Search

BACKGROUND: Treatment management and outcomes of unruptured nonsaccular aneurysms are different compared with their saccular counterparts. PURPOSE: Our aim was to analyze the outcomes after flow diversion among nonsaccular unruptured lesions. DATA SOURCES: A systematic search of 3 data bases (2005–2019) was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. STUDY SELECTION: We included studies reporting flow diversion for nonsaccular unruptured aneurysms of the posterior and distal anterior circulations. Anterior circulation lesions were included if located distal to the petrocavernous and supraclinoid ICA (MCA, A1, anterior communicating artery, A2). Giant dolichoectatic holobasilar lesions were excluded because of their poor treatment outcomes. DATA ANALYSIS: Aneurysm occlusion and complication rates were calculated (random effects meta-analysis). DATA SYNTHESIS: We included 15 studies (213 aneurysms). The long-term adequate occlusion rate was 85.3% (137/168; 95% CI, 78.2%–92.4%; I(2) = 42.3%). Treatment-related complications were 17.4% (41/213; 95% CI, 12.45%–22.4%; I(2) = 0%). Overall, 15% (37/213; 95% CI, 10%–20%; I(2) = 0%) were ischemic events. Procedure-related morbidity was 8% (20/213; 95% CI, 5%–12%; I(2) = 0%). Fusiform or dissecting types had comparable adequate occlusion (116/146 = 83%; 95% CI, 74%–92%; I(2) = 48% versus 33/36 = 89%; 95% CI, 80%–98%; I(2) = 0%; P = .31) and complication rates (35/162 = 17%; 95% CI, 10%–25%; I(2) = 24% versus 11/51 = 19%; 95% CI, 10%–31%; I(2) = 0%; P = .72). Aneurysm size (>10 versus ≤10 mm) was independently associated with a higher rate of complications (OR = 6.6; 95% CI, 1.3–15; P = .02). The rate of ischemic events after discontinuation of the antiplatelet therapy was 5% (5/93; 95% CI, 2%–9%; I(2) = 0%). LIMITATIONS: Small and retrospective studies were available for this meta-analysis. CONCLUSIONS: Unruptured nonsaccular aneurysms located in the posterior and distal anterior circulations can be effectively treated with flow diversion. Nevertheless, treatment-related complications are not negligible, with about 15% ischemic events and 8% morbidity. Larger size (>10 mm) significantly increases the risk of procedure-related adverse events.

Background and purposeFlow diverters are increasingly used for the treatment of intracranial aneurysms. Evaluation of the first devices available for clinical use showed high efficacy of this treatment although safety results were worse compared with coiling or balloon-assisted coiling. The Safety and Efficacy Analysis of FRED Embolic Device in Aneurysm Treatment (SAFE) trial is a single-arm, multicenter, prospective study conducted to precisely analyze the safety and efficacy of the FRED and FRED Jr devices.MethodsUnruptured and recanalized aneurysms located in the anterior circulation treated with FRED and FRED Jr were prospectively included. Adverse events were independently evaluated by a Clinical Event Committee with a vascular neurosurgeon and an interventional neuroradiologist. Primary safety outcome measures were morbidity and mortality rates at 6 months after treatment.ResultsA total of 103 patients/aneurysms were included in 13 interventional neuroradiology (INR) centers. Aneurysm locations were supraclinoid internal carotid artery (ICA) in 71 (68.9%), cavernous ICA in 15 (14.6%), anterior cerebral artery or anterior communicating artery in nine (8.7%), and middle cerebral artery in eight (7.8%). Aneurysms were small (ConclusionsAneurysm treatment with the FRED device is safe with low mortality (1.0%) and morbidity (2.0%).Clinical trial registrationNCT02921698.

BACKGROUND Woven EndoBridge (WEB; Sequent Medical) treatment is an innovative endovascular approach for treatment of wide-neck bifurcation aneurysms. Initial studies have shown high safety with good efficacy at short term confirmed by trials conducted in United States (WEB-Intrasaccular Therapy) and in Europe (WEB Clinical Assessment of Intrasaccular Aneurysm Therapy [WEBCAST], French Observatory, and WEBCAST-2). OBJECTIVE To report the 2-yr clinical and anatomical results of WEB treatment in the combined population of 3 European trials. METHODS In a French Observatory, 2-yr clinical and anatomical data were collected. In WEBCAST and WEBCAST-2, 2-yr follow-up was optional, and data were collected when follow-up was performed. Aneurysm occlusion was evaluated using a 3-grade scale: complete occlusion, neck remnant, and aneurysm remnant. RESULTS The population for safety was 138/168 patients (82.1%), including 89 females (64.5%), with mean age of 55.5 ± 10.2 yr. The population for efficacy was 121/169 aneurysms (71.6%). Aneurysm locations were middle cerebral artery in 65/121 aneurysms (53.7%), anterior-communicating artery in 25/121 (20.7%), basilar artery in 17/121 (14.0%), and internal carotid artery terminus in 14/121 (11.6%). No clinically relevant adverse events occurred between years 1 and 2. At 2 yr, complete occlusion was observed in 62/121 (51.2%) aneurysms, neck remnant in 36/121 (29.8%) aneurysms, and aneurysm remnant in 23/121 (19.0%) aneurysms. The global retreatment rate at 2 yr was 9.3%. CONCLUSION This analysis confirms the high safety profile of WEB treatment at 2 yr. Aneurysm occlusion is generally stable at 2 yr, and the retreatment rate between 1 yr and 2 yr is low (2.0%)., Graphical Abstract Graphical Abstract

BACKGROUND AND PURPOSE: Flow-diverting stents can be used to treat intracranial aneurysms that are not amenable to treatment with coils. We analyzed ophthalmic consequences due to coverage of the origin of the ophthalmic artery by flow-diverting stents for the treatment of internal carotid artery aneurysms. MATERIALS AND METHODS: From April 2009 to April 2013, the clinical and angiographic outcomes of all 28 patients treated for aneurysms with flow-diverting stents covering the origin of the ophthalmic artery were prospectively collected. The origin of the ophthalmic artery in relation to the target aneurysm was classified by using a 4-type classification. A complete ophthalmic examination was performed by a single ophthalmologist 48 hours before and 1 week after covering the ophthalmic artery. RESULTS: Ophthalmic artery patency was normal at the end of endovascular treatment in 24/28 cases (85.7%). With extensive ophthalmic examinations, 11 patients (39.3%) showed new ophthalmic complications. Patients with the ophthalmic artery originating from the aneurysm sac were at high risk for retinal emboli (4/5, 80%). Patients with the ophthalmic artery originating from the inner curve of the carotid siphon were at high risk for optic nerve ischemic atrophy (3/4, 75%). CONCLUSIONS: This prospective study shows that covering the ophthalmic artery with a flow-diverting stent is not without potential complications. Ophthalmic complications can occur but are often not diagnosed. The anatomic disposition of the ophthalmic artery in relation to the carotid siphon and aneurysm should be clearly understood because some configurations have a higher risk. When not required, covering of the ophthalmic artery by flow-diverting stents should be avoided.

Background and purpose: To evaluate behavioral and cognitive deficits following anterior communicating artery aneurysm rupture and determine critical lesion locations. Methods: We investigated 74 patients with standardized cognitive tests and behavioral inventory. Two examiners rated MRI signal abnormalities in 51 predetermined regions of interest. Classification tree analysis was used to select regions associated with each cognitive deficit. Results: Eleven patients presented behavioral executive deficits and 10 had cognitive executive deficit. Their presence depended on left hemisphere lesions only: (i) ventral striatum lesion was associated with behavioral executive deficit (P = 0.04), reduction of activities (P = 0.01), and hyperactivity (P = 0.02); (ii) superior frontal gyrus lesion, with cognitive executive deficit (P = 0.01), action initiation deficit (P = 0.02), and rule deduction deficit (P = 0.02); (iii) anterior half of centrum semiovale lesion, with Stroop inhibition deficit (P = 0.02); (iv) medial superior and middle frontal gyri lesions, with task coordination deficit (P = 0.01); and (v) middle frontal gyrus lesion, with words generation deficit (P = 0.02). Conclusion: This study supports that (i) cognitive executive deficits depend mostly on lateral prefrontal lesions, (ii) with locations varying according to executive process, and (iii) behavioral executive deficits are mainly due to left ventral striatum lesion in post-aneurysmal damage.

Background and Purpose— The management of unruptured intracranial aneurysms remains controversial and the results of endovascular treatment are not precisely known because no prospective data exist. The first prospective multicenter study (ATENA) was conducted in Canada and France to determine clinical outcome and risks of this treatment. Methods— Six hundred forty-nine patients harboring a total of 1100 aneurysms from 27 Canadian and French neurointerventional centers were prospectively and consecutively treated by endovascular coil embolization. Of these, 739 unruptured intracranial aneurysms were treated during 700 procedures. Aneurysms were selectively treated in the great majority of cases (98.4%) with coils alone (54.5%), the balloon remodeling technique (37.3%), or stenting (7.8%). Results— Endovascular treatment failed in 32 aneurysms (4.3%). Technical adverse events with or without clinical modification were encountered in 15.4% of patients and included thromboembolic complications (7.1% per procedure), intraoperative rupture (2.6% per procedure), and device-related problems (2.9% per procedure). Adverse events associated with transient or permanent neurological deficit or death were encountered in 5.4% of cases. The 1-month morbidity and mortality rates were 1.7% and 1.4%, respectively. Conclusions— Endovascular treatment of unruptured intracranial aneurysms is feasible in a high percentage of cases with low morbidity and mortality rates.

Intracranial cerebral aneurisms (ICA) are a frequent extra-renal manifestation of autosomal dominant polycystic kidney disease (ADPKD). Its main complication is subarachnoid haemorrhage, which is associated with a high morbidity and mortality. Aneurysms can be screened using time-of-flight magnetic resonance imagery (MRI) without gadolinium enhancement.A web-based survey was conducted among 420 French-speaking nephrologists to determine the determinants of screening for ICA in ADPKD patients. Patients consulting for ADPKD at Necker hospital had a targeted ICA screening using MRI. They were followed-up prospectively for subarachnoid haemorrhage, and the results of the screening MRI, if performed, were recorded. ICA screening practices were very heterogeneous among the nephrologists who participated to our study, apart from a few consensual indications such as in case of family history of subarachnoid haemorrhage. After targeted screening, the rate of aneurisms detected was high. However, subarachnoid haemorrhage occurred mostly in the population not targeted by this screening. Benefits of ICA screening in ADPKD have never been evaluated with a prospective, controlled study, and systematic screening is not recommended according to expert opinions. This study shows the necessity to evaluate the benefits of systematic versus targeted screening of ICA in this population using a randomised controlled trial. It will help to predict the rate of events and therefore to determine the number of subjects to include in such study.; Les anévrismes cérébraux sont des manifestations extra-rénales fréquentes dans la polykystose rénale autosomique dominante, dont la complication principale, la rupture anévrismale, présente une grande sévérité. Les anévrismes peuvent être dépistés à partir d’angio-IRM (ARM) cérébrales sans injection de produit de contraste. Une enquête des pratiques sur le dépistage des anévrismes a été conduite auprès de 420 néphrologues francophones qui ont répondu par email à un questionnaire sur leurs pratiques de prescription des ARM de dépistage. De plus, les patients polykystiques suivis en consultation à Necker ont fait l’objet d’une politique de dépistage ciblé et d’un suivi prospectif ; les résultats des ARM de dépistage et la survenue d’évènements neurologiques ont été surveillés. Les pratiques de dépistage paraissent très hétérogènes parmi les néphrologues interrogés, en dehors de quelques indications consensuelles, comme en cas d’antécédent familial d’hémorragie méningée. La réalisation d’un dépistage ciblé permet de mettre en évidence un taux élevé d’anévrisme sur les examens de dépistage. Toutefois, les ruptures d’anévrismes surviennent essentiellement dans la population non ciblée par ce dépistage dans notre étude. Le bénéfice du dépistage de ces anévrismes n’a jamais été étudié de façon prospective et contrôlée, et fait l’objet de recommandations basées sur des avis d’experts. Cette étude montre la nécessité d’évaluer à l’aide d’une étude contrôlée et randomisée le bénéfice d’un dépistage systématique par rapport à un dépistage ciblé des anévrismes dans cette population, et aidera à prévoir le taux d’événement attendu pour déterminer le nombre de sujets à inclure.

OBJECT It was initially considered safe for flow-diverting stents to cover the ostia of branching vessels during endovascular procedures for the treatment of intracranial aneurysms. As more recent evidence suggests, however, their use is not always free of ischemic concerns in terms of covered arterial ostia. The authors sought to determine the frequency of silent and clinically evident diffusion-weighted imaging (DWI)–detected abnormalities related to stent placement as a means of elucidating potential clinical risks. METHODS This is a prospective single-center study on a series of patients with intracranial aneurysms that were treated with flow-diverting stents. All patients systematically underwent an MRI protocol that included DWI before treatment, between 24 and 48 hours postprocedure, and 3 months postembolization. Effectiveness of anticoagulation treatment was assessed for all patients. Lesions seen on DWI were correlated to the parent artery and the side-branch territories and were statistically analyzed in relation to their time of occurrence and clinical presentation. The authors compared the DWI findings in these patients to findings obtained in patients treated with a stent-assisted coiling technique during the same time period. RESULTS Over the course of 18 consecutive months, 38 consecutive patients (7 males and 31 females) with 49 intracranial aneurysms were treated using flow-diverting stents. Overall, 81.6% of the DWI spots found remained clinically silent during the follow-up period. Five ischemic clinical complications (13.2%) occurred in the postprocedural period. No statistically significant correlation could be established between DWI spots or aneurysm location and clinical complications or follow-up modified Rankin Scale score at 3 months. The complication rate was 7.8% (n = 3) at the 3-month follow-up, and mortality was 0%. Compared with stent-assisted coiling, use of flow-diverting stents showed a statistically significant correlation with silent DWI findings postintervention. CONCLUSIONS Lesions seen on DWI resulting from the procedure are far more common than anticipated, but the technique remains safe and effective, providing an interesting alternative for “difficult” aneurysms, regardless of location. Late-occurring DWI-detected lesions distal to side arterial branches imply a local pressure gradient drop, related to flow competition by collateral networks. Further research is needed to assess the extent and significance of these events.

Human T-cell lymphotropic virus type 1 is endemic to central Australia among Indigenous Australians. However, virologic and clinical aspects of infection remain poorly understood. No attempt has been made to control transmission to indigenous children. We report 3 fatal cases of adult T-cell leukemia/lymphoma caused by human T-cell lymphotropic virus type 1 Australo-Melanesian subtype c.

International audience; BACKGROUND AND PURPOSE: Our aim was to compare 3D TOF-MRA sequences at 3T and 1.5T in the follow-up of coiled aneurysms. The follow-up of coiled intracranial aneurysms is mandatory to depict potential recanalization. 3D-TOF MRA is an appropriate tool for this purpose. MATERIALS AND METHODS: DSA and 3D TOF-MRA at 1.5T and 3T were performed in a prospective series of 126 aneurysms in 96 patients (58 women, 38 men; age, 25-75 years; mean, 51.3 ± 11.3 years). DSA was the reference standard to which the accuracy of 3D TOF-MRA was compared. The quality of aneurysm occlusion was assessed independently and anonymously by a core lab by using a 3-grade scale (total occlusion, neck remnant, and aneurysm remnant). Adequate occlusion was defined as total occlusion or neck remnant and used in a 2-grade scale: adequate occlusion/aneurysm remnant. RESULTS: With DSA, total occlusion was depicted in 58 aneurysms (46.0%); neck remnant, in 33 aneurysms (26.2%); and aneurysm remnant, in 35 aneurysms (27.8%). Adequate occlusion was seen in 91 cases (72.2%). A remnant (aneurysm or neck) was depicted in 68 cases (54.0%). For the 3 imaging techniques and regardless of scale used, the interobserver agreement was always greater at 3T than at 1.5T. SE and NPV for the prediction of aneurysm remnant versus adequate occlusion were higher at 3T than at 1.5T (SE 3T, 0.74; SE 1.5T, 0.54; NPV 3T, 0.90; NPV 1.5T, 0.85). CONCLUSIONS: In this large prospective series of patients, 3D TOF-MRA was superior at 3T to 1.5T for the evaluation of coiled intracranial aneurysms.

To compare 3D-TOF magnetic resonance angiography (MRA) and contrast-enhanced MRA (CE-MRA) sequences at 3T in the follow-up of coiled aneurysms with digital subtracted angiography (DSA) as the gold standard.DSA, 3D-TOF and CE-MRA were performed in a prospective series of 126 aneurysms in 96 patients (57 female, 39 male; age: 25-75 years, mean: 51.3 ± 11.3 years). The quality of aneurysm occlusion was assessed independently and anonymously by a core laboratory.Using DSA (gold standard technique), total occlusion was depicted in 57 aneurysms (45.2%), neck remnant in 34 aneurysms (27.0%) and aneurysm remnant in 35 aneurysms (27.8%). Sensitivity, specificity, positive predictive value and negative predictive value were very similar with 3D-TOF and CE-MRA. Visibility of coils was much better with 3D-TOF (95.2%) than with CE-MRA (23.0%) (P 0.001). Also, substantial artefacts were less frequent with 3D-TOF (4.0%) than with CE-MRA (11.9%; P = 0.012).In this large prospective series of patients with coiled aneurysms, at 3T 3D-TOF MRA was equivalent to CE-MRA for the evaluation of aneurysm occlusion, but coil visibility was superior at 3D-TOF. Thus the use of 3D-TOF at 3T is recommended for the follow-up of coiled intracranial aneurysms.• Different Magnetic Resonance (MR) imaging techniques are used to evaluate intracranial aneurysms. • At 3T MR, 3D-TOF and CE-MRA appear equivalent for evaluating coiled aneurysms.. • Coils are better visualised on 3D-TOF than on CE-MRA. • Combined analysis of 3D-TOF and CE-MRA does not seem helpful. • At 3T, 3D-TOF techniques are recommended for monitoring patients with coiled aneurysms.

International audience; Imaging of the cerebral arterial circle (CAC) is essential in neurovascular diseases such as ischemic stroke for detecting arterial occlusions and evaluating arterial supply, and in subarachnoid or intralobar hemorrhage for detecting intracranial malformations. Multidetector computed tomography angiography (MD-CTA) is increasingly being used for the detection and treatment planning of intracranial aneurysm. For optimal interpretation and treatment planning, this method requires suitable post-processing equipment, and extensive knowledge of the relevant anatomy and anatomical variants. Anatomical variants of the CAC are common, particularly in the anterior CAC, the most common site of intracranial aneurysm. The aim of this review is to illustrate the normal anatomy and most common anatomical variants of the anterior CAC detected by MD-CTA, and to discuss the relevant embryological and technical considerations.

International audience; 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 kappa statistics. RESULTS: DSA images were not interpretable for one patient. Interobserver agreement was determined as excellent for DSA (kappa=0.86) and TOF-MRA (kappa=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 (kappa=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.

Background and Purpose— We report our experience using Matrix coils in coiling of cerebral aneurysms. Methods— Clinical and angiographic outcomes of 152 patients (165 aneurysms) treated exclusively with Matrix coils were retrospectively analyzed. Results— There were 74 ruptured aneurysms (44.8%) and 91 unruptured (55.2%). After coiling, 84 (50.9%) aneurysms were occluded, 38 (23.0%) aneurysms had a neck remnant, and 43 (26.1%) aneurysms had a sac remnant. Packing ranged from 10% to 49% (mean and median, 27%). Overall treatment-induced morbidity was 6.6% and mortality was 1.3% (10 of 152 to 2 of 152, respectively). One hundred fifteen (69.7%) aneurysms were followed, disclosing 42 (36.5%) recurrences at a mean period of 9 months (median, 6 months; range, 1 to 28 months). The recurrence rate for small aneurysms (P =0.0336). When packing was ≤25%, the recurrence rate was 44.4%, whereas for aneurysms with packing >25%, the recurrence rate was 29.8% ( P =0.1588). Recurrence rate was not correlated to packing. Ruptured aneurysms recurred more frequently than unruptured aneurysms ( P =0.0004). Conclusion— Matrix coils provided no better recanalization rates than those reported previously for bare platinum coils.

International audience

International audience; Adequate instruments for measuring patient outcome after subarachnoid aneurysmal haemorrhage (SAH) are required to interpret results of clinical trials before making clinical recommendations. Graded measures are generally used, e.g. Glasgow Outcome Scale (GOS) and the modified Rankin Scale (mRS). However, these scales are inappropriate to measure cognitive dysfunction, particularly in patients with good outcome. We investigated the most frequent complains, the working status and the self-assessment of handicap (quality of life) in GOS-5 patients after their surgical treatment of a ruptured aneurysm. A questionnaire was sent to 126 patients one year following their discharge from hospital. The questionnaire assessed their motor activity, vitality and psychological troubles and handicap. Over 84 patients with GOS-5, 55 (65%) had persistent cognitive and psychological troubles including memory deficit, vitality and depressive troubles. Providing the use of combined scales to assess handicap and quality of life, these results suggest that SAH can result in a persistent alteration of cognitive function in patients, even in those classified as having a good outcome using the routine graded scales.