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Abstract Background The primitive trigeminal artery (PTA) is the most commonly described fetal anastomosis between the carotid and vertebrobasilar circulations. Case presentation We report a 42-year-old patient presenting with internal carotid dissection, and imaging features of brainstem infarction. Conclusion Based on the imaging studies we presume occlusive carotid dissection with extensive thrombosis within a persistent trigeminal artery as the cause of this brainstem ischemia.

Objectives: French healthcare students are required to carry out primary prevention interventions as part of the Healthcare Service by Healthcare Students (HSHS). The purpose of this study was to explore students' perceptions of preparedness to address the public's concerns about antibiotic use and how their perceptions changed after implementing their intervention., Methods: A questionnaire was sent twice during the 2020-2021 academic year to 920 multidisciplinary healthcare students (nursing, medicine, physiotherapy, pharmacy and midwifery students) enrolled in the HSHS in Franche-Comté (HSHS-FC)., Results: This study included 870/920 students (94.6%). Medical and pharmacy students were the most concerned about the issue of antimicrobial resistance. Before enrollment in the HSHS-FC, 463 of the 870 students included (53.2%) reported having sufficient knowledge about antibiotics to lead preventive interventions, reaching 87.9% (58/66) for pharmacy students. Despite this relative lack of knowledge, 77.2% of students felt confident to promote the appropriate use of antibiotics in the healthcare service context. This rate ranged from 68.0% (17/25) for midwifery students to 93.9% (62/66) for pharmacy students. Irrespective of the topic of the intervention, students significantly improved their knowledge and ability to promote antibiotic use after training in the HSHS-FC., Conclusions: Theoretical prerequisites and a feeling of concern vary widely depending on the curriculum. The HSHS-FC promotes multidisciplinary collaboration and can contribute to improving students' knowledge. The support of an expert in antimicrobial resistance may be necessary to validate the content of the interventions proposed by the students., (© The Author(s) 2023. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy.)

Endovascular management of spinal dural arteriovenous fistula (DAVF) is arduous because of complex angioarchitecture and motion artifacts and is limited by the two-dimensional (2D) view. However, cone beam computed tomography (CBCT) acquisitions with selective injections allow 3D multiplanar reconstructions contributing to high diagnostic, anatomical and safety value. In this study, we described the use of virtual injection software (VIS) computed from CBCT acquisition and already used for prostatic and cerebral embolization, for the endovascular management of spinal DAVFs (EmboAssist, GE HealthCare, Chicago, USA). The VIS has been designed to facilitate the analysis of the patient's vasculature during the planning of embolization procedures to define the afferent pedicles to the shunt and the incidence of oblique projection, allowing for a better anatomical understanding and helping for the selection of 2D incidence. Combined with 3D roadmapping, VIS allows vessel tracking for selective catheterism and embolization. The VIS is a useful tool for planification and navigation during endovascular treatment of spinal DAVF with a safety value.

Inborn and acquired deficits of type I interferon (IFN) immunity predispose to life-threatening COVID-19 pneumonia. We longitudinally profiled the B cell response to mRNA vaccination in SARS-CoV-2 naive patients with inherited TLR7, IRF7, or IFNAR1 deficiency, as well as young patients with autoantibodies neutralizing type I IFNs due to autoimmune polyendocrine syndrome type-1 (APS-1) and older individuals with age-associated autoantibodies to type I IFNs. The receptor-binding domain spike protein (RBD)-specific memory B cell response in all patients was quantitatively and qualitatively similar to healthy donors. Sustained germinal center responses led to accumulation of somatic hypermutations in immunoglobulin heavy chain genes. The amplitude and duration of, and viral neutralization by, RBD-specific IgG serological response were also largely unaffected by TLR7, IRF7, or IFNAR1 deficiencies up to 7 mo after vaccination in all patients. These results suggest that induction of type I IFN is not required for efficient generation of a humoral response against SARS-CoV-2 by mRNA vaccines., (© 2022 Sokal et al.)

Background: Study RTOG 9802 in high-risk diffuse low-grade gliomas (DLGGs) showed the potential synergistic effect on survival of the procarbazine, CCNU, and vincristine (PCV) radiotherapy (RT) combination. Limited data on long-term neurocognitive impact and quality of life (QoL) have yet been reported., Patients and Methods: We described a monocentric series of patients treated at first line by the combination of PCV immediately followed by RT between January 01, 1982 and January 01, 2017. Radiological data were collected and included volume, velocity of diametric expansion (VDE), and MRI aspects. Long-term neurocognitive and QoL were analyzed., Results: Twenty patients fulfilled the eligibility criteria. The median response rate was 65.1% (range, 9.6%-99%) at the time of maximal VDE decrease corresponding to a median volume reduction of 79.7 cm 3 (range, 3.1 to 174.2 cm 3 ), which occurred after a median period of 7.2 years (range, 0.3-21.9) after the end of RT. An ongoing negative VDE was measured in 13/16 patients after the end of RT, with a median duration of 6.7 years (range, 9 months-21.9 years). The median follow-up since radiological diagnosis was 17.5 years (range, 4.8 to 29.5). Estimated median survival was 17.4 years (95% CI: 12; NR). After a long-term follow-up, substantial neurotoxicity was noticed with dementia in six progression-free patients (30%), leading to ventriculo-peritoneal shunt procedures in three, and premature death in five. Thirteen patients (65%) were unable to work with disability status. Successive longitudinal neurocognitive assessments for living patients showed verbal episodic memory deterioration., Conclusions: PCV-RT combination seems to have not only an oncological synergy but also a long-term neurotoxic synergy to consider before initial therapeutic decision., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Blonski, Obara, Brzenczek, Pouget, Dillier, Meyer, Lavigne, Forthoffer, Broussois, Gauchotte, Baron, Rech, Mézières, Gaudeau, Verger, Vogin, Anxionnat, Moureaux and Taillandier.)

Background and Purpose: Direct aspiration (DA) using large-bore distal aspiration catheters is an established strategy for the endovascular thrombectomy (EVT) of large-vessel occlusion stroke (LVOS). However, the performance of individual catheters like SOFIA has yet to be examined., Methods: We present a cohort of 144 consecutive patients treated with first-line DA and SOFIA 6 F Plus catheter for LVOS. We also conducted a systematic review of the literature searching multiple databases for reports on thrombectomy with DA and SOFIA catheters and performed a meta-analysis of recanalization, safety, and clinical outcomes., Results: In the study cohort a successful recanalization (mTICI 2b-3) rate of 75.7% was achieved with DA alone, the global rate for functional independence (90-day mRS 0-2) was 40.3%. For the metanalysis we selected nine articles that included a total of 758 patients treated with first-line thrombectomy with the SOFIA catheters. The mTICI 2b-3 rate was 71.6% (95%CI, 66.3-76.5%) while a rescue stent-retriever was used in 24.1% (95%CI, 17.7-31.9%) of cases. The overall mTICI2b-3 rate after DA and rescue therapy was 88.9% (95%CI, 82.6-93.1%). We found a pooled estimate of 45.6% (95%CI, 38.6-52.8%) for functional independence, a mortality within 90 days of 19% (95%CI, 14.1-25.0%) and a rate of 5.8% (95%CI, 4.2-8.0%) of symptomatic intracranial hemorrhage., Conclusion: The DA approach for LVOS with the SOFIA catheters is highly effective with an efficacy and safety profile comparable to those found in contemporary thrombectomy trials and observational studies that use other devices or approaches.

Background and Purpose: Endovascular therapy for tandem occlusion strokes of the anterior circulation is an effective and safe treatment. The best treatment approach for the cervical internal carotid artery (ICA) lesion is still unknown. In this study, we aimed to compare the functional and safety outcomes between different treatment approaches for the cervical ICA lesion during endovascular therapy for acute ischemic strokes due to tandem occlusion in current clinical practice., Methods: Individual patients’ data were pooled from the French prospective multicenter observational ETIS (Endovascular Treatment in Ischemic Stroke) and the international TITAN (Thrombectomy in Tandem Lesions) registries. TITAN enrolled patients from January 2012 to September 2016, and ETIS from January 2013 to July 2019. Patients with acute ischemic stroke due to anterior circulation tandem occlusion who were treated with endovascular therapy were included. Patients were divided based on the cervical ICA lesion treatment into stent and no-stent groups. Outcomes were compared between the two treatment groups using propensity score methods., Results: A total of 603 patients were included, of whom 341 were treated with acute cervical ICA stenting. In unadjusted analysis, the stent group had higher rate of favorable outcome (90-day modified Rankin Scale score, 0–2; 57% versus 45%) and excellent outcome (90-day modified Rankin Scale score, 0–1; 40% versus 27%) compared with the no-stent group. In inverse probability of treatment weighting propensity score–adjusted analyses, stent group had higher odds of favorable outcome (adjusted odds ratio, 1.09 [95% CI, 1.01–1.19]; P=0.036) and successful reperfusion (modified Thrombolysis in Cerebral Ischemia score, 2b-3; adjusted odds ratio, 1.19 [95% CI, 1.11–1.27]; P<0.001). However, stent group had higher odds of any intracerebral hemorrhage (adjusted odds ratio, 1.10 [95%, 1.02–1.19]; P=0.017) but not higher rate of symptomatic intracerebral hemorrhage or parenchymal hemorrhage type 2. Subgroup analysis demonstrated heterogeneity according to the lesion type (atherosclerosis versus dissection; P for heterogeneity, 0.01), and the benefit from acute carotid stenting was only observed for patients with atherosclerosis., Conclusions: Patients treated with acute cervical ICA stenting for tandem occlusion strokes had higher odds of 90-day favorable outcome, despite higher odds of intracerebral hemorrhage; however, most of the intracerebral hemorrhages were asymptomatic.

Background and Purpose: Despite the widespread adoption of mechanical thrombectomy (MT) for the treatment of large vessel occlusion stroke (LVOS) in the anterior circulation, the optimal strategy for the treatment tandem occlusion related to cervical internal carotid artery (ICA) dissection is still debated. This individual patient pooled analysis investigated the safety and efficacy of prior intravenous thrombolysis (IVT) in anterior circulation tandem occlusion related to cervical ICA dissection treated with MT., Methods: We performed a retrospective analysis of two merged prospective multicenter international real-world observational registries: Endovascular Treatment in Ischemic Stroke (ETIS) and Thrombectomy In TANdem occlusions (TITAN) registries. Data from MT performed in the treatment of tandem LVOS related to cervical ICA dissection between January 2012 and December 2019 at 24 comprehensive stroke centers were analyzed. The primary endpoint was a favorable outcome defined as 90-day modified Rankin Scale (mRS) score of 0-2., Results: The study included 144 patients with tandem occlusion LVOS due to cervical ICA dissection, of whom 94 (65.3%) received IVT before MT. Prior IVT was significantly associated with a better clinical outcome considering the mRS shift analysis (common odds ratio, 2.59; 95% confidence interval [CI], 1.35 to 4.93; P=0.004 for a 1-point improvement) and excellent outcome (90-day mRS 0-1) (adjusted odds ratio [aOR], 4.23; 95% CI, 1.60 to 11.18). IVT was also associated with a higher rate of intracranial successful reperfusion (83.0% vs. 64.0%; aOR, 2.70; 95% CI, 1.21 to 6.03) and a lower rate of symptomatic intracranial hemorrhage (4.3% vs. 14.8%; aOR, 0.21; 95% CI, 0.05 to 0.80)., Conclusions: Prior IVT before MT for the treatment of tandem occlusion related to cervical ICA dissection was safe and associated with an improved 90-day functional outcome.

Background and Purpose: We aimed to evaluate among trained interventional neuroradiologist, whether increasing individual experience was associated with an improvement in mechanical thrombectomy (MT) procedural performance metrics., Methods: Individual MT procedural data from 5 centers of the Endovascular Treatment in Ischemic Stroke registry and 2 additional high-volume stroke centers were pooled. Operator experience was defined for each operator as a continuous variable, cumulating the number of MT procedures performed since January 2015, as MT became standard of care or, if later than this date, since the operator started performing mechanical thrombectomies in autonomy. We tested the associations between operator's experience and procedural metrics., Results: A total of 4516 procedures were included, performed by 36 operators at 7 distinct centers, with a median of 97.5 endovascular treatment procedures per operator (interquartile range, 57-170.2) over the study period. Higher operator's experience, analyzed as a continuous variable, was associated with a significantly shorter procedural duration (β estimate, -3.98 [95% CI, -5.1 to -2.8]; P <0.001), along with local anesthesia and M1 occlusion location in multivariable models. Increasing experience was associated with better Thrombolysis in Cerebral Infarction scores (estimate, 1.02 [1-1.04]; P =0.013)., Conclusions: In trained interventional neuroradiologists, increasing experience in MT is associated with significantly shorter procedural duration and better reperfusion rates, with a theoretical ceiling effect observed after around 100 procedures. These results may inform future training and practice guidelines to set minimal experience standards before autonomization, and to set-up operators' recertification processes tailored to individual case volume and prior experience.

Introduction: Mechanical thrombectomy (MT) increases functional independence in patients with acute ischaemic stroke with anterior circulation large vessel occlusion (LVO), and the probability to achieve functional independence decreases by 20% for each 1-hour delay to reperfusion. Therefore, we aim to investigate whether direct angiosuite transfer (DAT) is superior to standard imaging/emergency department-based management in achieving 90-day functional independence in patients presenting with an acute severe neurological deficit likely due to LVO and requiring emergent treatment with MT., Methods and Analysis: DIRECT ANGIO (Effect of DIRECT transfer to ANGIOsuite on functional outcome in patient with severe acute stroke treated with thrombectomy: the randomised DIRECT ANGIO Trial) trial is an investigator-initiated, multicentre, prospective, randomised, open-label, blinded endpoint (PROBE) study. Eligibility requires a patient ≤75 years, pre-stroke modified Rankin Scale (mRS) 0-2, presenting an acute severe neurological deficit and admitted within 5 hours of symptoms onset in an endovascular-capable centre. A total of 208 patients are randomly allocated in a 1:1 ratio to DAT or standard management. The primary outcome is the rate of patients achieving a functional independence, assessed as mRS 0-2 at 90 days. Secondary endpoints include patients presenting confirmed LVO, patients eligible to intravenous thrombolysis alone, patients with intracerebral haemorrhage and stroke-mimics, intrahospital time metrics, early neurological improvement (reduction in National Institutes of Health Stroke Scale by ≥8 points or reaching 0-1 at 24 hours) and mRS overall distribution at 90 days and 12 months. Safety outcomes are death and intracerebral haemorrhage transformation. Medico-economics analyses include health-related quality of life and cost utility assessment., Ethics and Dissemination: The DIRECT ANGIO trial was approved by the ethics committee of Ile de France 1. Study began in April 2020. Results will be published in an international peer-reviewed medical journal., Trial Registration Number: NCT03969511., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Purpose: The best anesthetic management for mechanical thrombectomy of large vessel occlusion strokes is still uncertain and could impact the quality of reperfusion and clinical outcome. We aimed to compare the efficacy and safety outcomes between local anesthesia (LA) and conscious sedation in a large cohort of acute ischemic stroke patients with anterior circulation large vessel occlusion strokes treated with mechanical thrombectomy in current, everyday clinical practice., Methods: Patients undergoing mechanical thrombectomy for anterior large vessel occlusion strokes at 4 comprehensive stroke centers in France between January 1, 2018, and December 31, 2018, were pooled from the ongoing prospective multicenter observational Endovascular Treatment in Ischemic Stroke Registry in France. Intention-to-treat and per-protocol analyses were used., Results: Among the included 1034 patients, 762 were included in the conscious sedation group and 272 were included in the LA group. In the propensity score matched cohort, the rate of favorable outcome (90-day modified Rankin Scale score 0-2) was significantly lower in the LA group than in the conscious sedation group (40.0% versus 52.0%, matched relative risk=0.76 [95% CI, 0.60-0.97]), as well as the rate of successful reperfusion (modified Thrombolysis in Cerebral Infarction grade 2b-3; 76.6% versus 87.1%; matched relative risk=0.88 [95% CI, 0.79-0.98]). There was no difference in procedure time between the 2 groups. In the inverse probability of treatment weighting-propensity score-adjusted cohort, similar significant differences were found for favorable outcomes and successful reperfusion. In inverse probability of treatment weighting-propensity score-adjusted cohort, a higher rate of 90-day mortality and a lower parenchymal hematoma were observed after LA. The sensitivity analysis restricted to our per-protocol sample provided similar results in the matched- and inverse probability of treatment weighting-propensity cohorts., Conclusions: In the Endovascular Treatment in Ischemic Stroke registry mainly included patients in early time window (<6 hours), LA was associated with lower odds of favorable outcome, successful reperfusion, and higher odds of mortality compared with conscious sedation for mechanical thrombectomy of large vessel occlusion.

Background: Chronic encapsulated intracerebral hematomas (CEIHs) are a rare, late complication of radiosurgery for intracranial AVM. We present 5 cases treated mostly by surgical excision and review the literature., Methods: Patients (age 39, 42, 36, 31, 62) presented with headache, paresthesia, hemiparesis or were asymptomatic. CEIHs presented 10 to 13 years (median 12 years) post radiosurgery. Three patients had demonstrated early radiation induced changes post radiosurgery. Angiographic cure, assessed with DSA, was present in all cases except 1 case with a small nidus remnant. MRI demonstrated mixed lesions with a solid enhancing part, organized hematoma and extensive surrounding edema while three cases had also a cystic component., Results: Excision of the CEIHs with complete or partial removal of the capsule was performed in 4 patients and resulted in marked clinical improvement. One patient was managed conservatively with administration of steroids as surgery was judged excessively hazardous with eventual stabilization of his symptoms., Conclusions: CEIHs are rare, late complications of radiosurgery for cranial AVM. They may be asymptomatic or provoke symptoms and may be preceded by early radiation induced changes. Complete removal of CEIHS is an effective treatment. Because of the long latency period of CEIHs, patients who had radiosurgery for brain AVMs should be followed by MRI at least 10 years even after complete obliteration.

Background and Purpose- Antiplatelet agents could be used in the setting of endovascular therapy for tandem occlusions to reduce the risk of de novo intracranial embolic migration, reocclusion of the extracranial internal carotid artery lesion, or in-stent thrombosis in case of carotid stent placement but have to be balanced with the intracerebral hemorrhagic transformation risk. In this study, we aim to investigate the impact of acute antiplatelet therapy administration on outcomes during endovascular therapy for anterior circulation tandem occlusions. Methods- This is a retrospective analysis of a collaborative pooled analysis of 11 prospective databases from the multicenter observational TITAN registry (Thrombectomy in Tandem Lesions). Patients were divided into groups based on the number of antiplatelet administered during endovascular therapy. The primary outcome was favorable outcome, defined as a modified Rankin Scale score of 0 to 2 at 90 days. Results- This study included a total of 369 patients; 145 (39.3%) did not receive any antiplatelet agent and 224 (60.7%) received at least 1 antiplatelet agent during the procedure. Rate of favorable outcome was nonsignificantly higher in patients treated with antiplatelet therapy (58.3%) compared with those treated without antiplatelet (46.0%; adjusted odds ratio, 1.38 [95% CI, 0.78-2.43]; P =0.26). Rate of 90-day mortality was significantly lower in patients treated with antiplatelet therapy (11.2% versus 18.7%; adjusted odds ratio, 0.47 [95% CI, 0.22-0.98]; P =0.042), without increasing the risk of any intracerebral hemorrhage. Successful reperfusion (modified Thrombolysis in Cerebral Ischemia score 2b-3) rate was significantly better in the antiplatelet therapy group (83.9% versus 71.0%; adjusted odds ratio, 1.89 [95% CI, 1.01-3.64]; P =0.045). Conclusions- Administration of antiplatelet therapy during endovascular therapy for anterior circulation tandem occlusions was safe and was associated with a lower 90-day mortality. Optimal antiplatelet therapy remains to be assessed, especially when emergent carotid artery stenting is performed. Further randomized controlled trials are needed.

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., Competing Interests: D.C.H.; F.T.; M.P.; J.L.; H.S.-A.; M.H.; C.T.; S.E.; P.P.; M.B.; A.H.S.; B.L.; F.D.; C.C.; M.K.; S.M.; M.R.; M.N.P.; A.M.S.; M.-A.L.; M.M.; A.B.; S.R.; J.A.G.; R.A.; S.B.; B.G. have nothing to disclose. R.G.N.: Stryker-Neurovacular (Trevo-2&DAWN/Trial PI), Covidien (SWIFT&SWIFT-PRIME/Steering-Committee, STAR Trial/Core-Lab), Penumbra (3-D Separator Trial/Executive-Committee)., (Copyright © 2019 by S. Karger AG, Basel.)

Background and Purpose- Flow diverters are used for endovascular therapy of intracranial aneurysms. We did a nationwide prospective study to investigate the safety and effectiveness of flow diversion at 12 months. Methods- DIVERSION was a national prospective cohort study including all flow diverters placement between October 2012 and February 2014 in France. The primary end point was the event-free survival rate at 12 months, defined as the occurrence of morbidity (intracranial hemorrhage, ischemic stroke, noncerebral hemorrhage, or neurological deficit due to mass effect), retreatment, or death within 12 months post-treatment. A quality control was carried out on 100% of the collected data and of at least 10% of the included patients in each center, chosen at random. All reported serious events were adjudicated by an independent Data Safety and Monitoring Board. Satisfactory occlusion was defined as 3 or 4 on Kamran scale by an independent imaging core laboratory at 12 months. Results- We enrolled 398 patients harboring 477 intracranial aneurysms. At least 1 morbidity-mortality event was noted in 95 of 408 interventions representing an event-free survival rate of 75.7% (95% CI, 71.1-79.7). The rate of permanent-related serious events and mortality was 5.9% and 1.2% at 12 months, respectively. Multivariate analysis showed that high baseline blood pressure (hazard ratio, 2.54; 95% CI, 1.35-4.79; P =0.039), diabetes mellitus (hazard ratio, 3.70; 95% CI, 1.60-8.6; P =0.0022), and larger aneurysms (hazard ratio, 1.07; 95% CI, 1.04-1.11; P <0.0001) were associated with the occurrence of a neurological deficit. The satisfactory occlusion rate at 12 months was 79.9%, and the absence of high baseline blood pressure (odds ratio, 2.01; 95% CI, 1.12-3.71; P =0.0193) and postprocedural satisfactory occlusion (odds ratio, 2.75; 95% CI, 1.49-5.09; P =0.0012) were associated with a 12-month satisfactory occlusion. Conclusions- A satisfactory occlusion was achieved in almost 80% of cases after flow diverter treatment with a permanent-related serious event and mortality rates of 5.9% and 1.2% at 12 months, respectively.

Background and Purpose: Emergent carotid artery stenting plus mechanical thrombectomy is an effective treatment for acute ischemic stroke patients with tandem occlusion of the anterior circulation. However, there is limited data supporting the safety of this approach in patients treated with prior intravenous thrombolysis (IVT). We aimed to investigate the safety of emergent carotid artery stenting-mechanical thrombectomy approach in stroke patient population treated with prior IVT, Methods: —We assessed patients with acute ischemic stroke because of atherosclerotic tandem occlusion that were treated with emergent carotid artery stenting-mechanical thrombectomy approach from the multicenter observational Thrombectomy in Tandem Lesions registry. Patients were divided into 2 groups based on pretreatment IVT (IVT versus no-IVT). Intracerebral hemorrhages were classified according to the European Cooperative Acute Stroke Study II criteria., Results: Among 205 patients included in the present study, 125 (60%) received prior IVT. Time from symptoms onsetto-groin puncture was shorter (234±100 versus 256±234 minutes; P=0.002), and heparin use was less in the IVT group (14% versus 35%; P<0.001); otherwise, there was no difference in the baseline characteristics. There was no significant difference between the IVT and no-IVT groups in the rate of symptomatic intracerebral hemorrhage (5% versus 8%; P=0.544), parenchymal hematoma type 1 to 2 (15% versus 18%; P=0.647), successful reperfusion (modified Thrombolysis in Cerebral Ischemia 2b–3), or 90-day favorable outcome (modified Rankin Scale score of 0–2 at 90 days). The 90-day all-cause mortality rate was significantly lower in the IVT group (8% versus 20%; P=0.017). After adjusting for covariates, IVT was not associated with symptomatic intracerebral hemorrhage or 90-day mortality, Conclusions: Emergent carotid artery stenting-mechanical thrombectomy approach was not associated with an increased risk of hemorrhagic complications in tandem occlusion patients who received IVT before the intervention.

Background: In acute ischemic stroke patients with large-artery occlusion, uncertainties remain about whether clinically important outcomes are comparable between first-line contact aspiration and stent-retriever thrombectomy, although two trials have investigated whether one strategy should be preferred over another., Purpose: The purpose of this article is to compare the efficacy and safety of first-line contact aspiration and stent-retriever thrombectomy in stroke patients with anterior circulation large-artery occlusion., Methods: We undertook a systematic review of studies of patients treated for large-artery occlusion, with the latest devices of either strategy, within six hours of stroke onset. We determined rates of final complete reperfusion (defined as modified Thrombolysis In Cerebral Infarction score = 3), periprocedural complications and 90-day functional independence (defined as modified Rankin Scale (mRS) score 0-2), and excellent outcome (defined as mRS score 0-1) after contact aspiration and after stent-retriever thrombectomy using random-effects meta-analyses. Any differential effects in rates between the two strategies were assessed using random-effects meta-regressions., Results: Fifteen studies (1817 patients) were included. There was no difference in rates of final complete reperfusion at the end of all endovascular procedures between contact aspiration and stent retrievers (51.1%, 95% confidence interval (CI) 39.3-62.9; vs 38.3%, 95% CI 28.6-48.0; p int  = 0.14), 90-day functional independence (45.0%, 40.7-49.2; vs 52.4%, 47.7-57.1; p int  = 0.45) and excellent outcome (32.1%, 25.7-38.5; vs 34.1%, 21.2-46.9; p int  = 0.94). Rates of periprocedural complications did not differ between the two strategies., Conclusions: Current data suggest no difference in efficacy and safety between first-line contact aspiration and stent-retriever thrombectomy in stroke patients with large-artery occlusion.

Background and Purpose- Acute stroke patients with a large ischemic core may still benefit from mechanical thrombectomy (MT), but the predictors of clinical outcome are not well known after MT. We investigated the clinical and imaging factors associated with good outcome and mortality at 90 days in acute stroke patients with a large baseline ischemic core treated with MT. Methods- Data from the multicentric prospective ETIS (Endovascular Treatment in Ischemic Stroke) registry of consecutive acute ischemic stroke patients treated with MT from January 1, 2012, to August 31, 2016, were retrospectively analyzed. Baseline large ischemic core was defined as diffusion-weighted imaging (DWI)-Alberta Stroke Program Early CT Score of ≤5. The degree of disability was assessed by the modified Rankin Scale at 90 days. Outcomes included good outcome (modified Rankin Scale score of ≤2), and mortality (modified Rankin Scale score of 6). Results- Among 216 patients with DWI-Alberta Stroke Program Early CT Score of ≤5 (median DWI volume 77 mL, interquartile range 52-120 mL) treated with MT, good outcome was achieved in 55 (25.4%) patients and 75 (34.7%) died at 90 days. Hemorrhagic transformation was detected in 40 (18.5%) patients within 24 hours post-MT. Older age (adjusted odds ratio [OR] for every 10 years, 0.62; 95% CI, 0.48-0.80; P<0.001) and increased DWI lesional volume (adjusted OR, 0.98; 95% CI, 0.97-0.99; P<0.001) were associated with a lower chance of achieving a good outcome, while successful recanalization (modified Thrombolysis in Cerebral Infarction [mTICI] grades of ≤2b) predicted good outcome (adjusted OR, 4.56; 95% CI, 1.79-11.62; P=0.001). Successful recanalization (OR, 0.46; 95% CI, 0.22-0.97; P=0.042), increased DWI lesional volume (OR, 1.02; 95% CI, 1.01-1.03; P<0.001), age (OR for every 10 years, 1.72; 95% CI, 1.31-2.26; P<0.001), and diabetes mellitus (OR, 3.23; 95% CI, 1.34-7.8; P=0.009) were independent predictors of 90-day mortality. Conclusions- Successful recanalization and baseline DWI lesional volume are the strongest predictors of outcome in stroke patients with a large ischemic core.

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., (© 2019 by American Journal of Neuroradiology.)

Background and Purpose: A direct aspiration first pass technique involves first-line aspiration to remove the thrombus through a large-bore aspiration catheter in large vessel strokes. The aim of this study was to assess safety and clinical outcomes with a direct aspiration first pass technique using the new ARC catheter., Methods: A retrospective analysis of prospectively collected data from three university hospitals was performed between June 2016 and May 2018. The following parameters of all acute ischemic stroke interventions using the ARC catheter were analyzed: use of intravenous thrombolysis, National Institutes of Health Stroke Scale scores at presentation and discharge, successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b-3), procedure duration, procedure-related complications and 90-day clinical outcome (modified Rankin Scale score)., Results: In total, 41 patients were included in the study and anterior circulation occlusion was noted in 35 (85%). The median National Institutes of Health Stroke Scale at admission was 18 and prior intravenous thrombolysis was administered in 35 patients (85%). Only six (15%) patients required the use of a rescue stent retriever. Successful reperfusion was achieved in 40 patients (98%) with a median procedure time of 32 minutes. No catheter-related complications were observed. Symptomatic intracerebral hemorrhage occurred in one patient (2%). Median National Institutes of Health Stroke Scale at discharge was 3; 49% were independent and 10% died at 90 days., Conclusions: In the present study, the ARC catheter allowed a 98% successful reperfusion rate. The complication rate was in line with those of previous a direct aspiration first pass technique publications.

Introduction: Endovascular therapy has been shown to be an effective and safe treatment for tandem occlusion. The endovascular therapeutic strategies for tandem occlusions strokes have not been adequately evaluated and the best approach is still controversial. The TITAN (Thrombectomy in TANdem occlusions) registry was a result of a collaborative effort to identify the best therapeutic approach for acute ischemic stroke due to tandem lesion. In this review, we aim to summarize the main findings of the TITAN study and discuss the challenges of treatment for tandem occlusion in the era of endovascular thrombectomy. Methods: A review of the data from the multicenter international observational and non-randomized TITAN registry was performed. The TITAN registry included acute ischemic stroke patients with tandem lesions (proximal intracranial occlusion and cervical carotid artery occlusion or stenosis>90%) who were treated with thrombectomy with or without carotid artery stenting. Results: Prior intravenous thrombolysis and emergent cervical carotid stenting were associated with higher reperfusion (mTICI 2b-3 and mTICI 3) rates at the end of the intervention. Poor outcome did not occur more frequently after stenting than after conservative treatment of the cervical carotid lesion. Emergent carotid stenting with antithrombotic agents and intracranial thrombectomy yielded higher reperfusion rate and good outcome (90 day mRS 0-2) compared to other strategies (carotid artery stenting and thrombectomy without antithrombotic, angioplasty and thrombectomy, or thrombectomy alone). Pretreatment intravenous thrombolysis was not associated with increased risk of hemorrhagic complications. Likewise, periprocedural unfractionated heparin did not modify the efficacy and safety results. Etiology of carotid artery lesion (atherosclerosis vs. dissection) did not emerge as predictor of outcome or recanalization. Conclusion: Emergent stenting of the cervical carotid lesion with antithrombotic agents in conjunction to thrombectomy appears to be the best treatment strategy for acute ischemic strokes with tandem lesions. These findings will be further investigated in the ongoing randomized controlled TITAN trial.

This article was first published in JNIS. Cite this article as: Pierot L, Jayaraman MV, Szikora I, et al. Standards of practice in acute ischemic stroke intervention: international recommendations. Journal of NeuroInterventional Surgery. Published Online First: 28 August 2018. doi: 10.1136/neurintsurg-2018-014287.

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., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Recanalization is 1 drawback of the EVT of intracranial aneurysms. An analysis of the factors affecting the midterm anatomic results after EVT of ruptured intracranial aneurysms in a large multicenter series (CLARITY) is presented., Materials and Methods: Of the 782 patients initially included in the CLARITY trial, 649 would theoretically undergo midterm follow-up examinations. Finally, 517/649 (79.7%) completed a midterm follow-up examination. Midterm anatomic results were independently and anonymously evaluated by 2 experienced neuroradiologists., Results: In univariate analysis, factors affecting the quality of midterm occlusion were the quality of the postoperative occlusion (P < .001), hypertension (P = .018), aneurysm size (P = .007), neck size (P = .005), and ICA location (P = .049). In multivariate analysis, 3 factors were associated with the quality of postoperative aneurysm occlusion: neck size (P = .003), use of the balloon remodeling technique (P = .031), and the quality of postoperative occlusion (P < .001). In univariate analysis, the evolution of aneurysm occlusion was affected by age (P = .024) and neck size (P = .041). In multivariate analysis, it was associated with the same factors: age (P = .025) and neck size (P = .043)., Conclusions: Among the many factors considered in this analysis, aneurysm neck size was identified as the single most important one in the quality of aneurysm occlusion at midterm follow-up after EVT. The present results suggest developing and evaluating new strategies of treatment and technique, especially for wide-neck aneurysms, with a focus on reinforcement and neoendothelialization at the level of the neck as objectives.

Background and Purpose: Matrix coils have been developed to prevent aneurysm recanalization. Midterm anatomic results in a prospective multicenter consecutive series including patients treated with GDC or Matrix coils for ruptured aneurysms are presented., Materials and Methods: Five hundred seventeen patients harboring ruptured aneurysms were treated with GDC (276 patients) or Matrix coils (241 patients). Postoperative and midterm anatomic results were evaluated anonymously and independently using the Modified Montreal Scale (complete occlusion, neck remnant, and aneurysm remnant)., Results: In the midterm follow-up (mean, 16.7 months in the GDC group and 15.4 months in the Matrix group), complete occlusion was reported in 95/276 aneurysms (34.4%) in the GDC group and 80/241 (33.2%) in the Matrix group, neck remnant in 127/276 (46.0%) in the GDC group and 118/241 (49.0%) in the Matrix group, and aneurysm remnant in 54/276 (19.6%) in the GDC group and 43/241 (17.8%) in the Matrix group. Evolution of aneurysm occlusion was improvement in 35/272 aneurysms (12.9%) in the GDC group and 27/239 (11.3%) in the Matrix group, stable situation in 98/272 (36.0%) in the GDC group and 97/239 (40.6%) in the Matrix group, and worsening in 139/272 (51.1%) in the GDC group and 115/239 (48.1%) in the Matrix group. A total of 32/517 patients were retreated during the follow-up period: 9/276 (3.3%) in the GDC group and 23/241 (9.5%) in the Matrix group (P = .003)., Conclusions: In this study, midterm anatomic results and evolution of aneurysm occlusion were not different in patients with ruptured aneurysms treated with GDC or Matrix coils.

Background and Purpose: The efficacy of the endovascular treatment in providing stable occlusion of intracranial aneurysms is still controversial and should be precisely analyzed. A first step is to carefully study immediate anatomical results. CLARITY (Clinical and Anatomical Results in the Treatment of Ruptured Intracranial Aneurysms) is a prospective multicenter consecutive series including patients treated by coiling for ruptured aneurysms. Immediate anatomic results are presented., Materials and Methods: Postoperative anatomic results were evaluated by DSA by the treating physician and anonymously and independently by 2 experienced neuroradiologists by using the 3-point Montreal Scale. Patients were divided into 2 groups: patients treated with GDC and those treated with Matrix detachable coils., Results: A total of 773 patients (461 women, 312 men; 19-80 years of age; mean, 51.2 +/- 13.2 years) with 773 ruptured aneurysms were included in the study. The rate of occlusion as determined by the treating physician was designated complete for 586 aneurysms (75.8%), neck remnant for 145 aneurysms (18.8%), and aneurysm remnant for 42 aneurysms (5.4%). The same evaluation as reported by the 2 independent reviewers was complete occlusion for 366 aneurysms (47.4%), neck remnant for 324 aneurysms (41.9%), and aneurysm remnant for 83 aneurysms (10.7%). Postoperative anatomic results were significantly linked to age but not to the technique of endovascular treatment or aneurysm characteristics (location, size, dome-to neck ratio). Results were not significantly different between the GDC and Matrix group., Conclusions: Endovascular treatment of ruptured intracranial aneurysms resulted in a high rate of satisfactory occlusion (complete occlusion and neck remnant in 89.3%). Patient age was the only factor associated with the rate of occlusion. The rate of aneurysm occlusion differed insignificantly between GDC and Matrix coils.

First developed in the 1960s, interventional neuroradiology has vastly improved the management of patients with vascular diseases of the brain and spine, including vascular malformations and stroke. Gradually replacing open-skull neurosurgical approaches, endovascular occlusion of ruptured intracranial aneurysms has improved the post-bleed prognosis. With the increasing number of fortuitously discovered aneurysms, international randomized studies are being organized to determine whether preventive treatment is better than abstention. A wide range of therapeutic strategies are available for brain arteriovenous malformations, including hyperselective embolization, open-skull surgery, radiosurgery, and abstention. The choice depends on multiple parameters, including symptoms, clinical status, the angioarchitecture of the malformation, and the patient's psychology and wishes (...).

A general methodology is described to validate a 3D imaging modality with respect to 2D digital subtracted angiography (DSA) for brain AVMs (BAVM) delineation. It relies on the assessment of the statistical compatibility of the radiosurgical target delineated in 3D with its delineations in 2D. This methodology is demonstrated through a preliminary evaluation of 3D rotational angiography (3DRA). Generally speaking, BAVM delineation cannot be performed on 3DRA alone. However, in our study, 3DRA showed similar performances to DSA for rather easy cases, and even better for three patients. Conversely, three problematic cases are identified and discussed.

Purpose: Autoscopy is a pathologic perception of one's body or one's face image within space, either from an internal ("as in a mirror") or from an external ("out-of-body experience") point of view. Among various psychiatric and neurologic disorders, partial epilepsy is the main etiology. However, the significance of this rare ictal symptom remains controversial. We report this phenomenon in three epilepsy patients and discuss its semiologic value and neuropsychological significance., Methods: Interictal EEG and/or video-EEG monitoring was performed, as well as neuropsychological examination and cerebral magnetic resonance imaging (MRI)., Results: The three patients had a lesion involving, or limited to, the right parietal region on cerebral MRI. All three patients experienced autoscopy associated with other ictal signs supporting a right parietal lobe origin of seizures. In one patient, seizure origin was documented with video and surface EEG ictal recordings., Conclusions: Autoscopy was shown to have an ictal mechanism and was associated with seizures arising from the nondominant parietal region. We hypothesize that ictal autoscopy may result from disruption of the normal integration of body representation.

Background and Purpose: Controversy still surrounds the question of when and how to manage cases of subarachnoid hemorrhage of Hunt and Hess grade IV and V aneurysms. Several authors are in favor of surgical treatment, reporting improved clinical outcomes and lower mortality rates. Considering that endovascular procedures are currently being increasingly used to treat aneurysms, we investigated their use in the management of subarachnoid bleeding in a retrospective review of 80 patients., Methods: Eighty patients were admitted to our hospital between October 1992 and October 1998 with subarachnoid hemorrhage of Hunt and Hess grade IV and V aneurysms. Patients received standard resuscitation treatment, nimodipine to prevent vasospasm, CSF shunt when necessary, and selective occlusion with Guglielmi detachable coil. They were subsequently followed up for at least 1 year. Aneurysm occlusion was monitored with MR angiography and/or angiography at 6 months and at 1 year., Results: Of the 80 patients, 42 (52.5%) did well (Glasgow Outcome Scale score of 1 or 2) (62% of the 56 patients with grade IV and 25% of the 24 patients with grade V aneurysms), seven (8.75%) presented with poor neurologic status (Glasgow Outcome Scale score of 3), and 30 (37.5%) died during the first 6 months (26.7% of the patients with grade IV and 62% of the patients with grade V aneurysms). One patient was lost to follow-up. The main causes of death were consequences of initial bleeding in the patients with grade V aneurysms and vasospasm in the patients with grade IV aneurysms., Conclusion: The results are at least as encouraging as the outcomes reported for the surgical series and suggest that early endovascular treatment of high grade hemorrhage is a feasible option, especially because endovascular maneuvers can be performed at any time, even during vasospasm.