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OBJECTIVE The role of endovascular treatment in the management of patients with brain arteriovenous malformations (AVMs) remains uncertain. AVM embolization can be offered as stand-alone curative therapy or prior to surgery or stereotactic radiosurgery (SRS) (pre-embolization). The Treatment of Brain AVMs Study (TOBAS) is an all-inclusive pragmatic study that comprises two randomized trials and multiple registries. METHODS Results from the TOBAS curative and pre-embolization registries are reported. The primary outcome for this report is death or dependency (modified Rankin Scale [mRS] score > 2) at last follow-up. Secondary outcomes include angiographic results, perioperative serious adverse events (SAEs), and permanent treatment-related complications leading to an mRS score > 2. RESULTS From June 2014 to May 2021, 1010 patients were recruited in TOBAS. Embolization was chosen as the primary curative treatment for 116 patients and pre-embolization prior to surgery or SRS for 92 patients. Clinical and angiographic outcomes were available in 106 (91%) of 116 and 77 (84%) of 92 patients, respectively. In the curative embolization registry, 70% of AVMs were ruptured, and 62% were low-grade AVMs (Spetzler-Martin grade I or II), while the pre-embolization registry had 70% ruptured AVMs and 58% low-grade AVMs. The primary outcome of death or disability (mRS score > 2) occurred in 15 (14%, 95% CI 8%–22%) of the 106 patients in the curative embolization registry (4 [12%, 95% CI 5%–28%] of 32 unruptured AVMs and 11 [15%, 95% CI 8%–25%] of 74 ruptured AVMs) and 9 (12%, 95% CI 6%–21%) of the 77 patients in the pre-embolization registry (4 [17%, 95% CI 7%–37%] of 23 unruptured AVMs and 5 [9%, 95% CI 4%–20%] of 54 ruptured AVMs) at 2 years. Embolization alone was confirmed to occlude the AVM in 32 (30%, 95% CI 21%–40%) of the 106 curative attempts and in 9 (12%, 95% CI 6%–21%) of 77 patients in the pre-embolization registry. SAEs occurred in 28 of the 106 attempted curative patients (26%, 95% CI 18%–35%, including 21 new symptomatic hemorrhages [20%, 95% CI 13%–29%]). Five of the new hemorrhages were in previously unruptured AVMs (n = 32; 16%, 95% CI 5%–33%). Of the 77 pre-embolization patients, 18 had SAEs (23%, 95% CI 15%–34%), including 12 new symptomatic hemorrhages [16%, 95% CI 9%–26%]). Three of the hemorrhages were in previously unruptured AVMs (3/23; 13%, 95% CI 3%–34%). CONCLUSIONS Embolization as a curative treatment for brain AVMs was often incomplete. Hemorrhagic complications were frequent, even when the specified intent was pre-embolization before surgery or SRS. Because the role of endovascular treatment remains uncertain, it should preferably, when possible, be offered in the context of a randomized trial.

OBJECTIVE The Treatment of Brain Arteriovenous Malformations Study (TOBAS) is a pragmatic study that includes 2 randomized trials and registries of treated or conservatively managed patients. The authors report the results of the surgical registry. METHODS TOBAS patients are managed according to an algorithm that combines clinical judgment and randomized allocation. For patients considered for curative treatment, clinicians selected from surgery, endovascular therapy, or radiation therapy as the primary curative method, and whether observation was a reasonable alternative. When surgery was selected and observation was deemed unreasonable, the patient was not included in the randomized controlled trial but placed in the surgical registry. The primary outcome of the trial was mRS score > 2 at 10 years (at last follow-up for the current report). Secondary outcomes include angiographic results, perioperative serious adverse events, and permanent treatment-related complications leading to mRS score > 2. RESULTS From June 2014 to May 2021, 1010 patients were recruited at 30 TOBAS centers. Surgery was selected for 229/512 patients (44%) considered for curative treatment; 77 (34%) were included in the surgery versus observation randomized trial and 152 (66%) were placed in the surgical registry. Surgical registry patients had 124/152 (82%) ruptured and 28/152 (18%) unruptured arteriovenous malformations (AVMs), with the majority categorized as low-grade Spetzler-Martin grade I–II AVM (118/152 [78%]). Thirteen patients were excluded, leaving 139 patients for analysis. Embolization was performed prior to surgery in 78/139 (56%) patients. Surgical angiographic cure was obtained in 123/139 all-grade (89%, 95% CI 82%–93%) and 105/110 low-grade (95%, 95% CI 90%–98%) AVM patients. At the mean follow-up of 18.1 months, 16 patients (12%, 95% CI 7%–18%) had reached the primary safety outcome of mRS score > 2, including 11/16 who had a baseline mRS score ≥ 3 due to previous AVM rupture. Serious adverse events occurred in 29 patients (21%, 95% CI 15%–28%). Permanent treatment-related complications leading to mRS score > 2 occurred in 6/139 patients (4%, 95% CI 2%–9%), 5 (83%) of whom had complications due to preoperative embolization. CONCLUSIONS The surgical treatment of brain AVMs in the TOBAS registry was curative in 88% of patients. The participation of more patients, surgeons, and centers in randomized trials is needed to definitively establish the role of surgery in the treatment of unruptured brain AVMs. Clinical trial registration no.: NCT02098252 (ClinicalTrials.gov)

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

BackgroundNon-ischemic cerebral enhancing (NICE) lesions are exceptionally rare following aneurysm endovascular therapy (EVT).ObjectiveTo investigate the presenting features and longitudinal follow-up of patients with NICE lesions following aneurysm EVT.MethodsPatients included in a retrospective national multicentre inception cohort were analysed. NICE lesions were defined, using MRI, as delayed onset punctate, nodular or annular foci enhancements with peri-lesion edema, distributed in the vascular territory of the aneurysm EVT, with no other confounding disease.ResultsFrom a pool of 58 815 aneurysm endovascular treatment procedures during the study sampling period (2006–2019), 21/37 centres identified 31 patients with 32 aneurysms of the anterior circulation who developed NICE lesions (mean age 45±10 years). Mean delay to diagnosis was 5±9 months, with onset occurring a month or less after the index EVT procedure in 10 out of 31 patients (32%). NICE lesions were symptomatic at time of onset in 23 of 31 patients (74%). After a mean follow-up of 25±26 months, 25 patients (81%) were asymptomatic or minimally symptomatic without disability (modified Rankin Scale (mRS) score 0–1) at last follow-up while 4 (13%) presented with mild disability (mRS score 2). Clinical follow-up data were unavailable for two patients. Follow-up MRI (available in 27 patients; mean time interval after onset of 22±22 months) demonstrated persistent enhancement in 71% of cases.ConclusionsThe clinical spectrum of NICE lesions following aneurysm EVT therapy spans a wide range of neurological symptoms. Clinical course is most commonly benign, although persistent long-term enhancement is frequent.

Symptomatic intracerebral hemorrhage (sICH) is a common complication of acute ischemic stroke (AIS) associated with limited treatments and poor outcomes. We aimed to identify predictive factors of sICH in patients with AIS following mechanical thrombectomy (MT) in a real-world setting. Patients with large vessel occlusion of the anterior circulation treated with MT were consecutively included in a prospective monocentric cohort. Clinical, biological, and radiological parameters were collected to identify pre-procedural predictors for sICH. 637 patients were included in our study. Magnetic resonance imaging was performed on most patients (86.7%). sICH occurred in 55 patients (8.6%). 428 patients (67.2%) were treated with intravenous thrombolysis. After multivariate analysis, prior use of antiplatelet therapies (odd ratio (OR) 1.84, 95% confidence interval (CI) 1.01–3.32), high C-reactive protein (OR per standard deviation (SD) increase 1.28, 95% 1.01–1.63), elevated mean arterial blood pressure (OR per 10 mmHg increase 1.22, 95% CI 1.03–1.44), hyperglycemia (OR per one SD-log increase 1.38, 95% CI 1.02–1.87), and low ASPECTS (OR per 1-point decrease 1.42, 95% CI 1.12–1.80) were found to be independent predictive factors of sICH. The pre-procedural predictors did not change when the absence of successful recanalization was considered as a covariate. Patients with strokes of unknown onset time were not especially vulnerable for sICH. sICH after MT was associated with several pre-procedural risk factors: prior use of antiplatelet therapies, high C-reactive protein and hyperglycemia at baseline, elevated mean arterial blood pressure, and low ASPECTS.

Background and purpose The PHASES score was formulated to predict the 5-year risk of rupture for intracranial aneurysms. We retrospectively analyzed all patients treated in our institution for aneurysmal SAH and applied the PHASES score to estimate the probable predicted risk of bleeding in this group of patients. Methods Between February 2015 and August 2018, all patients with aneurysmal SAH were retrospectively analyzed and the PHASES score was applied. A total of 155 patients were included with a mean age of 53.8 years, including 60 males and 95 females. Results Of our patients 110 (70.9%) had a PHASES score of below or equal to 5, with a hemorrhagic risk of up to 1.3% over 5 years. If we analyze the patients with a risk of below 2% this figure increases to 122 patients (78.7%). Of these 99.3% were European and 0.6% were Japanese (1 patient). In 86 patients (55.4%), the aneurysm was smaller than 5 mm and in 10 patients (6.4%) the aneurysm was located in the posterior circulation. Conclusion Of our patients 78.7% had less than a 2% 5-year rupture risk based on their PHASES score, highlighting the discrepancy of the rupture risk calculated with the PHASES score when hypothetically applied to this group of patients. In the hypothetical scenario that our patients had unruptured aneurysms, our retrospective analysis shows that the PHASES score may only provide a weak tool for clinicians to use in the decision-making process as to whether or not to treat these aneurysms.

BackgroundThe CLinical Assessment of WEB device in Ruptured aneurYSms (CLARYS) study has shown that the endovascular treatment of ruptured bifurcation aneurysms with the Woven EndoBridge (WEB) is safe and effective and provides protection against rebleeding at 1 month and 1 year. The 12-month angiographic follow-up is an important endpoint of the study.MethodsThe CLARYS study is a prospective multicenter study conducted in 13 European centers. The study enrolled 60 patients with 60 ruptured aneurysms of the anterior and posterior circulation. The study was conducted with an independent assessment of safety outcomes and imaging.ResultsSixty patients with 60 ruptured bifurcation aneurysms to be treated with the WEB were included. Fifty-three aneurysms (88.3%) had a broad base with a dome to neck ratio ConclusionsThe CLARYS study has previously shown that the use of the WEB in the endovascular treatment of ruptured bifurcation aneurysms provides effective protection against rebleeding with a good safety profile. The angiographic occlusion rates at 1 year reported here are comparable to those already seen in previous multicenter studies which primarily included unruptured aneurysms.

BackgroundWoven EndoBridge (WEB) devices are becoming a reliable option for the treatment of wide-neck bifurcation aneurysms, but clear predictive factors are still missing to understand the one in five aneurysm remnant rate.ObjectiveTo evaluate occlusion outcomes after WEB treatment to identify potential determinants of aneurysm occlusion.MethodsA single-center database with consecutive aneurysms treated with WEB between July 2012 and October 2021 was reviewed for potential determinants of aneurysm adequate occlusion (defined as a Bicêtre Occlusion Scale Score (BOSS) of 0, 0’, 1 or 2), through univariate and multivariable analysis. Patients without angiographic follow-up were excluded.Results215 of 247 individual aneurysms were included in the final analysis, of which 59 (27%) were ruptured. Mean age of patients was 56 years (range 23–90 years) and 65% were female. Mean angiographic follow-up was at 18 months (range 3–97 months). Adequate and complete occlusion were achieved in 171/215 (79.5%) and 135/215 (62.8%) of cases, respectively. Aneurysm irregular shape (aOR=0.42, 95% CI 0.20 to 0.88; p=0.02), aneurysm height (aOR=0.79, 95% CI 0.66 to 0.94; pConclusionIn this study we demonstrated that a width oversizing strategy of the WEB device was an independent predictor of aneurysm angiographic occlusion. Conversely, aneurysm height, irregular aneurysm, and WEB shape modification were all independent determinants of angiographic aneurysm remnant. These results may help to select aneurysms suitable for the WEB device and WEB sizing.

BackgroundThe primary goal of the CLARYS study is to assess the protection against rebleeding when treating ruptured bifurcation aneurysms with the Woven EndoBridge (WEB) device.MethodsThe CLARYS study is a prospective, multicenter study conducted in 13 European centers. Patients with ruptured bifurcation aneurysms were consecutively included between February 2016 and September 2017. The primary endpoint was defined as the rebleeding rate of the target aneurysm treated with the WEB within 30 days postprocedure. Secondary endpoints included periprocedural and postprocedural adverse events, total procedure and fluoroscopy times, and modified Rankin Scale score at 1 month and 1 year.ResultsSixty patients with 60 ruptured bifurcation aneurysms to be treated with the WEB were included. A WEB device was successfully implanted in 93.3%. The rebleeding rate at 1 month and 1 year was 0%. The mean fluoroscopy time was 27.0 min. Twenty-three periprocedural complications were observed in 18 patients and resolved without sequelae in 16 patients. Two of these complications were attributed to the procedure and/or the use of the WEB, leading to a procedure/device-related intraoperative complication rate of 3.3%. Overall mortality at 1 month and 1 year was 1.7% and 3.8%, respectively and overall morbidity at 1 month and 1 year was 15% and 9.6%, respectively. WEB-related 1-month and 1-year morbidity and mortality was 0%.ConclusionsThe interim results of CLARYS show that the endovascular treatment of ruptured bifurcation aneurysms with the WEB is safe and effective and, in particular, provides effective protection against rebleeding. It may induce profound change in the endovascular management of ruptured bifurcation aneurysms.

To compare outcomes of minor stroke patients with intracranial vessel occlusions (IVO) underwent mechanical thrombectomy (MT) versus those treated with intravenous thrombolysis alone (IVT).We retrospectively reviewed two large prospective stroke databases from two European centers searching for patients admitted with minor stroke (i.e. NIHSS Score░≤░5), baseline mRS░=░0 and occlusion of the M1-M2 segment of the middle cerebral artery (MCA). Groups receiving (A) IVT alone and (B) MT+/-IVT were compared. Primary outcome measures were MT safety, successful recanalization rate (mTICI 2b-3) and NIHSS shift (discharge NIHSS minus admission NIHSS); secondary outcomes included discharge rates and excellent outcome (mRS 0-1) at 3 months. Univariate and multivariate analyses were performed.Thirty-two patients were enrolled in Group B (19░MT alone; 13 MT░+░IVT) and 24 in Group A. Successful recanalization (mTICI 2b-3) was obtained in 100% of cases in Group B vs 38% in Group A. Symptomatic hemorrhagic transformation rate did not differ between the two groups. Multivariate analysis reported MT as the only predictor of early (░12░h) favorable NIHSS shift and lower NIHSS at discharge. Moreover, discharge at home and excellent outcome at 3-month follow-up were statistically associated with MT.MT in patients with minor strokes and intracranial vessel occlusion (IVO) is safe and can determine a rapid improvement of NIHSS Score. MT seems also associated with a higher rate of patients discharged at home after hospitalization and better clinical outcome at 3-month follow-up. Larger randomized trials are warranted to confirm these results.

BackgroundAround 10% of Woven EndoBridge device (WEB)-treated intracranial aneurysms will need retreatment, and it is generally believed to be more challenging than retreatment after an initial coiling. We aim to report retreatment strategies and outcomes after initial WEB embolizations.MethodsDatabases from four treatment centers, containing consecutive aneurysms treated with a WEB between 2013 and 2022, were reviewed. Demographics, aneurysm characteristics, retreatment strategies and outcomes were collected and analyzed.ResultsFrom a 756 WEB database, 57 aneurysms were included. The global retreatment rate was 7.5% (95% CI 5.6% to 9.4%). The retreatment rate was significantly higher in the ruptured compared with the unruptured population (13% vs 3.9%, respectively, PConclusionThe retreatment rate after an initial WEB treatment seems to compare favorably with that of coiling. Endovascular treatment of recurrence following WEB implantation is feasible in most situations; it generally requires the use of a stent and leads to a high rate of satisfactory occlusion.

BACKGROUND AND PURPOSE: Woven EndoBridge (WEB) devices are increasingly used to treat intracranial aneurysms. A1 asymmetry contributes to anterior communicating artery aneurysm formation and to treatment instability after coiling. We sought to evaluate whether A1 asymmetry had an impact on angiographic outcome in anterior communicating artery aneurysms treated with the WEB. MATERIALS AND METHODS: Anterior communicating artery aneurysms treated between July 2012 and July 2020 with the WEB from an institutional review board–approved database were reviewed. A1 asymmetry was categorized as the following: absence of the A1 segment on 1 side (unilateral A1) versus bilateral A1. Univariate and multivariable analyses assessed independent predictors of adequate (WEB Occlusion Scale A, B, and C) and complete occlusion (WEB Occlusion Scale A and B). RESULTS: Forty-eight individual aneurysms (47 patients) were included in the final analysis, of which 16 (33%) were acutely ruptured. The mean size was 6.5 (SD, 2.2) mm. Adequate and complete occlusion was achieved in 33 (69%) and 30 (63%) cases, respectively. Unilateral A1 was associated with significantly higher rates of adequate (92% versus 60% for bilateral A1; P = .03) and complete occlusion (92% versus 50% for bilateral A1; P < .01). Multivariable logistic regression confirmed unilateral A1 as an independent predictor of both adequate (OR = 10.6; 95% CI, 1.6–220.7; P = .04) and complete occlusion (OR = 9.5, 95% CI, 1.5–190.2; P = .04. A sensitivity analysis comparing unilateral “functional” A1 with bilateral “functional” A1 showed similar results. WEB shape modification was not influenced by the unilateral A1 configuration (P = .70). CONCLUSIONS: Anterior communicating artery aneurysms with a unilateral A1 configuration treated with WEB devices are associated with better angiographic outcome than those with bilateral A1. This finding supports the hypothesis that WEB devices are resistant to unilateral flow in the aneurysm as opposed to coils.

Purpose: Pediatric intracranial aneurysms (PIA) are rarer and more complex when compared to adult aneurysms. In general, the clinical presentation of PIA is due to a mass effect, but the presenting symptoms can be also related to ischemia, subarachnoid hemorrhage (SAH), or in a combination of different symptoms. This paper aimed to report a single-center experience with clinical and angiographic aspects of brain aneurysm in children. Methods: We retrospectively reviewed our prospectively maintained database for patients with intracranial aneurysms in our institution from July 2015 to February 2021. Among these, all patients under 18 years of age submitted to a diagnostic or therapeutic procedure for an intracranial aneurysm were included. Results: Twelve patients were submitted to diagnostic or therapeutic procedures in our department. Three of them had multiple aneurysms, and in total, 17 intracranial aneurysms were assessed in this study. The most frequent location was in the middle cerebral artery (7 cases/41%). Five out of twelve children (42%) presented SAH due to ruptured aneurysm. Three patients (25%) had symptoms due to the mass effect from large aneurysms, with compression of cranial nerves or brainstem. Aneurysms diameters ranged from 1.5 mm to 34 mm (mean 14.2 mm), with six aneurysms being giant and eight being nonsaccular/fusiform. Twelve aneurysms were submitted to endovascular treatment, with one treatment-related clinical complication and later death. Conclusion: PIAs are rare diseases that can arise from a variety of different underlying pathological mechanisms. The management of these conditions requires a detailed understanding of the pathology and a multidisciplinary approach. Despite the availability of new technologies, parent vessel occlusion remains a valid option for aneurysms in the pediatric population.

BACKGROUND AND PURPOSE: The Woven Endobridge has proved to be a safe and effective treatment, especially for wide-neck intracranial aneurysms. The recent fifth-generation Woven Endobridge came with smaller devices. The purpose of this study was to assess the safety and efficiency of Woven Endobridge treatment of small and very small aneurysms. MATERIALS AND METHODS: Between September 2017 and March 2020, all consecutive patients treated with a 3- or 3.5 mm-width Woven Endobridge device were included in this retrospective intention-to-treat study. Clinical and radiologic findings were evaluated at immediate and last-available follow-up. Angiographic outcome was assessed by an external expert reader. RESULTS: One hundred twenty-eight aneurysms were treated with a fifth-generation Woven Endobridge device including 29 with a width of ≤3.5 mm. Ten aneurysms were ruptured (34%). In 3 cases (10%), Woven Endobridge treatment could not be performed because the aneurysm was still too small for the smallest available Woven Endobridge device and another endovascular strategy was chosen. The median follow-up time was 11.2 months. Complete and adequate occlusion was obtained in 71% and 90% of the treated aneurysms, respectively. Retreatment was needed in 2 cases (10%). Symptomatic ischemic complications leading to transient neurologic deficits occurred in 2 cases (7%) (1 procedure-related and 1 device-related) but with full spontaneous recovery at discharge. CONCLUSIONS: The fifth-generation Woven Endobridge device seems to be a safe and technically feasible treatment for both ruptured and unruptured small and very small intracranial aneurysms, with satisfactory occlusion rates on midterm follow-up. However, further study is needed to evaluate longer-term efficiency.

BackgroundWoven EndoBridge (WEB) device treatment of wide-neck bifurcation aneurysms has proved to be safe and effective, but the use of these devices in sidewall aneurysms has been reported only in a small number of case series.ObjectiveTo report our results in a cohort of consecutive patients in whom a WEB device was used as first-line treatment for posterior communicating artery (PComA) aneurysms.MethodsWe conducted a retrospective analysis of a prospectively maintained database of PComA aneurysms treated with a WEB device in our institution from June 1, 2012 to November 15, 2020. Clinical and radiological findings were evaluated at immediate and last follow-up.ResultsA total of 219 aneurysms were treated with a WEB device, including 15 PComA aneurysms in 15 patients, 10 of which were ruptured. Aneurysms were wide necked, with a mean aspect ratio of 1.6 (range 0.7–3.0) and a mean neck size of 4.2 mm (range 2.6–7.4 mm). No intraoperative rupture occurred and only one thromboembolic event was noted. Among the group with at least a 3-month digital subtraction angiography (DSA) follow-up, complete and adequate occlusion were obtained in 54% and 72%, respectively (average follow-up 13 months). Re-treatment was needed for two initially ruptured aneurysms. No procedure-related morbidity or mortality was reported.ConclusionThis series suggests the high safety profile of WEB devices even when used in off-label indications. Treatment with these devices seems to be a valuable strategy for ruptured wide-neck PComA aneurysms, avoiding the need for antiplatelet medication. However, occlusion rates should be investigated in further larger studies.

BackgroundThe Woven EndoBridge (WEB) shape modification (WShM) during follow-up may be a potential cause of poor angiographic outcomes. WShM predisposing factors have not yet been determined. Our systematic use of rotational cone beam computed tomography (VasoCT) imaging during follow-up allowed us to perform the first quantitative analysis of the shape of WEBs over time. Our goal was to identify possible strategies to reduce the occurrence of this phenomenon.MethodsAll patients treated in our hospital with a WEB device between October 2015 and January 2019 were included. Using VasoCT acquisitions, systematically performed after implantation and during follow-up, we analyzed WEB morphology. WShM was defined as the percentage reduction in the distance between the two WEB markers.ResultsSixty-three aneurysms treated with a WEB device were finally included in this analysis. At the last follow-up (mean 15.5 months), mean WShM was 48%±24. The mean WShM was significantly higher in the aneurysm recurrence group than in the adequate occlusion group (51±6.5% vs 36±3.4%, difference 15% points (95% CI 0.7 to 30); pConclusionWShM can be partly overcome by use of an appropriate width oversizing strategy that could lead to improved angiographic results.

Purpose WEB device shape modification (WShM) is a potential cause of poor angiographic outcome during follow-up, despite an initial complete aneurysmal occlusion. The prevalence, the factors affecting WShM and the ways to prevent this phenomenon are only partially established. Materials and Methods Patients treated in Bicetre hospital with a WEB device between were included October 2015 and January 2019. Exclusion criteria were the lack of follow-up or a combined treatment. Thanks to rotational cone-beam CT (CBCT) acquisitions, systematically performed after implant and during follow-up, we have analyzed WEB morphology over time. WshM was correlated with anatomical and procedures parameters. Angiographic occlusion was evaluated according to the Bicetre occlusion scale (BOSS). Results 92 aneurysms were treated with a WEB device and 68% were finally included in this register. 87% of WEB devices presented WShM during follow-up (at least 20% of height reduction). We did not find a direct relationship between the extent of WShM and occlusion rates. But in the worsening occlusion group the average WShM was significantly higher than in the stable occlusion group (50% vs 43%, p Conclusion CBCT allowed us to perform the first precise and quantitative analysis of WEB shape modification during follow-up. WShM is a very frequent phenomenon, negatively affecting occlusion rates. But it can be partly overcome with an appropriate oversizing strategy. Disclosures J. Caroff: None. C. Mihalea: None. L. Ikka: None. A. Ozanne: None. S. Gallas: None. V. Chalumeau: None. J. Moret: None. L. Spelle: None.

This case report describes a combined neurosurgical and endovascular approach for the treatment of a conus medullaris arteriovenous malformation resulting in considerable improvement in the patient’s neurological condition (modified Rankin Scale score 2).

BackgroundNeo-intimal hyperplasia (NIH) is frequently observed after flow-diverter stent (FDS) implantation. Although mostly asymptomatic, this vascular response can sometimes lead to delayed ischemic strokes. This study intended to evaluate the factors potentially influencing the rates of NIH following FDS treatment.Material and MethodsAll aneurysm treatments performed with a Pipeline embolization device (PED) or a SILK stent from May 2011 to May 2015 were collected in a prospectively maintained database. Patient demographics, clinical, and angiographic outcomes including both digital subtraction angiography and C-arm cone-beam CT were registered. Two blind reviewers rated the presence of NIH on a binary scale (present/absent).ResultsFrom 148 patients, 63 datasets were available for analysis. Inter-reader agreement was excellent (Kappa=0.88). NIH was positively correlated with smoking, dyslipidemia, and high blood pressure, but not with aneurysm characteristics. At early follow-up (ConclusionNIH is a dual-vessel reaction after FDS implant. When planning a treatment in locations at risk of ischemic complications if severe NIH would occur, then the stent design should be considered. However, minimal NIH might also be needed as it is involved in aneurysm healing. Before treatment patients should be recommended best medical management of their cardiovascular risks factors to prevent an excessive NIH reaction.

Background Recent reports have revealed a worsening of aneurysm occlusion between WEB treatment baseline and angiographic follow-up due to “compression” of the device. Objective We utilized computational fluid dynamics (CFD) in order to determine whether the underlying mechanism of this worsening is flow related. Methods We included data from all consecutive patients treated in our institution with a WEB for unruptured aneurysms located either at the middle cerebral artery or basilar tip. The CFD study was performed using pre-operative 3D rotational angiography. From digital subtraction follow-up angiographies patients were dichotomized into two groups: one with WEB “compression” and one without. We performed statistical analyses to determine a potential correlation between WEB compression and CFD inflow ratio. Results Between July 2012 and June 2015, a total of 22 unruptured middle cerebral artery or basilar tip aneurysms were treated with a WEB device in our department. Three patients were excluded from the analysis and the mean follow-up period was 17 months. Eleven WEBs presented “compression” during follow-up. Interestingly, device “compression” was statistically correlated to the CFD inflow ratio ( P = 0.018), although not to aneurysm volume, aspect ratio or neck size. Conclusion The mechanisms underlying the worsening of aneurysm occlusion in WEB-treated patients due to device compression are most likely complex as well as multifactorial. However, it is apparent from our pilot study that a high arterial inflow is, at least, partially involved. Further theoretical and animal research studies are needed to increase our understanding of this phenomenon.

BACKGROUND AND PURPOSE: The treatment of wide-neck, large basilar apex aneurysms is challenging with either an endovascular or a surgical approach. The aim of the present study was to report our experience treating basilar apex aneurysms with flow-diverter stents and to evaluate their efficacy and safety profile in this specific anatomic condition. MATERIALS AND METHODS: We retrospectively analyzed data from all consecutive patients treated with flow-diverter stents at our institution between January 2011 and January 2015. Patients with large basilar apex aneurysms treated with a flow-diverter stent were included in the study. Clinical presentations, technical details, intra- and perioperative complications, and clinical and angiographic outcomes were recorded, with a midterm follow-up. RESULTS: Of the 175 aneurysms treated with flow-diverter stents at our institution, 5 patients (2 women and 3 men; age range, 44–58 years) received flow-diverter stent for basilar apex aneurysms. The mean follow-up after stent deployment was 21 months (range, 15–24 months). One patient died on day 31 from an early postprocedural midbrain hemorrhage. One patient had a right cerebellar hemispheric ischemic lesion with a transient cerebellar syndrome resolved within 24 hours without neurologic sequelae at the latest follow-up. The mRS was 0 in 4 patients and 6 in 1 patient at last follow-up. CONCLUSIONS: Flow diversion is a feasible technique with an efficacy demonstrated at a midterm follow-up, especially in the case of basilar apex aneurysm recurrences after previous endovascular treatments. Concern about its safety profile still exists.

This case report describes a combined neurosurgical and endovascular approach for the treatment of a conus medullaris arteriovenous malformation resulting in considerable improvement in the patient’s neurological condition (modified Rankin Scale score 2).

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 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.

BackgroundWoven EndoBridge (WEB) deployment remains challenging in aneurysms with a complex shape or orientation.ObjectiveTo show that embolization of wide-neck bifurcation aneurysms using the WEB device balloon remodeling-assisted technique is a feasible and elegant endovascular solution compared with other techniques, such as balloon remodeling or stent-assisted coiling.Materials and methods10 cases (10 aneurysms in 9 patients) of balloon remodeling-assisted WEB treatment of unruptured complex bifurcation aneurysms were treated in our institution and retrospectively analyzed. Details of clinical presentations, technical details, perioperative and postoperative complications, and outcomes were collected. Immediate and long-term angiographic results were also evaluated.ResultsAneurysms included six middle cerebral artery aneurysms, one anterior communicating artery aneurysm, one posterior communicating artery aneurysm, one basilar artery aneurysm, and one T-shaped carotid aneurysm. Mean dome width was 6.55 mm, mean neck size 4.5 mm, mean height 4.79 mm, and mean dome-to-neck ratio was 1:1.46. Treatment was performed exclusively with the balloon remodeling-assisted WEB technique in all cases. The device was successfully deployed in every case. Periprocedural thromboembolic or hemorrhagic events did not occur. The modified Rankin Scale score at discharge was 0 for all patients. At mid-term or long-term angiographic follow-up, adequate occlusion was observed in 7 aneurysms from 8 controlled cases (87.5%), and one patient (2 aneurysms) did not have angiographic follow-up.ConclusionThe balloon remodeling-assisted WEB technique seems to be a safe and effective solution for endovascular treatment of unruptured wide-neck bifurcation aneurysms with specific complex anatomy. However, further studies are needed to evaluate the rate of complications and long-term efficacy.

BackgroundAneurysms of the anterior communicating artery (ACoA) are difficult to treat with coiling or clipping because of the anatomical variation in this region. Flow diversion represents a feasible treatment, but no consensus exists as to which stent deployment technique is more suitable.MethodsAll patients with ACoA aneurysms treated with flow diverters between April 2014 and November 2018 were retrospectively analyzed. Aneurysm characteristics, follow-up results, and clinical outcome data were recorded, and a new classification comparing the diameters of both A1 segments is proposed: H1=same diameters; H2=ResultsWe analyzed 30 procedures in 30 patients with ACoA aneurysms, including 16 ruptured aneurysms treated with coiling embolization and 4 previously unruptured aneurysms (two Medina and two Woven EndoBridge devices). Adequate aneurysm occlusion occurred in 86.9%; one patient (3.3%) experienced symptomatic ischemic stroke. The global thromboembolic complications for each group were 17.6% (H1), 25% (H2), and 60% (H3).ConclusionFlow diversion treatment in this region is safe, feasible, and effective. The most suitable anatomical configuration for flow diverter treatment seems to be the H1 configuration where the ‘I technique’ is suitable (from an A1 segment to the ipsilateral A2). There is a tendency that the H3 configuration is not a good indication for flow diverter treatment. However, further studies are needed to evaluate the feasibility of this anatomical classification and the reproducibility of our findings.

Background: Randomized controlled trials for calcium antagonists therapy in patients with acute ischemic stroke have failed to show a benefit as a stand-alone therapy, due largely to the reduction of blood pressure, especially in the absence of early recanalization. Since mechanical thrombectomy (MT) has led to high successful recanalization rates, the effect of nimodipin as an adjuvant therapy during MT has not been evaluated. Materials and Methods: We retrospectively reviewed all consecutive cases of MT for which Nimodipin was used as an adjuvant therapy after at least one pass of any device. Clinical and angiographic characteristics, as well as immediate vessel caliber modifications, reperfusion status and early neurological improvement were collected between January 2016 and December 2017. Results: Procedural intra-arterial nimodipin infusion was administered in 10.3 % (58/559; 95%CI 7.8-12.8 %) of patients, after at least one pass of MT device. In 52/58 patients, < 3 manoeuvers of MT were performed. Angiographic vasospasm was identified on the carotid artery in 17/58 (29.3%) cases, on the middle cerebral artery in 35/58 (60.4%) cases and in vertebro-basilar artery in 6/58 (10.3%) cases. The vasospasm was responsible for an immediate reocclusion in 12% of the patients. Angiographic effect of nimodipin with the restauration of a normal vessel caliber and the improvement of the reperfusion without supplementary maneuver was observed in 77.5% % of the cases. Successful recanalization TICI 2b/3 was reached in 81% patients. Significant drop of blood pressure (BP) with need for additional vasopressive drugs was observed in 6 cases. Symptomatic hemorrhage occurred in 3 patients (5%). Concomitant fibrinolytic therapy did not influence the rate of intracranial hemorrhage rate after procedural nimodipin infusion (p=0.912). Early neurological improvement was reached in 46% and was not associated with a high initial systolic and diastolic BP at the admission (p=0.89) or with the modality of anesthesia (p =0.76). Conclusion: Nimodipin can be an efficient and safe adjuvant therapy in the setting of vasospasm due to MT, by normalizing the caliber of the recanalized artery and then, improving the reperfusion status without supplementary maneuver of MT.

Introduction The treatment of wide-neck bifurcation aneurysms is still challenging despite the use of new techniques, such as Y-stenting, the waffle-cone technique and intrasaccular flow disrupters, in recent years. Moreover, the use of flow diverter stents in bifurcation aneurysms has been proposed by several teams, although the results remain controversial. This study aims to evaluate the feasibility and efficacy of Y-stent assisted coiling of bifurcation aneurysms with braided stents. Methods We retrospectively reviewed all patients in whom Y-stenting with braided stents had been performed in our center. Six patients were identified and analyzed. Technical success, complications, angiographic outcomes, procedural data, and follow-up controls are reported here. This study was approved by our local ethical committee. Results Technical success was achieved in all procedures. Overall procedure-related morbidity and mortality was 0%. In the immediate post-treatment angiography, adequate occlusion (neck remnant or total occlusion) was observed in all patients. Short- and long-term follow-up angiography showed adequate occlusion of the aneurysms. Conclusions In this small, retrospective single-center analysis we showed that Y-stent assisted coiling with braided stents is a safe and feasible technique. Moreover, it has a high immediate occlusion rate and very good long-term stability.

BackroundThe treatment of wide neck bifurcation aneurysms remains challenging despite the introduction of new techniques (Y stenting, waffle cone technique, or flow diverter stents). The Woven EndoBridge (WEB) device is an innovative solution for this type of cerebral aneurysm. A new WEB 17 is now available and has been designed to offer smaller sized devices to optimize navigability and delivery.MethodsBetween February 2017 and April 2018 all patients treated with the WEB 17 device in our center were retrospectively reviewed. 25 patients with 28 non-ruptured aneurysms were identified and analyzed. Three patients with two aneurysms both treated with the WEB device were identified.ResultsThe device was successfully deployed in all cases. Procedure related morbidity was 4% and mortality was 0%. In one case, a delayed postprocedural thromboembolic event occurred owing to device protrusion. Technical success, complications, angiographic outcomes, procedural data, and follow-ups are reported. The modified Rankin Scale score at discharge was 0 for 24 patients (96%). At the 3, 6, or 9 month follow-up, angiograms were taken of 21 of the 25 patients (84%) (24 of 28 aneurysms had been controlled); 3 patients (3 aneurysms) did not receive angiographic follow-up at the time of submission of this work. Complete occlusion was achieved in 22 of 24 aneurysms (91.66%), and 2 of 24 aneurysm (8.33%) showed a neck remnant.ConclusionsThe WEB 17 is safe and technically feasible, according to this retrospective single center analysis. For very small bifurcation aneurysms, the WEB 17 seems to have lower complication rates than stent assisted techniques. However, further studies are needed to evaluate the complication rate and long term efficiency.

Objectif La modification de forme du dispositif WEB est potentiellement a l’origine d’une mauvaise occlusion anevrismale lors du suivi malgre un resultat initial satisfaisant ( Fig. 1 ). La frequence, les causes et les moyens de prevention de ce phenomene sont jusqu’a ce jour meconnus. Methodes A l’aide d’acquisitions angiographiques rotationnelles systematiques, nous avons analyse les caracteristiques anatomiques des anevrismes traites ainsi que la morphologie du dispositif WEB, lors de la pose puis du suivi. Les taux d’occlusion ont ete evalues selon l’echelle de Bicetre. Resultats Entre octobre 2015 et janvier 2019, 63 anevrismes intracrâniens traites par WEB seul et disposant d’un suivi ont ete analyses dans ce registre. Lors du dernier suivi (12 mois), la retraction moyenne etait de 50 %. Celle-ci est plus importante dans le groupe des anevrismes presentant une recanalisation (p = 0,01). Nous n’avons pas trouve de difference entre la derniere generation de WEB (Via17) et les precedentes (p = 0,2). Il existe une correlation entre l’ovalisation de la forme du WEB lorsqu’il est delivre et une reduction de la retraction lors du suivi. Conclusion La modification de forme est un phenomene frequent lors du suivi apres utilisation de WEB. Grâce a un oversizing de la largeur du WEB, il est possible de diminuer la frequence de ce phenomene.

Introduction The intrasaccular flow diversion device WEB is a system used in the treatment of wide necked bifurcation aneurysm. The large number of clinical studies conducted have included mainly unruptured aneurysms. The CLARYS study has been set up to evaluate the efficacy and the safety of the WEB system used to treat bifurcation ruptured aneurysms. Materials and methods The CLARYS study is a prospective, multicenter evaluation conducted in 13 interventional neuroradiological departments in France and Germany. The study design meets the Good Clinical Practice (GCP) standards with data collected in an eDC 100% monitored and endpoints independently evaluated. The primary endpoint is defined as the re-bleeding rate at 1 month post procedure. The secondary endpoints are the rate of adverse events related to the device, the procedure or the disease, the neurological evaluation at 1 month and 1 year based on mRS, the occlusion at 1 year based on the WEB Occlusion Scale (WOS) and the procedure and fluoroscopy time. Results From February 2016 to September 2017, 60 patients (women: 31, 51.7%; mean age: 54.5±1.49 years) with 60 aneurysms were included in the study. The aneurysms locations were at the anterior communicating artery (26/60, 43.3%), the middle cerebral artery bifurcation (23/60, 38.3%), the basilar apex (7/60, 11.7%), the anterior cerebral artery (2/60, 3.3%), the internal carotid artery terminus (1/60, 1.7%) and the posterior communicating artery (1/60, 1.7%). The WEB device was successfully implanted in 56/60 cases (95.0%) The adverse events reported by the sites and adjudicated by the Clinical Event Adjudicator (CEA) were described based on timeline occurrence (per procedure or post procedure), category of events, clinical impact and relationship to device, procedure or disease. The primary endpoint will be presented as well as the morbidity and mortality at 1 month. The 12 months data are under collection so will not be available. Conclusion The study results at 1 month will be presented to address the rate of re bleeding and the safety of the device used in the treatment of ruptured bifurcation aneurysm, following clinical evaluation conducted according to study GCP. Disclosures D. Herbreteau: 2; C; MicroVention. A. Narata: None. R. Bibi: None. L. Ikka: None. C. Mihalea: None. J. Caroff: None. J. Moret: 2; C; MicroVention, Medtronic, Balt. 4; C; Sensome. X. Barreau: None. J. Ferre: None. J. Gauvrit: None. H. Raoult: None. J. Fiehler: 1; C; German Ministry of Science and Education (BMBF), German Ministry of Economy and Innovation (BMWi), German Research Foundation (DFG), European Union (EU), Hamburgische Investitions-und Forderbank (IFB), Medtronic, MicroVention, Philips, Stryker. 2; C; Acandis, Boehringer Ingelheim, Cerenovus, Covidien, Medtronic, Medina, MicroVention, Penumbra, Route 92, Stryker. J. Buhk: 2; C; Sequent, MicroVention. V. Costalat: 2; C; Medtronic, Stryker, Balt, Cerenovus, MicroVention. A. Januel: None. C. Cognard: 2; C; Stryker, MicroVention, Medtronic, Cerenovus. T. Liebig:None. M. Bester: None. H. Desal: None. B. Daumas-Duport: None. R. Bourcier: None. M. Mohlenbruch: None. J. Berkefeld: 2; C; Sequent/MicroVention. R. Du Mesnil de Rochemont: 2; C; Sequent. W. Weber: 2; C; Phenox, MicroVention, Medtronic, Penumbra, Stryker. S. Velasco:None. A. Biondi: None. J. Byrne: 2; C; Oxford Endovascular Ltd. L. Pierot: 2; C; Balt, Cerus Endovascular, MicroVention/Sequent, Phenox, Vesalio, Penumbra.

Introduction Le traitement des anevrismes a bifurcation a collet large reste difficile malgre l’introduction de nouvelles techniques (stent en Y ou stent a derivation de flux). Le dispositif Woven Endobridge (WEB) est une solution innovante pour ce type d’anevrisme cerebral. Un nouveau site Web 17 est maintenant disponible et a ete concu pour offrir des dispositifs de plus petite taille afin d’optimiser la navigabilite et le deploiement dans le sac anevrismal ( Fig. 1 ). Methodes Entre fevrier 2017 et avril 2018, tous les patients traites avec le dispositif WEB 17 dans notre centre ont ete examines retrospectivement. Vingt-cinq patients avec 28 anevrismes non rompus ont ete identifies et analyses. Les patients de l’arbre avec deux cabines d’anevrismes traites par le dispositif WEB ont ete identifies. Resultats Le peripherique a ete deploye avec succes dans tous les cas. La morbidite liee a la procedure etait de 4 % et la mortalite de 0 %. Dans un cas, un evenement thromboembolique post-procedural retarde est survenu en raison de la protrusion du dispositif. Les succes techniques, les complications, les resultats agiographiques, les donnees de procedure et les suivis sont rapportes. Le score mRS a la sortie etait de 0 pour 24 patients (96 %). Suivi a 3, 6 ou 9 mois, des angiographies ont ete prises chez 21 patients sur 25 (84 %) (24 anevrismes sur 28 ont ete controles) ; 3 patients (3 anevrismes) n’ont pas recu de suivi agiographique au moment de la soumission de ce travail. Une occlusion complete a ete realisee dans 22 anevrismes sur 24 (91,66 %) et 2 anevrismes sur 24 (8,33 %) ont montre un reste de collet. Conclusions WEB 17 est sur et techniquement realisable selon cette analyse retrospective mono-centrique. Pour les tres petits anevrismes de bifurcation, WEB 17 semble avoir des taux de complications plus faibles que les techniques assistees par stent. Cependant, d’autres etudes sont necessaires pour evaluer le taux de complications et l’efficacite a long-terme.

Introduction Le deploiement du dispositif WEB reste difficile dans les anevrismes de forme ou d’orientation complexes. Le but de cette etude etait de montrer que l’embolisation d’anevrysmes a bifurcation a col large a l’aide de la technique assistee de remodelage du ballonnet par dispositif WEB est une solution endo-vasculaire realisable et elegante par rapport a d’autres techniques, telles que le remodelage du ballonnet ou coiling assiste par stent. Materiels et methodes Dix cas (10 anevrismes chez 9 patients) du traitement par mise en place du WEB assiste par remodelage du ballon pour de anevrismes de bifurcation complexes non rompus ont ete traites dans notre etablissement et analyses retrospectivement. Les details des presentations cliniques, les details techniques, les complications peri-operatoires et post-operatoires et les resultats ont ete recueillis. Les resultats agiographiques immediats et a long terme ont egalement ete evalues. Resultats Les anevrismes inclus comprenaient six anevrysmes de l’artere cerebrale moyenne, un anevrisme de l’artere communicante anterieure, un anevrisme de l’artere communicante posterieure, un anevrisme de l’artere basilaire et un anevrysme de la terminaison carotidienne. La largeur moyenne du dome etait de 6,55 mm, la taille moyenne du cou de 4,5 mm, la hauteur moyenne de 4,79 mm et le rapport moyen du dome au cou de 1 : 1,46. Le traitement a ete realise exclusivement avec la technique de deploiement WEB assistee par le remodelage du ballon dans tous les cas. Le dispositif a ete deploye avec succes dans tous les cas ( Fig. 1 ). Evenements thromboemboliques ou hemorragiques peri-proceduraux ne se sont pas produits. Le score de l’echelle modifie de Rankin a la sortie etait de 0 pour tous les patients. Au suivi agiographique a moyen ou a long terme, une occlusion adequate a ete observee dans 7 anevrismes de 8 cas controles (87,5 %) et un patient (2 anevrismes) n’a pas ete suivi en angiographie. Conclusion La technique de deploiement de l’endo-prothese WEB assiste par remodelage du ballon semble etre une solution sure et efficace pour le traitement endo-vasculaire d’anevrismes de bifurcation a collet large non rompus avec anatomie complexe specifique. Cependant, d’autres etudes sont necessaires pour evaluer le taux de complications et l’efficacite a long terme.

The dorsal scapular artery (DSA) can be either a direct branch of the subclavian artery (SCA), or a branch of the transverse cervical artery (TCA). In mandibular reconstruction, when a free flap is contraindicated a pedicled scapular flap has been described vascularized by the DSA. During the dissection of this flap, there is a risk of lesion of the TCA, which could be fatal to the flap if the DCA is a branch of the TCA. To evaluate the frequency of this anatomic situation, a dissection and radiologic study has been performed. 50 anatomic dissections on fresh cadavers and 93 arteriographies from 47 patients have been studied, to determine what was the DSA origin. In our dissections we found the origin of the DSA was a type I origin in 19 cases (38 %), a type II in 19 cases (38 %) and a type III in 12 cases (24 %). In our radiologic study, the DSA and the TCA had a common origin from the SCA (Type I) in 57/93 cases (61.3 %), the DSA was a direct branch of the SCA and the TCA (type II) in 22/93 cases (23.7 %), the DSA and the TCA had a common origin from the TCT (type III) in 14/93 cases (15 %). The DSA is coming from the TCA in 1/5 cases. A careful dissection of this flap in the subclavian area is necessary in all cases, a preoperative arteriography could be proposed to limit the risk of pedicle injury.

BACKGROUND AND PURPOSE: The flow-diverter stent has been proved a feasible, safe, and efficient technique, particularly for the treatment of large and broad-neck carotid siphon aneurysms. Wide-neck bifurcation aneurysms remain, in some cases, a challenge for neurointerventionalists. We report the outcomes of the treatment of saccular middle cerebral artery bifurcation aneurysms with flow diversion in our institution. MATERIALS AND METHODS: From the institution data base, all saccular, nondissecting MCA bifurcation aneurysms, treated with flow-diverter stents, were retrospectively reviewed. Technical issues, immediate posttreatment and follow-up angiographic findings, and clinical outcomes were assessed. RESULTS: Fourteen patients with 15 aneurysms were included in the study. Ischemic complications, as confirmed by MR imaging, occurred in 6 patients (43%). Procedure-related morbidity and mortality at last follow-up were 21% and 0%, respectively. Angiographic follow-up was available for 13 aneurysms, with a mean follow-up of 16 months. Complete occlusion was obtained for 8 aneurysms (62%). CONCLUSIONS: Compared with other available therapeutic options, the flow-diverter stent does not appear to be a suitable solution for the treatment of saccular MCA bifurcation aneurysms.

International audience; Intracranial aneurysms (IAs) are acquired cerebrovascular abnormalities characterized by localized dilation and wall thinning in intracranial arteries, possibly leading to subarachnoid hemorrhage and severe outcome in case of rupture. Here, we identified one rare nonsense variant (c.1378A>T) in the last exon of ANGPTL6 (Angiopoietin-Like 6)—which encodes a circulating pro-angiogenic factor mainly secreted from the liver—shared by the four tested affected members of a large pedigree with multiple IA-affected case subjects. We showed a 50% reduction of ANGPTL6 serum concentration in individuals heterozygous for the c.1378A>T allele (p.Lys460Ter) compared to relatives homozygous for the normal allele, probably due to the non-secretion of the truncated protein produced by the c.1378A>T transcripts. Sequencing ANGPTL6 in a series of 94 additional index case subjects with familial IA identified three other rare coding variants in five case subjects. Overall, we detected a significant enrichment (p = 0.023) in rare coding variants within this gene among the 95 index case subjects with familial IA, compared to a reference population of 404 individuals with French ancestry. Among the 6 recruited families, 12 out of 13 (92%) individuals carrying IA also carry such variants in ANGPTL6, versus 15 out of 41 (37%) unaffected ones. We observed a higher rate of individuals with a history of high blood pressure among affected versus healthy individuals carrying ANGPTL6 variants, suggesting that ANGPTL6 could trigger cerebrovascular lesions when combined with other risk factors such as hypertension. Altogether, our results indicate that rare coding variants in ANGPTL6 are causally related to familial forms of IA.

Endovascular treatment of ruptured wide-neck bifurcation aneurysms presents a challenge. While still under evaluation, the Woven Endobridge (WEB) aneurysm embolization system has so far shown promising results in the treatment of complex bifurcation aneurysms. We aimed to evaluate the feasibility and short-term follow-up of endovascular treatment of ruptured wide-neck aneurysm with the WEB device. Six patients referred to our institution for acute symptomatic subarachnoid hemorrhage (SAH) and treated with the WEB device were enrolled in this study. Clinical presentations, technical details, intraoperative and postoperative complications, and outcomes were recorded. Immediate and 3-month angiographic results were also evaluated. Three middle cerebral artery (MCA) and three anterior communicating artery aneurysms were treated between 1 and 14 days after rupturing. Average dome width was 5.8 mm (range 5–7), average neck size was 4.5 mm (range 4–5), and average dome-to-neck ratio was 1.3 (range 1–1.7). The WEB system was the exclusive treatment and was successfully deployed in all cases. Per procedural thromboembolic events occurred in two cases and were treated with intra-arterial administration of antiplatelet agents without any clinical consequences. The modified Rankin Scale (mRS) score at discharge was 0 for all patients. The 3-month angiographic follow-up showed adequate occlusion in four of our six patients (67 %). From this preliminary study, the high feasibility rate and lack of need for systematic antiplatelet agents favor the WEB device providing a solution for endovascular treatment of ruptured wide-neck bifurcation aneurysms during the acute phase. However, further studies are needed to evaluate the complication rate and long-term efficiency.

Introduction Le traitement des anevrysmes a bifurcation a collet large reste difficile malgre l’utilisation de nouvelles techniques, telles que le stenting en Y, la technique du « cone gaufre » et les dispositifs intravasculaires de type WEB, ces dernieres annees. De plus, l’utilisation de stents a deviation de flux dans les anevrismes a bifurcation a ete proposee par plusieurs equipes, bien que les Resultats restent controverses. Cette etude vise a evaluer la faisabilite et l’efficacite de le coiling assiste par un stent en Y des anevrismes de bifurcation avec des stents tresses. Methodes Nous avons examine retrospectivement tous les patients chez qui un stent Y avait ete realise avec des stents tresses dans notre centre. Six patients ont ete identifies et analyses. Le succes technique, les complications, les Resultats agiographiques, les donnees de procedure et les controles de suivi sont rapportes ici. Cette etude a ete approuvee par notre comite d’ethique local. Resultats Le succes technique a ete atteint dans toutes les procedures. La morbidite et la mortalite liees a la procedure etaient globalement de 0 %. Dans l’angiographie post-traitement immediate, une occlusion adequate (occlusion totale ou residuelle du collet) a ete observee chez tous les patients. L’angiographie de suivi a court et a long-terme a montre une occlusion adequate des anevrismes. Conclusions Dans cette petite analyse retrospective mono-centrique, nous avons montre que le coilling assiste par end prothese Y avec stents tressees est une technique sure et realisable. De plus, il presente un taux d’occlusion immediat eleve et une tres bonne stabilite a long-terme (Fig 1).

BackgroundDirect punctures of intracranial tumors have rarely been described in the literature.ObjectiveTo assess the feasibility, safety, efficacy, and advantages of using 3D DSA-guided direct puncture rather than the traditional transarterial route to preoperatively devascularize intracranial lesions in particular clinical situations, paying special attention to any correlation with surgical observations; we present the largest series to date.MethodsBetween July 2015 and July 2016, data from all presurgical embolizations performed in our institution were prospectively collected. Information on tumor type, location, size, eventual bone erosion, complications, devascularization percentage, and estimated blood loss was analyzed.ResultsTumors of four patients (two meningioma, two endolymphatic sac tumor) were embolized using direct puncture. 3D XperGuide planning software was used in all procedures. Embolization was feasible in all cases. In one case, a small craniotomy was specifically performed to allow needle positioning. In all cases n-butyl cyanoacrylate was used. No ischemic or hemorrhagic complications related to embolization occurred. Complete or near complete devascularization was obtained in all cases. In one case, surgery was not performed and the patient was monitored. Resection was complete without significant blood loss in two cases, and resection was incomplete but satisfactory in one case.ConclusionsIn selected cases, 3D-guided direct puncture of intracranial tumors appears safe, feasible, and efficient for preoperative embolization.

Study design Case series. Objective To report our early experience of percutaneous vertebro-plasty via a transoral approach of the lesions of the lateral mass of C1. Summary of background data Percutaneous vertebroplasty has gained acceptance for the treatment of osteolytic lesions of the spine. However, scant data are available on the percutaneous vertebroplasty of the C1 lesions. Methods Two patients (a 74-yr-old female and a 53-yr-old male) presenting respectively a metastasis of the left lateral mass of C1 from a pancreatic adenocarcinoma and a hemangioma of the left lateral mass of C1 underwent a percutaneous vertebroplasty via a transoral approach in a hybrid angio suite associating a monoplane flat panel and a computed tomography scan, using polymethylmetacrilate bone cement.For the second patient, a nondetachable balloon was used to protect the vertebral artery from cement leakage. Results Satisfactory filing of the lesions was obtained in both patients. No complication was recorded. Both patients experienced pain improvement. Conclusion Transoral approach for the treatment of osteolytic tumor lesions of the lateral mass of the atlas is feasible and seems to be a safe and effective technique.

Endovascular treatment of dural arteriovenous malformation is challenging especially if the related dural venous sinus is patent and might be usable for normal venous drainage. A new particular venous balloon remodeling technique was described in the treatment of transverse–sigmoid dural arteriovenous malformation by using transarterial Onyx. The goal was obliteration of the malformation with preservation of the dural sinus. Two illustrative cases with 6-month follow-up result were narrated. The penetration of Onyx in the dural arterial feeders was well achieved. Obliteration of the malformation with preservation of the dural sinus was finally demonstrated. Transvenous balloon assistance is a useful and feasible technique in the treatment of dural arteriovenous malformation when sinus preservation is in concern.

OBJECT The concept of the flow-diverter stent (FDS) is to induce aneurysmal thrombosis while preserving the patency of the parent vessel and any covered branches. In some circumstances, it is impossible to avoid dangerously covering small branches, such as the anterior choroidal artery (AChA), with the stent. In this paper, the authors describe the clinical and angiographic effects of covering the AChA with an FDS. METHODS Between April 2011 and July 2013, 92 patients with intracranial aneurysms were treated with the use of FDSs in the authors’ institution. For 20 consecutive patients (21.7%) retrospectively included in this study, this involved the unavoidable covering of the AChA with a single FDS during endovascular therapy. AChAs feeding the choroid plexus were classified as the long-course group (14 cases), and those not feeding the choroid plexus were classified as the short-course group (6 cases). Clinical symptoms and the angiographic aspect of the AChA were evaluated immediately after stent delivery and during follow-up. Neurological examinations were performed to rule out hemiparesis, hemihypesthesia, hemianopsia, and other cortical signs. RESULTS FDS placement had no immediate effect on AChA blood flow. Data were obtained from 1-month clinical follow-up in all patients and from midterm angiographic follow-up in 17 patients (85.0%), with a mean length of 9.8 ± 5.4 months. No patient in either group complained of transient or permanent symptoms related to an AChA occlusion. In all cases, the AChA remained patent without any flow changes. CONCLUSIONS The results of this study suggest that when impossible to avoid, the AChA may be safely covered with a single FDS during intracranial aneurysm treatment, irrespective of anatomy and anastomoses.

We read with interest the article by Fiorella et al 1 on interobserver variability in the assessment of aneurysm occlusion with the WEB aneurysm embolisation system recently published in the journal. In this study the authors evaluated the interobserver variability of the previously published Web Occlusion Scale (WOS).2 They showed substantial overall interobserver agreement and proposed that the WOS should be used as a primary angiographic endpoint in future clinical studies. We have just completed a retrospective multicenter study addressing the safety of the use of single layer WEBs in 98 aneurysms.3 In this study we …

BACKGROUND AND PURPOSE: The WEB aneurysm embolization system is still under evaluation but seems to be a promising technique to treat wide-neck bifurcation aneurysms. However, this device is barely visible using conventional DSA; thus, high-resolution contrast-enhanced flat panel detector CT (VasoCT) may be useful before detachment to assess the sizing and positioning of the WEB. The purpose of this study was to evaluate the interest of VasoCT during WEB procedures. MATERIALS AND METHODS: From March 2012 to July 2013, twelve patients (10 women and 2 men; age range, 44–55 years) were treated for 13 intracranial aneurysms with the WEB device. DSA and VasoCT were used and compared to depict any protrusion of the device in parent arteries before detachment. Two neuroradiologists reviewed each VasoCT scan, and the quality was graded on a subjective quality scale. RESULTS: The mesh of the WEB was very well-depicted in all cases, allowing a very good assessment of its deployment. Device protrusion was clearly detected with VasoCT in 5 cases, leading to WEB repositioning or size substitution. During follow-up, VasoCT also allows good assessment of eventual residual blood flow inside the aneurysm or the WEB device. CONCLUSIONS: Unlike DSA, VasoCT is an excellent tool to assess WEB deployment and positioning. In our experience, it allowed a precise evaluation of the WEB sizing and its relation to the parent vessel. Such information very likely enhances the ability to safely use this device, avoiding potential thromboembolic events in cases of protrusion in the parent arteries.

Cerebral blood volume (CBV) measurement by flat panel detector CT (FPCT) in the angiography suite seems to be a promising tool for patient management during endovascular therapies. A steady state of contrast agent distribution is mandatory during acquisition for accurate FPCT CBV assessment. To the best of our knowledge, this was the first time that steady-state parameters were studied in clinical practice. Before the CBV study, test injections were performed and analyzed to determine a customized acquisition delay from injection for each patient. Injection protocol consisted in the administration of 72 mL of contrast agent material at the injection rate of 4.0 mL/s followed by a saline flush bolus at the same injection rate. Peripheral or central venous accesses were used depending on their availability. Twenty-four patients were treated for different types of neurovascular diseases. Maximal attenuation, steady-state length, and steady-state delay from injection were derived from the test injections’ time attenuation curves. With a 15 % threshold from maximum attenuation values, average steady-state duration was less than 10 s. Maximum average steady-state duration with minimal delay variation was obtained with central injection protocols. With clinically acceptable contrast agent volumes, steady state is a brief condition; thus, fast rotation speed acquisitions are needed. The use of central injections decreases the variability of steady-state’s delay from injection. Further studies are needed to optimize and standardize injection protocols to allow a larger diffusion of the FPCT CBV measurement during endovascular treatments.

Introduction Les hypersignaux en diffusion a la phase aigue d’un infarctus cerebral sont partiellement reversibles. Nous rapportons le cas d’une patiente avec infarctus cerebral etendu et regression majeure des lesions en diffusion (RLD) apres thrombectomie seule. Observation Une femme de 40 ans, a ete hospitalisee dans notre service pour hemiplegie gauche brutale et mutisme, a 3 h 30 du debut des symptomes. A l’examen, NIHSS = 20 avec hemiplegie et anesthesie gauche aux 3 etages, anarthrie, negligence, HLH gauche. L’IRM cerebrale a retrouve un infarctus sylvien droit total (volume = 228 cm3) en rapport avec une occlusion carotido-sylvienne droite, un score ASPECTS = 0 et une absence de collateralite d’avale (absence de flux lents). Une thrombectomie seule fut realisee (contre-indication de la thrombolyse au vu de l’etendue de l’infarctus) avec repermeabilisation complete TICI 3 a 4 h 30 du debut. L’evolution a ete favorable avec un NIHSS a 8 a j7 et 1 a j15. L’evaluation a j7 de la taille de l’infarctus (sequence FLAIR) a montre une regression majeure des hypersignaux en diffusion (volume infarctus constitue = 88 cm3 soit 62 % de regression). L’evolution clinique et radiologique a 3 mois seront presentees au congres. Discussion La RLD concerne environ 10–20 % des lesions et jusqu’a 50 % des patients. Les facteurs associes sont : taille initiale limitee de l’infarctus, recanalisation precoce, absence d’occlusion proximale, bonne collateralite. Il existe une heterogeneite au sein des hypersignaux en diffusion (zone d’hypoperfusion severe reversible ou necrose definitive) et dans la RLD, la substance blanche semblant plus resistante a l’ischemie. Conclusion Hypersignal en diffusion n’est pas synonyme de necrose definitive mais peut etre le marqueur d’une hypoperfusion severe partiellement reversible. Les habitudes utilisees en thrombolyse IV ne sont peut-etre pas transposables a la thrombectomie mecanique.