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In the absence of randomized evidence, the optimal management of patients with unruptured intracranial aneurysms (UIA) remains uncertain. Comprehensive Aneurysm Management (CAM) is an all-inclusive care trial combined with a registry. Any patient with a UIA (no history of intracranial hemorrhage within the previous 30 days) can be recruited, and treatment allocation will follow an algorithm combining clinical judgment and randomization. Patients eligible for at least 2 management options will be randomly allocated 1:1 to conservative or curative treatment. Minimization will be used to balance risk factors, using aneurysm size (≥7 mm), location (anterior or posterior circulation), and age <60 years. The CAM primary outcome is survival without neurologic dependency (modified Rankin Scale [mRS] score <3) at 10 years. Secondary outcome measures include the incidence of subarachnoid hemorrhage during follow-up and related morbidity and mortality; morbidity and mortality related to endovascular treatment or surgical treatment of the UIA at 1 year; overall morbidity and mortality at 1, 5, and 10 years; when relevant, duration of hospitalization; and, when relevant, discharge to a location other than home. The primary hypothesis for patients randomly allocated to at least 2 options, 1 of which is conservative management, is that active UIA treatment will reduce the 10-year combined neurologic morbidity and mortality (mRS score >2) from 24% to 16%. At least 961 patients recruited from at least 20 centers over 4 years will be needed for the randomized portion of the study. Patients with unruptured intracranial aneurysms can be comprehensively managed within the context of an all-inclusive care trial. [ABSTRACT FROM AUTHOR]

Résumé L’échographie est actuellement couramment utilisée dans notre pratique quotidienne en rhumatologie. Elle est principalement utilisée pour l’examen des articulations périphériques et quelques articles ont montré son utilisation possible pour l’étude de l’anatomie rachidienne. Son intérêt dans le diagnostic des pathologies rachidiennes reste cependant inconnu. Nous rapportons le cas d’une femme de 25 ans chez laquelle a été découverte une malformation veineuse lombaire rachidienne. L’écho-doppler, l’angio-IRM et le scanner montraient une dilatation veineuse venant combler le foramen L3-L4 droit. Cette dilatation veineuse foraminale était associée à une malformation de la veine cave inférieure. Nous avons donc pu montrer dans ce cas clinique que l’exploration du rachis par échographie associée au doppler pouvait détecter des anomalies veineuses péri-rachidiennes. Elle pourrait donc être utile dans l’exploration de lésions atypiques du rachis pour caractériser leur origine vasculaire. [ABSTRACT FROM AUTHOR]

Data processing is proposed for accurate quantification of localized proton spectra. Localized proton NMR spectra from phantoms and 30 healthy volunteers were acquired. Scalar coupled spin systems were simulated, allowing for the J-modulation and second order effects. Curve fitting was carried out by a linear combination of the simulated multiplets. The error in curve fitting is approximately 5 times lower than that attained using the standard protocol proposed by the manufacturer. The curve-fitting protocol eliminates the operator-dependent tasks, facilitating and accelerating the quantification of the major metabolite concentrations. [ABSTRACT FROM AUTHOR]

Background: Although carotid web (CaW) is increasingly diagnosed as a cause of cryptogenic stroke, data are still limited to monocentric small sample cohort. To broaden knowledge on symptomatic CaW, CAROWEB registry has been recently implemented. Aims: In a large cohort of symptomatic CaW patients, we described epidemiologic characteristics, admission clinical and imaging features, and the current management including the secondary preventive strategy choice made in comprehensive French Stroke Units. Methods: CAROWEB is an ongoing French observational multicenter registry enrolling consecutive CaW patients diagnosed after an ipsilateral ischemic stroke (IS) or transient ischemic attack (TIA). Submitted cases were validated by two experienced neurologist and neuroradiologist. Clinical, imaging, and management features were collected for this study. Results: Between June 2019 and December 2021, 244 cases were submitted by 14 centers, 42 rejected, and 202 included (IS, 91.6%; TIA, 7.9%; retinal infarction, 0.5%; mean age, 50.8 ± 12.2 years; female, 62.9%; Caucasian, 47.5%; Afro-Caribbean, 20.3%). IS patients showed median (interquartile range (IQR)) admission National Institutes of Health Stroke Scale (NIHSS) score, 8 (2–15); intracranial artery occlusion, 71.8%; ipsilateral chronic cerebral infarction (CCI), 16.3%; and reperfusion treatment, 57.3%. CaW was not identified during the mechanical thrombectomy procedure in 30 of 85 (35.3%) patients. Secondary prevention was invasive in 55.6% (stenting, n = 80; surgery, n = 30). In multivariable analysis, the invasive therapeutic option was associated with ipsilateral CCI (odds ratio (OR): 4.24 (1.27–14.2), p = 0.019) and inversely associated with risk factors (OR: 0.47 (0.24–0.91), p = 0.025) and admission NIHSS score (OR: 0.93 (0.89–0.97), p = 0.001). Conclusion: CaW must be considered in all ethnic groups including Caucasians. Secondary prevention is heterogeneous in large French Stroke Centers. The absence of risk factors, milder severity strokes, and ipsilateral CCI were predictive variables of secondary invasive treatment. The high rate of invasive treatment suggests that medical treatment alone is deemed ineffective to avoid recurrence and emphasize the need of randomized trials. [ABSTRACT FROM AUTHOR]

Ultrasonography is currently widely used in the rheumatology practice. Although mainly performed to study peripheral joint, several articles have underlined its interest to study spinal anatomy. However, its ability to provide diagnostic features is unknown. We studied the case of a 25-year-old woman having low back pain. Three different imaging modalities (Computed Tomography [CT], Magnetic Resonance Imaging [MRI] and Ultrasound) were used to explore it. CT and MRI showed a foraminal dilation of the lombo-ovarian vein at the L3-L4 level with a scalloping of the lateral edge of L3. We were able to detect it with Color Doppler Ultrasound and a malformation of the inferior vena cava was also found. We showed for the first time that Color Doppler Ultrasound can detect venous malformation of the spine. This imaging modality could help us in the diagnosis of atypical lesions of the spine to confirm their vascular origin. [ABSTRACT FROM AUTHOR]

Summary This pilot study aimed at assessing the effect of transcutaneous electrical nerve stimulation (TENS) of the occipital nerve (ON) to treat chronic refractory headache secondary to intracranial endovascular procedures (iEVP) in 4 patients. The duration of ON-TENS therapy was only 1 month (n = 2) or longer than 4 months (n = 2). Overall, pain intensity decreased from 7.8 (on a 0–10 scale) at baseline to 0.8 at 6 months after ON-TENS therapy initiation (−90%), while drug treatment was reduced from 34.3 to 0.8 (−98%) on the medication quantification scale. ON-TENS is a simple technique that may benefit patients with post-iEVP refractory headache. [ABSTRACT FROM AUTHOR]

Background and purpose: Magnetic resonance imaging quantitative T2* mapping has shown reliable identification of thrombus red blood cell content in vitro. The thrombus composition has been in vivo, associated with outcomes after endovascular therapy for acute ischemic stroke. We aim to analyze the red blood cell content of thrombi retrieved from patients with large vessel occlusions in relation to the thrombus-T2* relaxation time in magnetic resonance imaging. Material and methods: Consecutive acute ischemic stroke patients treated by endovascular therapy were scanned with an magnetic resonance imaging quantitative T2* mapping sequence. Quantitative histologic evaluations of red blood cell content were performed. A linear regression assessed the association between vascular risk factors, comorbidities, antithrombotic drugs intake, baseline National Institutes of Health Stroke Scale (NIHSS), intravenous thrombolysis before endovascular therapy, time between onset and groin puncture, patient's outcome at 3 months, magnetic resonance imaging quantitative T2* mapping results, and the red blood cell content of thrombi. The correlation between the mean thrombus-T2* relaxation time and red blood cell content was assessed by calculating the Pearson correlation coefficient. Results: Among 31 thrombi, 16 were "Fibrin rich" and 15 "red blood cell dominant." The median red blood cell content was 39 (range, 0–90; interquartile range, 37). The median (interquartile range) thrombus-T2* relaxation time was shorter in "red blood cell dominant" thrombi (21, interquartile range 6) than in "Fibrin rich" thrombi (24, interquartile range 7), without significant difference (p = 0.15), as shown in the Box plot. An inverse correlation between thrombus-T2* relaxation time and red blood cell content was found, with a correlation coefficient of −0.41 (95% CI, −0.67 to −0.08, p = 0.02). Conclusion: Our study shows that a shorter thrombus-T2* relaxation time is related to a higher red blood cell content within in vivo thrombi. [ABSTRACT FROM AUTHOR]

Importance: Mechanical thrombectomy using a stent retriever or contact aspiration is widely used for treatment of patients with acute ischemic stroke due to anterior circulation large vessel occlusion, but the additional benefit of combining contact aspiration with stent retriever is uncertain.Objective: To determine whether mechanical thrombectomy for treatment of anterior circulation large vessel occlusion stroke with initial contact aspiration and stent retriever combined results in better final angiographic outcome than with standard stent retriever alone.Design, Setting, and Participants: This trial was a multicenter randomized, open-label, blinded end point evaluation that enrolled 408 patients from October 16, 2017, to May 29, 2018, in 11 French comprehensive stroke centers, with a 12-month outcome follow-up. Patients with a large vessel occlusion in the anterior circulation were included up to 8 hours after symptom onset. The final date of follow-up was June, 19, 2019.Interventions: Patients were randomly assigned (1:1 allocation) to receive initial thrombectomy with contact aspiration and stent retriever combined (205) or stent retriever alone (203).Main Outcomes and Measures: The primary outcome was the rate of expanded Thrombolysis In Cerebral Infarction score of 2c or 3 (eTICI 2c/3; ie, scores indicate near-total and total reperfusion grades) at the end of the procedure.Results: Among the 408 patients who were randomized, 3 were excluded, and 405 (99.3%) patients (mean age, 73 years; 220 [54%] women and 185 [46%] men) were included in the primary analysis. The rate of eTICI 2c/3 at the end of the endovascular procedure was not significantly different between the 2 thrombectomy groups (64.5% [131 of 203 patients] for contact aspiration and stent retriever combined vs 57.9% [117 of 202 patients] for stent retriever alone; risk difference, 6.6% [95% CI, -3.0% to 16.2%]; adjusted odds ratio [OR], 1.33 [95% CI, 0.88 to 1.99]; P = .17). Of 14 prespecified secondary efficacy end points, 12 showed no significant difference. A higher rate of successful reperfusion was achieved in the contact aspiration combined with stent retriever group vs the stent retriever alone group (eTICI 2b50/2c/3, 86.2% vs 72.3%; adjusted OR, 2.54 [95% CI, 1.51 to 4.28]; P < .001) and of near-total or total reperfusion (eTICI 2c/3, 59.6% vs 49.5%; adjusted OR, 1.52 [95% CI, 1.02 to 2.27]; P = .04) after the assigned initial intervention alone.Conclusions and Relevance: Among patients with acute ischemic stroke due to large vessel occlusion, an initial thrombectomy technique consisting of contact aspiration and stent retriever combined, compared with stent retriever alone, did not significantly improve the rate of near-total or total reperfusion (eTICI 2c/3) at the end of the endovascular procedure, although the trial may have been underpowered to detect smaller differences between groups.Trial Registration: ClinicalTrials.gov Identifier: NCT03290885. [ABSTRACT FROM AUTHOR]

Introduction: Circulatory assistance from a SynCardia Total Artificial Heart (SynCardia-TAH) is a reliable bridge-to-transplant solution for patients with end-stage biventricular heart failure. Ischemic strokes affect about 10% of patients with a SynCardia-TAH. We report for the first time in the literature two successful thrombectomies to treat the acute phase of ischemic stroke in two patients treated with a SynCardia-TAH in the bridge-to-transplant (BTT). Case report: We follow two patients with circulatory support from a SynCardia-TAH in the bridge-to-transplant for terminal biventricular cardiac failure with ischemic stroke during the support period. An early in-hospital diagnosis enables the completion of a mechanical thrombectomy within the first 6 h of the onset of symptoms. There was no intracranial hemorrhagic complication during or after the procedure and the patients fully recovered from neurological deficits, allowing a successful heart transplant. Conclusion: This case report describes the possibility of treating ischemic strokes under a SynCardia-TAH by mechanical thrombectomy following the same recommendations as for the general population with excellent results and without any hemorrhagic complication during or after the procedure. [ABSTRACT FROM AUTHOR]

Background: Fluid attenuated inversion recovery (FLAIR) vascular hyperintensity (FVH) document slowed vascular flow at the level and after the occlusion site patients with acute ischemic stroke (AIS). We aimed to assess the accuracy of FVH for the confirmation and location of a large vessel occlusion (LVO). Methods: Three radiologists reviewed the FLAIR sequence of the admission MRI exam of patients with suspected AIS at a single academic center. Readers were provided with the main clinical deficit with National Institute of Health Stroke Severity score and were asked to identify and locate an LVO when appropriate. Kappa coefficients were calculated for agreement along with diagnosis performances of FVH to recognize and locate an LVO with digital subtracted angiography (DSA) as gold standard. Results: Among 125 patients screened with MRI for a suspected AIS, 96 (81%) were diagnosed with AIS and 47 (38%) patients had an anterior LVO of whom 25 (20%) had a DSA for mechanical thrombectomy. Kappa coefficients for intra- and inter-readers were good to excellent. Overall, the sensitivity and the specificity of the FVH to predict an anterior LVO was 0.98 (95% confidence interval [CI]: 0.94–1) and 0.86 (95% CI: 0.79–0.96), respectively, while PPV and NPV were 0.87 (95% CI: 0.85–0.95) and 0.98 (0.97–1), respectively. FVH also showed good to excellent accuracy for identifying M1 and M2 versus internal carotid artery occlusion site. Conclusion: We found that FVH demonstrated excellent diagnostic performances for the identification of LVO and its level with good to excellent reproducibility. This MRI radio marker of occlusion provides additional arguments and may speed-up the detection of potential candidates for MT. [ABSTRACT FROM AUTHOR]

The evolution of neurological recovery during the first year after aneurysmal Subarachnoid Haemorrhage (SAH) is poorly described. Patients with SAH in one university hospital from March the 1st 2010, to December 31st 2012, with a one-year follow-up. Evaluation was performed via phone call at 3, 6 and 12 months. Primary endpoint was poor neurological recovery (modified Rankin Scale 3–4–5–6), one year after SAH. Secondary endpoints were the incidence of lack of self-perceived previous health status recovery and incidence of cognitive disorders, one year after SAH. Risk factors of poor neurological recovery were retrieved with multivariable logistic regression. Two hundred and eleven patients were included and 208 had a complete follow-up. One hundred and twenty (57.7%) patients were female, 112 (53.8%) had a WFNS grade I–II–III. Seventy (33.6%) patients displayed one-year poor neurological outcome and risk factors of poor outcome were age, baseline Glasgow Coma Score ≤ 8, external ventricular drainage, intra-cranial hypertension and angiographic vasospasm. We observed an improvement in good outcome at 3 months [112 (53.8%) patients], 6 months [127 (61.1%) patients] and one-year [138 (66.3%) patients]. Fifty-nine (35.3%) patients recovered previous health status, 96 (57.5%) had persistent behaviour disorders, and 71 (42.5%) suffered from memory losses at one year. Neurological recovery seems to improve over time. The same key complications should be targeted worldwide in SAH patients. Neurological complications in the following of SAH should be actively treated in order to improve outcome. The early neuro-ICU phase remains a key determinant of long-term recovery. [ABSTRACT FROM AUTHOR]

Objective: We aimed to determine in the "THRACE" trial, the clinical and MRI technical parameters associated with the two-layered susceptibility vessel sign (TL-SVS) and the overestimation ratio (overR).Materials and Methods: Patients with pre-treatment brain gradient echo (GRE) sequence and an etiological work-up were identified. Two readers reviewed TL-SVS, i.e., a SVS with a linear low-intense signal core surrounded by a higher intensity and measured the overR as the width of SVS divided by the width of the artery. Binomial and ordinal logistic regression respectively tested the association between TL-SVS and quartiles of overR with patient characteristics, cardioembolic stroke (CES), time from onset to imaging, and GRE sequence parameters (inter slice gap, slice thickness, echo time, flip angle, voxel size, and field strength).Results: Among 258 included patients, 102 patients were examined by 3 Tesla MRI and 156 by 1.5 Tesla MRI. Intra- and inter-reader agreements for quartiles of overR and TL-SVS were good to excellent. The median overR was 1.59 (IQR, 1.30 to 1.86). TL-SVS was present in 101 patients (39.2%, 95%CI, 33.1 to 45.1%). In multivariate analysis, only CES was associated with overR quartiles (OR, 1.83; 95%CI, 1.11 to 2.99), and every 60 min increase from onset to MRI time was associated with TL-SVS (OR, 1.72; 95%CI, 1.10 to 2.67). MRI technical parameters were statistically associated with neither overR nor TL-SVS.Conclusion: Independent of GRE sequence parameters, an increased overR was associated to CES, while the TL-SVS is independently related to a longer time from onset to MRI.Key Points: • An imaging biomarker would be useful to predict the etiology of stroke in order to adapt secondary prevention of stroke. • The two-layered susceptibility vessel sign and the overestimation ratio are paramagnetic effect derived markers that vary according to the MRI machines and sequence parameters. • Independent of sequence parameters, an increased overestimation ratio was associated to cardioembolic stroke, while the two-layered susceptibility vessel sign is independently related to a longer time from onset to MRI. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Evidence regarding whether imaging can be used effectively to select patients for endovascular thrombectomy (EVT) is scarce. We aimed to investigate the association between baseline imaging features and safety and efficacy of EVT in acute ischaemic stroke caused by anterior large-vessel occlusion.Methods: In this meta-analysis of individual patient-level data, the HERMES collaboration identified in PubMed seven randomised trials in endovascular stroke that compared EVT with standard medical therapy, published between Jan 1, 2010, and Oct 31, 2017. Only trials that required vessel imaging to identify patients with proximal anterior circulation ischaemic stroke and that used predominantly stent retrievers or second-generation neurothrombectomy devices in the EVT group were included. Risk of bias was assessed with the Cochrane handbook methodology. Central investigators, masked to clinical information other than stroke side, categorised baseline imaging features of ischaemic change with the Alberta Stroke Program Early CT Score (ASPECTS) or according to involvement of more than 33% of middle cerebral artery territory, and by thrombus volume, hyperdensity, and collateral status. The primary endpoint was neurological functional disability scored on the modified Rankin Scale (mRS) score at 90 days after randomisation. Safety outcomes included symptomatic intracranial haemorrhage, parenchymal haematoma type 2 within 5 days of randomisation, and mortality within 90 days. For the primary analysis, we used mixed-methods ordinal logistic regression adjusted for age, sex, National Institutes of Health Stroke Scale score at admission, intravenous alteplase, and time from onset to randomisation, and we used interaction terms to test whether imaging categorisation at baseline modifies the association between treatment and outcome. This meta-analysis was prospectively designed by the HERMES executive committee but has not been registered.Findings: Among 1764 pooled patients, 871 were allocated to the EVT group and 893 to the control group. Risk of bias was low except in the THRACE study, which used unblinded assessment of outcomes 90 days after randomisation and MRI predominantly as the primary baseline imaging tool. The overall treatment effect favoured EVT (adjusted common odds ratio [cOR] for a shift towards better outcome on the mRS 2·00, 95% CI 1·69-2·38; p<0·0001). EVT achieved better outcomes at 90 days than standard medical therapy alone across a broad range of baseline imaging categories. Mortality at 90 days (14·7% vs 17·3%, p=0·15), symptomatic intracranial haemorrhage (3·8% vs 3·5%, p=0·90), and parenchymal haematoma type 2 (5·6% vs 4·8%, p=0·52) did not differ between the EVT and control groups. No treatment effect modification by baseline imaging features was noted for mortality at 90 days and parenchymal haematoma type 2. Among patients with ASPECTS 0-4, symptomatic intracranial haemorrhage was seen in ten (19%) of 52 patients in the EVT group versus three (5%) of 66 patients in the control group (adjusted cOR 3·94, 95% CI 0·94-16·49; pinteraction=0·025), and among patients with more than 33% involvement of middle cerebral artery territory, symptomatic intracranial haemorrhage was observed in 15 (14%) of 108 patients in the EVT group versus four (4%) of 113 patients in the control group (4·17, 1·30-13·44, pinteraction=0·012).Interpretation: EVT achieves better outcomes at 90 days than standard medical therapy across a broad range of baseline imaging categories, including infarcts affecting more than 33% of middle cerebral artery territory or ASPECTS less than 6, although in these patients the risk of symptomatic intracranial haemorrhage was higher in the EVT group than the control group. This analysis provides preliminary evidence for potential use of EVT in patients with large infarcts at baseline.Funding: Medtronic. [ABSTRACT FROM AUTHOR]

Rationale: Mechanical thrombectomy with a stent retriever is now the standard of care in anterior circulation ischemic stroke caused by large vessel occlusion. New techniques for mechanical thrombectomy, such as contact aspiration, appear promising to increase reperfusion status and improve clinical outcome. Aim: We aim at ascertaining whether contact aspiration is more efficient than the stent retriever as a first-line endovascular procedure. Sample size estimates: With a two-sided test (alpha = 5%, power = 90%) and an anticipated rate of spontaneous recanalization and catheterization failures of 15%, we estimate that a sample size of 380 patients will be necessary to detect an absolute difference of 15% in primary outcome (superiority design). Methods and design: The ASTER trial is a prospective, randomized, multicenter, controlled, open-label, blinded endpoint clinical trial. Patients admitted with suspected ischemic anterior circulation stroke secondary to large vessel occlusion, with onset of symptoms <6 h, will be randomly assigned to contact aspiration or stent retriever in a 1:1 ratio; stratified by center and prior IV thrombolysis. If the assigned treatment technique is not successful after three attempts, another technique will be applied, at the operator's discretion. Study outcomes: The primary outcome will be successful recanalization (modified Thrombolysis in Cerebral Infarction score 2b-3) at the end of the endovascular procedures. Secondary outcome will include successful recanalization after the assigned first-line treatment technique alone, procedural times, the need for a rescue technique, complications and modified Rankin Scale at three months. Discussion: No previous head to head randomized trials have directly compared contact aspiration versus stent retriever reperfusion techniques. This prospective trial aims to provide further evidence of benefit of contact aspiration versus stent retriever techniques among patients with ischemic stroke. [ABSTRACT FROM AUTHOR]

Background and Purpose: The susceptibility vessel sign (SVS) on magnetic resonance imaging (MRI) is related to thrombus location, composition, and size in acute stroke. No previous study has determined its inter-MRI scanner variability. We aimed to compare the diagnostic accuracy in-vitro of four different MRI scanners for the characterization of histologic thrombus composition.Methods: Thirty-five manufactured thrombi analogs of different composition that were histologically categorized as fibrin-dominant, mixed, or red blood cell (RBC)-dominant were scanned on four different MRI units with T2* sequence. Nine radiologists, blinded to thrombus composition and MRI scanner model, classified twice, in a 2-week interval, the SVS of each thrombus as absent, questionable, or present. We calculated the weighted kappa with 95% confidence interval (CI), sensitivity, specificity and accuracy of the SVS on each MRI scanner to detect RBC-dominant thrombi.Results: The SVS was present in 42%, absent in 33%, and questionable in 25% of thrombi. The interscanner agreement was moderate to good, ranging from .45 (CI: .37-.52) to .67 (CI: .61-.74). The correlation between the SVS and the thrombus composition was moderate (κ: .50 [CI: .44-.55]) to good κ: .76 ([CI: .72-.80]). Sensitivity, specificity, and accuracy to identify RBC-dominant clots were significantly different between MRI scanners (P < .001).Conclusion: The diagnostic accuracy of SVS to determine thrombus composition varies significantly among MRI scanners. Normalization of T2*sequences between scanners may be needed to better predict thrombus composition in multicenter studies. [ABSTRACT FROM AUTHOR]

Background and purpose: No series reported the mid-term results of Trufill DCS Orbit and Orbit Galaxy detachable coils with independent evaluation. We present the one-year safety and efficacy of these coils in real-life routine clinical practice. Methods: A total of 167 patients with 167 aneurysms (39.1% ruptured) were enrolled in the prospective TRULINE study. The primary endpoint was the safety, assessed by the combined morbidity-mortality rate observed since the time of the procedure and up to one-year follow-up. For safety, primary analyses were performed on intent-to-treat population (attempted coils procedure) and all adverse events have been reviewed by an independent Data Safety Monitoring Board. For efficacy, primary analyses were performed on the per-protocol population (patients treated with more than 70% of Trufill coils and not retreated during the follow-up period) and an independent core laboratory evaluated angiographic results. Results: At one-year post-procedure, neurologic impairment was observed in 6.5% (95% confidence interval: 3.5-11.8) of the patients, and 2.6% (95% confidence interval: 1.0-6.8) had a permanent neurological deterioration. Three deaths were observed, unrelated to the procedure or coils. At one year, complete occlusion was seen in 52 aneurysms (54.2%), neck remnant in 28 aneurysms (29.2%), and aneurysm remnant in 16 aneurysms (16.7%). During the one-year follow-up, the overall incidence of recurrence was 30.2% with a mean interval of 13.8 ± 4.5 months and the retreatment for major recanalization was needed in nine patients (6.3%). Conclusions: The TRULINE study confirms that endovascular coiling with Trufill DCS Orbit and Orbit Galaxy detachable coils is safe and effective. [ABSTRACT FROM AUTHOR]

Importance: The benefits of endovascular revascularization using the contact aspiration technique vs the stent retriever technique in patients with acute ischemic stroke remain uncertain because of lack of evidence from randomized trials.Objective: To compare efficacy and adverse events using the contact aspiration technique vs the standard stent retriever technique as a first-line endovascular treatment for successful revascularization among patients with acute ischemic stroke and large vessel occlusion.Design, Setting, and Participants: The Contact Aspiration vs Stent Retriever for Successful Revascularization (ASTER) study was a randomized, open-label, blinded end-point clinical trial conducted in 8 comprehensive stroke centers in France (October 2015-October 2016). Patients who presented with acute ischemic stroke and a large vessel occlusion in the anterior circulation within 6 hours of symptom onset were included.Interventions: Patients were randomly assigned to first-line contact aspiration (n = 192) or first-line stent retriever (n = 189) immediately prior to mechanical thrombectomy.Main Outcomes and Measures: The primary outcome was the proportion of patients with successful revascularization defined as a modified Thrombolysis in Cerebral Infarction score of 2b or 3 at the end of all endovascular procedures. Secondary outcomes included degree of disability assessed by overall distribution of the modified Rankin Scale (mRS) score at 90 days, change in National Institutes of Health Stroke Scale (NIHSS) score at 24 hours, all-cause mortality at 90 days, and procedure-related serious adverse events.Results: Among 381 patients randomized (mean age, 69.9 years; 174 women [45.7%]), 363 (95.3%) completed the trial. Median time from symptom onset to arterial puncture was 227 minutes (interquartile range, 180-280 minutes). For the primary outcome, the proportion of patients with successful revascularization was 85.4% (n = 164) in the contact aspiration group vs 83.1% (n = 157) in the stent retriever group (odds ratio, 1.20 [95% CI, 0.68-2.10]; P = .53; difference, 2.4% [95% CI, -5.4% to 9.7%]). For the clinical efficacy outcomes (change in NIHSS score at 24 hours, mRS score at 90 days) and adverse events, there were no significant differences between groups.Conclusions and Relevance: Among patients with ischemic stroke in the anterior circulation undergoing thrombectomy, first-line thrombectomy with contact aspiration compared with stent retriever did not result in an increased successful revascularization rate at the end of the procedure.Trial Registration: clinicaltrials.gov Identifier: NCT02523261. [ABSTRACT FROM AUTHOR]

Purpose To assess efficacy, toxicity, and their predictive factors for dynamic conformal arc arteriovenous malformations (AVM) stereotactic radiosurgery. Method Data concerning 90 consecutive patients were retrospectively studied. Clinical, radiological, dosimetrical data and quality indexes were computed. Results AVM median volume was 1.06 cc. Median prescribed dose was 22 Gy. Total occlusion was obtained for 69% of patients. Post-radiosurgery annual hemorrhage rate was 2.2%. Predictive factor for total occlusion was delivered dose. Undesirable events occurred for 28% of patients. Predictive factors for adverse events were AVM revealing mode with seizure or headache, age ≤ 28, AVM diameter ≥ 3 cm Spetzler–Martin score ≥ 4, V12 Gy ≥ 2 cc, large target volume and low homogeneity index ( p < 0.05). Brain parenchymal radiological reactions concerned 23% of patients, and their predictive factors were AVM revelation by seizure, deep localization, AVM diameter ≥ 3 cm, Spetzler–Martin score ≥ 4, previous radiosurgery, numerous embolization, target volume, V12 Gy and low homogeneity index ( p < 0.05). Conclusion Occlusion rate and toxicities are comparable to other series. Specific attention must be paid on pre-treatment clinical data, and target volume should be as small as possible, without reducing the delivered dose. [ABSTRACT FROM AUTHOR]

Introduction: Ventral sulcus spinal cord arteriovenous shunts (SCAVS) are rare vascular lesions that are located outside the spinal cord, are exclusively vascularized by the anterior spinal axis, and drain exclusively through the anterior spinal vein. We report the anatomical, clinical, and neuro-radiological features of SCAVS managed by our team. Methods: We conducted a retrospective study of patients with SCAVSs evaluated by the senior author of this report (GR) between 1981 and 2014. Data were collected by reviewing clinical notes and by a systematic analysis of spinal angiograms and MRI. Results: Among 358 patients, we identified 8 patients (3 women) with ventral sulcus spinal cord arteriovenous shunts. Mean age was 30.5 years. Six patients presented with progressive neurological symptoms, and two with acute neurological symptoms related to hematomyelia. Three shunts were located in the cervical cord, four in the thoracic cord, and one at the conus medullaris; there were two nidus type A-V shunts (AVMs) and six fistula type A-V shunts (AVFs). Seven patients were treated by endovascular therapy with glue embolization. Embolization led to anatomical cure in 5 cases, and a significant reduction of shunt volume and flow of more than 75% in 2 cases. In none of the cases we observed permanent morbidity. Conclusions: AVS of the ventral sulcus of the spinal cord are rare. Recognition of these lesions and precise localization of the anatomical space in which they are located, may allow a better understanding of their pathophysiology and clinical manifestations and guide proper therapeutic decisions. [ABSTRACT FROM AUTHOR]

Introduction: The Woven EndoBridge (WEB) system is an innovative device under evaluation for its capacity to treat wide-neck bifurcation intracranial aneurysms. The purpose of this study is to evaluate the use of the different occlusion scales available in clinical practice. Methods: Seven WEB-experienced neurointerventionalists were provided with 30 angiographic follow-up data sets and asked to grade each evaluation point according to the Bicêtre Occlusion Scale Score (BOSS), firstly based on DSA images only then using additional C-Arm VasoCT analysis. This BOSS evaluation was then converted into the WEB Occlusion Scale (WOS) and into a dichotomized scale (complete occlusion or not). To estimate the inter-rater agreement among the seven raters, an overall kappa coefficient [1] and its standard error (SE) were computed. Results: Using the five-grade BOSS, raters showed 'moderate' agreement (kappa = 0.56). Using the three-grade WOS, agreement appeared slightly better (kappa = 0.59). Strongest inter-rater agreement was observed with a dichotomized version of the scale (complete occlusion or not), which enabled an 'almost perfect' agreement (kappa = 0.88). VasoCT consistently enhanced the agreement particularly with regards depicting intra-WEB residual filling. Conclusion: The WOS is a consistent means to angiographically evaluate the WEB device efficiency. But the five-grade BOSS scale allows to identify aneurysm subgroups with differing risks of recurrence and/or rehemorrhage, which needs to be separated especially at the initial phase of evaluation of this innovative device. The additional use of VasoCT allows better inter-rater agreement in evaluating occlusion and specially in depicting intra-WEB persistent filling. [ABSTRACT FROM AUTHOR]

Cerebral aspergillosis is associated with a significant morbidity and mortality rate. The imaging data present different patterns and no full consensus exists on typical imaging characteristics of the cerebral lesions. We reviewed MRI findings in 21 patients with cerebral aspergillosis and correlated them to the immune status of the patients and to neuropathological findings when tissue was available. The lesions were characterized by their number, topography, and MRI signal. Dissemination to the brain resulted from direct spread from paranasal sinuses in 8 patients, 6 of them being immunocompetent. Hematogenous dissemination was observed in 13 patients, all were immunosuppressed. In this later group we identified a total of 329 parenchymal abscesses involving the whole brain with a predilection for the corticomedullary junction. More than half the patients had a corpus callosum lesion. Hemorrhagic lesions accounted for 13% and contrast enhancement was observed in 61% of the lesions. Patients with hematogenous dissemination were younger (p = 0.003), had more intracranial lesions (p = 0.0004) and had a higher 12-week mortality rate (p = 0.046) than patients with direct spread from paranasal sinuses. Analysis of 12 aneurysms allowed us to highlight two distinct situations. In case of direct spread from the paranasal sinuses, aneurysms are saccular and located on the proximal artery portions, while the hematogenous dissemination in immunocompromised patients is more frequently associated with distal and fusiform aneurysms. MRI is the exam of choice for cerebral aspergillosis. Number and type of lesions are different according to the mode of dissemination of the infection. [ABSTRACT FROM AUTHOR]

Purpose: Stress cardiomyopathy is a common life-threatening complication after aneurysmal subarachnoid hemorrhage (SAH). We hypothesized that left ventricular (LV) longitudinal strain alterations assessed with speckle tracking could identify early systolic function impairment.Methods: This was an observational single-center prospective pilot controlled study conducted in a neuro-intensive care unit. Forty-six patients with severe SAH with a World Federation of Neurological Surgeons grade (WFNS) ≥ III were included. Transthoracic echocardiography (TTE) was performed on day 1, day 3, and day 7 after the patient's admission. A cardiologist blinded to the patient's management analyzed the LV global longitudinal strain (GLS). The control group comprised normal subjects matched according to gender and age.Results: On day 1 median (25th-75th percentile) GLS was clearly impaired in SAH patients compared to controls [-16.7 (-18.7/-13.7) % versus -20 (-22/-19) %, p < 0.0001], whereas LVEF was preserved [65 (59-70) %]. GLS was severely impaired in patients with a WFNS score of V versus III-IV [-15.6 (-16.9/-12.3) % versus -17.8 (-20.6/-15.8) %, p = 0.008]. Seventeen (37 %) patients had a severe GLS alteration (>- 16 %). In these patients, GLS improved from day 1 [-12.4 (-14.8/-10.9) %] to last evaluation [-16.2 (-19/-14.6) %, p = 0.0007] in agreement with the natural evolution of stress cardiomyopathy.Conclusions: On the basis of LV GLS assessment, we demonstrated for the first time that myocardial alteration compatible with a stress cardiomyopathy is detectable in up to 37 % of patients with severe SAH while LVEF is preserved. GLS could be used for sensitive detection of stress cardiomyopathy. This is critical because cardiac impairment remains a major cause of morbidity and mortality after SAH. [ABSTRACT FROM AUTHOR]

Background Aneurysmal subarachnoid haemorrhage (ASH) with intracerebral hematoma (ICH) has a poor prognosis. The treatment is to secure the aneurysm and do an ICH evacuation. Objective The aim of the study was to determine if aneurysm coiling followed by ICH evacuation is a viable alternative treatment compared to exclusive surgery, regardless of the clinical or paraclinical presentations. Methods A retrospective study was conducted between 2004 and 2014, which included 44 patients. The patients were divided up in four groups. Two were principal groups: The clipped group (aneurysm clipping with ICH evacuation) and the coiled group (aneurysm coiling, followed by ICH evacuation); and two were subgroups of the latter: Aneurysm coiling with ICH evacuation after 24 hours and ICH evacuation followed by aneurysm coiling. We studied the demographic and radiologic characteristics, and the 3-month outcome. Results We included 17 patients in the coiled group: The outcome was better for the patients with World Federation of Neurosurgery (WFNS) scores of 1, 2 and 3; compared to the patients with WFNS scores 4 and 5. We included 16 patients in the clipped group: The outcome was better, compared the coiled group, for those patients with WFNS scores 4 and 5. Six patients were treated with aneurysm coiling, followed by ICH evacuation after 24 hours: 33% had a good outcome. Five patients were treated by ICH evacuation, followed by aneurysm coiling: None had a good outcome. Conclusions It was necessary to realise a prospective study to compare the outcomes of patients with WFNS scores of 1, 2 or 3; between those with aneurysm coiling followed by ICH evacuation and aneurysm clipping with ICH evacuation, to determine the potential of using the coiling first, for these patients. [ABSTRACT FROM AUTHOR]

Introduction: Endovascular treatment of large, wide-necked intracranial aneurysms with coils is associated with low rates of initial angiographic occlusion and high rates of recurrence. The Pipeline™ Embolization Device has shown high rates of complete occlusion in uncontrolled clinical series. Methods: The study is a prospective, controlled, randomized, multicenter, phase 2 open-label trial. Intention-to-treat population includes age ≥18, unruptured saccular aneurysm located in the intra-dural area, neck diameter ≥4 and ≤10 mm, sac diameter ≥7 mm and ≤20 mm, 'dome/neck' ratio is ≥1, diameter of the parent artery ≥2 mm and ≤5 mm, and no prior treatment of the aneurysm. Site can only participate if five patients have been previously treated with the Pipeline device. The primary end point of the study is complete occlusion of the aneurysm on angiogram performed 12 months after the endovascular procedure. Complete aneurysm occlusion is defined as the absence of visible blood flow, grade 1 according to the Raymond scale for the standard procedure group and grade 4 according to the grading scale of Kamran for the flow diverter group. Results: The trial is currently enrolling and results of the data are pending the completion of enrollment and follow-up. Conclusion: This paper details the trial design of the French EVIDENCE phase 2 trial, a blinded, controlled randomized trial of wide-neck intra-dural aneurysms amenable to either traditional endovascular strategy or flow diversion with Pipeline device. [ABSTRACT FROM AUTHOR]

The article presents a study of whether magnetic resonance imaging (MRI) at the subacute stage can detect lesions that are linked with poor functional outcome in mild traumatic brain injury (mTBI) with persistent behavioral impairment by using anatomical images (T1) and diffusion tensor imaging (DTI). The study involved 23 mTBI patients and 23 healthy volunteers. According to the findings, DTI at this stage may be a predictive marker of poor outcome in this condition. One cited limitation of the study was the small patients' sample size.

Abstract: Objective: To compare 3D time-of-flight MR angiography (TOF-MRA) at 3 Tesla (3T) with digital subtraction angiography (DSA) for the evaluation of intracranial aneurysm occlusion after endovascular coiling. Methods: In a prospective study, 51 consecutive patients (25 females, 26 males; median age, 51 years) with 51 saccular aneurysms treated with endovascular coiling underwent simultaneous DSA and 3T TOF-MRA at follow-up. DSA and TOF-MRA images were analyzed independently by two senior neuroradiologists. Findings were assigned to 1 of 3 categories in the Raymond classification: complete obliteration, residual neck or residual aneurysm. Agreement between observers and techniques was evaluated using κ statistics. Results: DSA images were not interpretable for one patient. Interobserver agreement was determined as excellent for DSA (κ =0.86) and TOF-MRA (κ =0.80). After reaching a consensus, DSA follow-up showed 26 (51%) complete obliterations, 20 (39%) residual necks and 4 (8%) residual aneurysms. TOF-MRA showed 23 (45%) complete obliterations, 22 (43%) residual necks and 6 (12%) residual aneurysms. Comparison between TOF-MRA and DSA showed excellent agreement between the techniques (κ =0.86). In the four cases that were misclassified, TOF-MRA findings were assigned to a higher class than for DSA. Conclusion: TOF-MRA at 3T is at least as efficient as DSA for the evaluation of intracranial aneurysm occlusion after endovascular treatment with detachable coils. We suggest that TOF-MRA at 3T might be used as the primary method for imaging follow-up of coiled intracranial aneurysms. [Copyright &y& Elsevier]