo), State University of New York (SUNY), Hôpital Foch [Suresnes], University-Hospital Munich-Großhadern [München], Service de neuroradiologie [CHU Toulouse], CHU Toulouse [Toulouse], Paracelsus Medizinische Privatuniversität = Paracelsus Medical University (PMU), Careggi University Hospital, Vall d'Hebron University Hospital [Barcelona], University Medical Center Göttingen (UMG), Medical University of South Carolina [Charleston] (MUSC), Service de Neuroradiologie [CHU Lariboisière], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpital Lariboisière-Fernand-Widal [APHP], Service de Neuroradiologie [CHRU Besançon], Centre Hospitalier Régional Universitaire de Besançon (CHRU Besançon), Défaillance Cardiovasculaire Aiguë et Chronique (DCAC), Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lorraine (UL), Service de neurologie [CHRU Nancy], Hospices Civils de Lyon (HCL), CHU Rothschild [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU), Universitäts Klinikum Freiburg = University Medical Center Freiburg (Uniklinik), Pôle Cardiovasculaire et Métabolique [CHU Toulouse], and Centre Hospitalier Universitaire de Toulouse (CHU Toulouse)

Subjects
Male, medicine.medical_specialty, Time Factors, Endovascular Treatment, Brain Ischemia, 030218 nuclear medicine & medical imaging, Tandem occlusion, 03 medical and health sciences, Anticoagulation, 0302 clinical medicine, Modified Rankin Scale, Occlusion, medicine, Humans, Radiology, Nuclear Medicine and imaging, Prospective Studies, Registries, Propensity Score, Stroke, Acute ischemic stroke, Retrospective Studies, Thrombectomy, business.industry, Heparin, Endovascular Procedures, Anticoagulants, Middle Aged, medicine.disease, Combined Modality Therapy, 3. Good health, Surgery, Treatment Outcome, Propensity score matching, Cohort, Female, Observational study, Cardiology and Cardiovascular Medicine, business, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology, medicine.drug
Abstract

International audience; Background and purpose: Data on safety and efficacy of periprocedural use of heparin are limited during treatment of acute ischemic stroke patients with anterior circulation tandem occlusion. This study aimed to investigate the impact of heparin use during endovascular therapy of anterior circulation tandem occlusions on the functional and safety outcomes.Methods: A retrospective analysis of the multicenter observational TITAN registry was performed. Patients with anterior circulation tandem occlusion and treated with endovascular therapy (EVT) were included, with or without extracranial carotid intervention. We divided patients into two groups based on periprocedural heparin use (heparin vs. non-heparin). The dose of intravenous unfractionated heparin ranged from 1500 to 2500 I.U. Primary study endpoint was 90-day Modified Rankin Scale (mRS). Secondary study endpoint included angiographic and safety endpoints such as hemorrhagic complications. A propensity-score-matched analysis was performed.Results: Among 369 patients, heparin was used in 68 patients (18.4%). In the propensity-score-matched cohort, favorable outcome (mRS 0-2) occurred in 51.3% in heparin group and 58.0% in non-heparin group (matched OR, 0.76; 95% CI, 0.32-1.78; P = 0.52). Similar result was found in propensity-score-adjusted cohort (adjusted OR, 0.72; 95%CI, 0.39-1.32; P = 0.28). Likewise, there was no difference in the rate of successful reperfusion (mTICI 2b-3) (propensity-score-adjusted OR, 1.03; 95%CI, 0.50-2.09; P = 0.93) neither in safety endpoints between the two groups.Conclusions: Periprocedural heparin use during EVT of anterior circulation tandem occlusions was not associated with better functional, angiographic or safety outcomes. These findings are applicable for low doses of heparin, and further studies are warranted.

Published
2019
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3. Abstract WP10: Impact of Prior Intravenous Thrombolysis on the Outcome of Emergent Carotid Stenting in Acute Stroke Patients With Tandem Occlusion: A Collaborative Pooled Analysis

Author

René Anxionnat, Sebastian Eiden, Salvatore Mangiafico, Marc Ribó, Diogo C Haussen, Benjamin Gory, Marc A Labeyrie, Monika Killer, Franziska Dorn, Bertrand Lapergue, Mohammad Anadani, Henrik Steglich-Arnholm, Marios Psychogios, Alejandro M Spiotta, Biondi Alessandra, Markus Holtmannspötter, Serge Bracard, Sébastien Richard, Christian Taschner, Michel Piotin, Mikael Mazighi, Christophe Cognard, Raul G Nogueira, Panagiotis Papanagiotou, Francis Turjman, Maria Boutchakova, Steven Lauzon, Adnan H. Siddiqui, Medical University of South Carolina [Charleston] (MUSC), Hôpital de la Fondation Ophtalmologique Adolphe de Rothschild [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU), Hospices Civils de Lyon (HCL), Rigshospitalet [Copenhagen], Copenhagen University Hospital, Freiburg University Medical Center, Emory University School of Medicine, Emory University [Atlanta, GA], Klinikum Bremen-Mitte, University at Buffalo [SUNY] (SUNY Buffalo), State University of New York (SUNY), Hôpital Foch [Suresnes], Klinikum der Universität [München], Neuroradiologie Diagnostique et Thérapeutique [Toulouse], Université Toulouse III - Paul Sabatier (UT3), Université Fédérale Toulouse Midi-Pyrénées-Université Fédérale Toulouse Midi-Pyrénées-CHU Toulouse [Toulouse]-Hôpital Purpan [Toulouse], CHU Toulouse [Toulouse], Paracelsus Medizinische Privatuniversität = Paracelsus Medical University (PMU), Azienda Ospedaliero-Universitaria Careggi (AOU Careggi), Vall d'Hebron University Hospital [Barcelona], University Medical Center Göttingen (UMG), Service de Neuroradiologie [CHU Lariboisière], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpital Lariboisière-Fernand-Widal [APHP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Centre Hospitalier Régional Universitaire de Besançon (CHRU Besançon), Département de neuroradiologie diagnostique et thérapeutique [CHRU Nancy], Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy), Imagerie Adaptative Diagnostique et Interventionnelle (IADI), and Université de Lorraine (UL)-Institut National de la Santé et de la Recherche Médicale (INSERM)

Subjects
medicine.medical_specialty, medicine.medical_treatment, [SDV.IB.MN]Life Sciences [q-bio]/Bioengineering/Nuclear medicine, 030204 cardiovascular system & hematology, 03 medical and health sciences, 0302 clinical medicine, Internal medicine, Occlusion, medicine, [INFO.INFO-IM]Computer Science [cs]/Medical Imaging, Stroke, ComputingMilieux_MISCELLANEOUS, Acute stroke, Advanced and Specialized Nursing, business.industry, Stent, Thrombolysis, medicine.disease, Pooled analysis, Cardiology, Neurology (clinical), Carotid stenting, Cardiology and Cardiovascular Medicine, business, 030217 neurology & neurosurgery, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology
Abstract

Background: Acute tandem occlusion (ATO) management is technically challenging and was not sufficiently evaluated in trials. There is evidence suggesting the efficacy and safety of emergent carotid stenting in conjunction with mechanical thrombectomy (MT) for ATO treatment. However, the safety of carotid stenting (CS) post intravenous tPA (IVT) treatment remains unclear. Objective: to report the safety and functional outcomes of emergent CS post IVT, and compare it to non-IVT patients. Methods: This was a retrospective multicenter international TITAN collaboration including 18 endovascular databases. In the present analysis, patients were included if they presented with acute ischemic stroke (AIS) due to ATO and were treated with CS in conjunction with MT. ATO was defined as an extracranial internal carotid artery (ICA) lesion (complete occlusion or stenosis >=90%) and an intracranial proximal occlusion (distal ICA and/or first or second segment of the middle cerebral artery). Outcome measures included final mTICI score, 90 day-modified Rankin Scale (mRS), mortality, procedural complications, and symptomatic intracerebral hemorrhage. Mixed effects logistic model was used to determine the predictors of each outcome Results: Among 454 patients with ATO, 289 were treated with CS and included in the present analysis. One hundred seventy-five patients (60%) of the included patients received IVT prior to MT. Onset to groin was shorter in the IVT group (259 ±251 vs. 353±238; p=0.013). Otherwise, there was no difference in baseline characteristics between the two groups. Heparin use during procedure was less in IVT group (20% vs. 54%; p Conclusion: Emergent CS in association with MT after IVT was safe and was not associated with an increased risk of sICH or procedural complications.

Published
2019
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4. Abstract TP29: Complete Occlusion is Associated With Lower Recanalization Rate in Patients With Acute Stroke With Tandem Lesion Treated With Thrombectomy

Author

Mikael Mazighi, Serge Bracard, Diogo C Haussen, Panagiotis Papanagiotou, Franziska Dorn, Marios Psychogios, Bertrand Lapergue, Monika Killer, Marc Ribó, Christophe Cognard, Christian Taschner, Mohammad Anadani, Michel Piotin, Alessandra Biondi, Adnan H. Siddiqui, Markus Holtmannspötter, Francis Turjman, Henrik Steglich-Arnholm, Sébastien Richard, Raul G Nogueira, Benjamin Gory, Sebastian Eiden, René Anxionnat, Salvatore Mangiafico, Marc A Labeyrie, Alejandro M Spiotta, Maria Boutchakova, Medical University of South Carolina [Charleston] (MUSC), Hôpital de la Fondation Ophtalmologique Adolphe de Rothschild [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU), Hospices Civils de Lyon (HCL), Rigshospitalet [Copenhagen], Copenhagen University Hospital, Freiburg University Medical Center, Emory University School of Medicine, Emory University [Atlanta, GA], Klinikum Bremen-Mitte, University at Buffalo [SUNY] (SUNY Buffalo), State University of New York (SUNY), Hôpital Foch [Suresnes], Klinikum der Universität [München], CHU Toulouse [Toulouse], Paracelsus Medizinische Privatuniversität = Paracelsus Medical University (PMU), Azienda Ospedaliero-Universitaria Careggi (AOU Careggi), Vall d'Hebron University Hospital [Barcelona], University Medical Center Göttingen (UMG), Hôpital Lariboisière-Fernand-Widal [APHP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Centre Hospitalier Régional Universitaire de Besançon (CHRU Besançon), Centre d'investigation clinique plurithématique Pierre Drouin [Nancy] (CIC-P), Centre d'investigation clinique [Nancy] (CIC), Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lorraine (UL)-Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lorraine (UL), Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy), Imagerie Adaptative Diagnostique et Interventionnelle (IADI), and Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lorraine (UL)

Subjects
Advanced and Specialized Nursing, medicine.medical_specialty, business.industry, medicine.medical_treatment, Thrombolysis, [SDV.IB.MN]Life Sciences [q-bio]/Bioengineering/Nuclear medicine, medicine.disease, Lesion, medicine.artery, Internal medicine, Complete occlusion, Occlusion, Cardiology, [INFO.INFO-IM]Computer Science [cs]/Medical Imaging, Medicine, In patient, Neurology (clinical), Internal carotid artery, medicine.symptom, Cardiology and Cardiovascular Medicine, business, Stroke, ComputingMilieux_MISCELLANEOUS, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology, Acute stroke
Abstract

Introduction: Previous studies showed that mechanical thrombectomy (MT) is safe and effective in tandem steno-occlusive lesion. The effect on initial tandem extracranial internal carotid artery (ICA) lesion severity on outcome is unknown. In this study, we aimed to compare angiographic, functional and hemorrhagic outcomes according to initial lesion severity Methods: A multicenter international retrospective study that included 18 stroke centers. Patients were included if they presented with ischemic stroke due to tandem lesion and were treated with MT with or without carotid stenting. Tandem lesion was defined as proximal intracranial occlusion (distal ICA, M1/M2) and extracranial internal carotid artery (ICA) occlusion or ≥90% stenosis NASCET. We divided patients into two groups based on extracranial ICA lesion severity (severe stenosis vs. complete occlusion) at the first angiographic run. Outcome measures included 90 day mRS, final mTICI score, procedural complications and symptomatic hemorrhage. Symptomatic hemorrhage (Sich) was defined based on ECASS criteria. Results: A total of 305 patients were included in the present analysis. 134 patients had complete ICA occlusion (group 1) ,and 170 had ≥90% ICA stenosis (group 2). Hyperlipidemia was more frequent in group 1 ((46.5% vs. 33.6%, p=0.032), and diabetes was less frequent (12.4 vs. 23.8%;p=0.011). Otherwise there was no significant difference in baseline characteristics, pretreatment tPA , and ASPECTS between two groups. With respect to outcome, successful recanalization (TICI 2b-3) was lower in group 1 than group 2 (70% vs. 80%; p=0.038). Similarly TICI 3 was achieved in less patients in group 1 (24% vs. 40%;p=0.022). Favorable outcome (mRS 0-2), sICH and procedural complications were similar in both groups. Conclusion: Initial angiographic severity of extracranial ICA lesion in tandem occlusions was associated with lower recanalization rates after MT, without impact on clinical outcomes.

Published
2019
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5. Carotid Stenting With Antithrombotic Agents and Intracranial Thrombectomy Leads to the Highest Recanalization Rate in Patients With Acute Stroke With Tandem Lesions

Author

Panagiotis Papanagiotou, Diogo C. Haussen, Francis Turjman, Julien Labreuche, Michel Piotin, Andreas Kastrup, Henrik Steglich-Arnholm, Markus Holtmannspötter, Christian Taschner, Sebastian Eiden, Raul G. Nogueira, Maria Boutchakova, Adnan Siddiqui, Bertrand Lapergue, Franziska Dorn, Christophe Cognard, Monika Killer, Salvatore Mangiafico, Marc Ribo, Marios N. Psychogios, Alejandro Spiotta, Marc Antoine Labeyrie, Alessandra Biondi, Mikaël Mazighi, Sébastien Richard, René Anxionnat, Serge Bracard, Benjamin Gory, Jonathan Andrew Grossberg, Adrien Guenego, Julien Darcourt, Isabelle Vukasinovic, Elisa Pomero, Jason Davies, Leonardo Renieri, Corentin Hecker, Maria Muchada Muchada, Arturo Consoli, Georges Rodesch, Emmanuel Houdart, Raymond Turner, Aquilla Turk, Imran Chaudry, Paul-Emile Labeyrie, Roberto Riva, Johanna Lockau, Raphaël Blanc, Hocine Redjem, Daniel Behme, Hussain Shallwani, Maurer Christopher, Anne-Laure Derelle, Romain Tonnelet, Liang Liao, Camille Amaz, Klinikum Bremen-Mitte, Emory University School of Medicine, Emory University [Atlanta, GA], Service de neuroradiologie [Lyon], Hôpital neurologique et neurochirurgical Pierre Wertheimer [CHU - HCL], Hospices Civils de Lyon (HCL)-Hospices Civils de Lyon (HCL), Evaluation des technologies de santé et des pratiques médicales - ULR 2694 (METRICS), Université de Lille-Centre Hospitalier Régional Universitaire [Lille] (CHRU Lille), Hôpital de la Fondation Ophtalmologique Adolphe de Rothschild [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU), Rigshospitalet [Copenhagen], Copenhagen University Hospital, Freiburg University Medical Center, State University of New York (SUNY), Hôpital Foch [Suresnes], University-Hospital Munich-Großhadern [München], Neuroradiologie Diagnostique et Thérapeutique [Toulouse], Université Toulouse III - Paul Sabatier (UT3), Université Fédérale Toulouse Midi-Pyrénées-Université Fédérale Toulouse Midi-Pyrénées-CHU Toulouse [Toulouse]-Hôpital Purpan [Toulouse], CHU Toulouse [Toulouse], Paracelsus Medizinische Privatuniversität = Paracelsus Medical University (PMU), Azienda Ospedaliero-Universitaria Careggi (AOU Careggi), Vall d'Hebron University Hospital [Barcelona], University Medical Center Göttingen (UMG), Medical University of South Carolina [Charleston] (MUSC), Service de Neuroradiologie [CHU Lariboisière], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpital Lariboisière-Fernand-Widal [APHP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Centre Hospitalier Régional Universitaire de Besançon (CHRU Besançon), Service de neurologie [CHRU Nancy], Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy), Département de neuroradiologie diagnostique et thérapeutique [CHRU Nancy], Imagerie Adaptative Diagnostique et Interventionnelle (IADI), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lorraine (UL), Service Neuroradiologie diagnostique et interventionnelle [Hôpital Foch], Universitäts Klinikum Freiburg = University Medical Center Freiburg (Uniklinik), Service Neuroradiologie Diagnostique et Thérapeutique [CHU Toulouse], Pôle imagerie médicale [CHU Toulouse], Centre Hospitalier Universitaire de Toulouse (CHU Toulouse)-Centre Hospitalier Universitaire de Toulouse (CHU Toulouse), and Azienda Ospedaliero-Universitaria Careggi [Firenze] (AOUC)

Subjects
Carotid Artery Diseases, Male, medicine.medical_specialty, Time Factors, medicine.medical_treatment, [SDV.IB.MN]Life Sciences [q-bio]/Bioengineering/Nuclear medicine, 030204 cardiovascular system & hematology, Brain Ischemia, 03 medical and health sciences, 0302 clinical medicine, Fibrinolytic Agents, Risk Factors, Internal medicine, Angioplasty, medicine.artery, Antithrombotic, medicine, [INFO.INFO-IM]Computer Science [cs]/Medical Imaging, Humans, cardiovascular diseases, Registries, ComputingMilieux_MISCELLANEOUS, Aged, Retrospective Studies, Thrombectomy, Intracerebral hemorrhage, Univariate analysis, Cerebral infarction, business.industry, Endovascular Procedures, Thrombolysis, Middle Aged, medicine.disease, United States, 3. Good health, Europe, Stroke, Treatment Outcome, Cardiology, Female, Stents, Internal carotid artery, Carotid stenting, Cardiology and Cardiovascular Medicine, business, 030217 neurology & neurosurgery, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology
Abstract

Objectives The aim of this study was to identify the optimal endovascular approach in patients with acute stroke with tandem lesions. Background At present, there is no consensus about the ideal technical strategy for the endovascular treatment of patients with acute ischemic stroke with tandem lesions of the extracranial internal carotid artery (ICA) and intracranial cerebral arteries. Methods This was an international, multicenter registry with a total of 482 patients with acute ischemic stroke and tandem lesions. Patients were treated by intracranial thrombectomy as well as 1 of the following 4 strategies: 1) acute carotid artery stenting of the extracranial ICA with antithrombotic agents; 2) acute carotid artery stenting of the extracranial ICA without antithrombotic agents; 3) balloon angioplasty of the extracranial ICA; and 4) intracranial thrombectomy alone. The main outcome endpoints of the study were the degree of recanalization and the 90-day clinical outcome. The safety endpoints were symptomatic intracerebral hemorrhage and all causes of mortality at 90 days. Results Using univariate analysis, the rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction grades 2B and 3) and favorable clinical outcome after 90 days were significantly higher after acute carotid stenting with antithrombotic therapy and thrombectomy compared with the group with thrombectomy alone. After adjusting for confounding variables, acute stenting with antithrombotic therapy was independently associated with successful recanalization (odds ratio: 2.4; 95% confidence interval: 1.25 to 4.59; p = 0.008). The rates of symptomatic intracerebral hemorrhage and 90-day mortality were comparable among all 4 treatment groups. Conclusions Acute stenting of the extracranial ICA with antithrombotic therapy in combination with intracranial thrombectomy is associated with higher recanalization rates in treatment of patients with acute stroke with tandem lesions.

Published
2018
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6. Second-Generation Hydrogel Coils for the Endovascular Treatment of Intracranial Aneurysms: A Randomized Controlled Trial

Author

Hervé Brunel, Xavier Barreau, Denis Herbreteau, Jérôme Berge, Hubert Desal, Joachim Berkefeld, Betty Jean, Erika Graf, Samer Elsheikh, Sophie Gallas, Alessandra Biondi, Horst Urbach, René Chapot, Christian Taschner, Alain Bonafe, Patrick Courtheoux, Jens Fiehler, Vincent Costalat, Laurent Pierot, Raphaël Blanc, Ansgar Berlis, P. Machi, Krzysztof Kadziolka, Département de Neuroradiologie[Montpellier], Hôpital Gui de Chauliac [Montpellier]-Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier)-Université Montpellier 1 (UM1)-Université de Montpellier (UM), Université de Montpellier (UM), Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier), Départment de Neuroradiologie [CHU Caen], Université de Caen Normandie (UNICAEN), Normandie Université (NU)-Normandie Université (NU)-CHU Caen, Normandie Université (NU)-Tumorothèque de Caen Basse-Normandie (TCBN)-Tumorothèque de Caen Basse-Normandie (TCBN), Département de Neuro-Radiologie [Bordeaux] (DNR - Bordeaux), CHU Bordeaux [Bordeaux], Centre Hospitalier Universitaire de Reims (CHU Reims), CHU Clermont-Ferrand, Hôpital Rothschild [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Centre Hospitalier Régional Universitaire de Besançon (CHRU Besançon), Assistance Publique - Hôpitaux de Marseille (APHM), CHU Henri Mondor, Centre Hospitalier Régional Universitaire de Tours (CHRU TOURS), Universitätsklinikum Frankfurt, Universitaetsklinikum Hamburg-Eppendorf = University Medical Center Hamburg-Eppendorf [Hamburg] (UKE), Centre hospitalier universitaire de Nantes (CHU Nantes), Hôpital Guillaume-et-René-Laennec [Saint-Herblain], Institut des Neurosciences de Montpellier - Déficits sensoriels et moteurs (INM), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Montpellier (UM), Université Montpellier 1 (UM1)-Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier)-Hôpital Gui de Chauliac [Montpellier]-Université de Montpellier (UM), Centre Hospitalier Régional Universitaire de Tours (CHRU Tours), and Université de Montpellier (UM)-Institut National de la Santé et de la Recherche Médicale (INSERM)

Subjects
Male, medicine.medical_treatment, Original Contributions, [SDV.NEU.NB]Life Sciences [q-bio]/Neurons and Cognition [q-bio.NC]/Neurobiology, embolization, therapeutic, 030218 nuclear medicine & medical imaging, law.invention, 0302 clinical medicine, Randomized controlled trial, Coated Materials, Biocompatible, law, Clinical endpoint, Embolization, aneurysm, ruptured, Hydrogels, hydrogel, polyethylene glycol dimethacrylate, Middle Aged, 3. Good health, ComputingMethodologies_DOCUMENTANDTEXTPROCESSING, Female, Stents, Cardiology and Cardiovascular Medicine, Adult, medicine.medical_specialty, Randomization, Adolescent, Clinical Sciences, 03 medical and health sciences, Aneurysm, [SDV.MHEP.CSC]Life Sciences [q-bio]/Human health and pathology/Cardiology and cardiovascular system, medicine, Humans, ddc:610, Adverse effect, Aged, Advanced and Specialized Nursing, business.industry, Intracranial Aneurysm, medicine.disease, Confidence interval, Surgery, Cerebral Angiography, Clinical trial, randomized controlled trial, Neurology (clinical), business, 030217 neurology & neurosurgery, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology
Abstract

Supplemental Digital Content is available in the text., Background and Purpose— Endovascular embolization of intracranial aneurysms with hydrogel-coated coils lowers the risk of major recurrence, but technical limitations (coil stiffness and time restriction for placement) have prevented their wider clinical use. We aimed to assess the efficacy of softer, second-generation hydrogel coils. Methods— A randomized controlled trial was conducted at 22 centers in France and Germany. Patients aged 18 to 75 years with untreated ruptured or unruptured intracranial aneurysms measuring 4 to 12 mm in diameter were eligible and randomized (1:1 using a web-based system, stratified by rupture status) to coiling with either second-generation hydrogel coils or bare platinum coils. Assist devices were allowed as clinically required. Independent imaging core laboratory was masked to allocation. Primary end point was a composite outcome measure including major aneurysm recurrence, aneurysm retreatment, morbidity that prevented angiographic controls, and any death during treatment and follow-up. Data were analyzed as randomized. Results— Randomization began on October 15, 2009, and stopped on January 31, 2014, after 513 patients (hydrogel, n=256; bare platinum, n=257); 20 patients were excluded for missing informed consent and 9 for treatment-related criteria. Four hundred eighty-four patients (hydrogel, n=243; bare platinum, n=241) were included in the analysis; 208 (43%) were treated for ruptured aneurysms. Final end point data were available for 456 patients. Forty-five out of 226 (19.9%) patients in the hydrogel group and 66/230 (28.7%) in the control group had an unfavorable composite primary outcome, giving a statistically significant reduction in the proportion of an unfavorable composite primary outcome with hydrogel coils—adjusted for rupture status—of 8.4% (95% confidence interval, 0.5–16.2; P=0.036). Adverse and serious adverse events were evenly distributed between groups. Conclusions— Our results suggest that endovascular coil embolization with second-generation hydrogel coils may reduce the rate of unfavorable outcome events in patients with small- and medium-sized intracranial aneurysms. Clinical Trial Registration— URL: https://www.drks.de/drks_web/. Unique identifier: DRKS00003132.

Published
2018
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