Publications by authors named "Eimad Shotar"

60 Publications

Onyx injection by direct puncture for presurgical embolization of a C2 hypervascular metastasis from a thyroid cancer.

J Neurointerv Surg 2021 Mar 23. Epub 2021 Mar 23.

Orthopedic Surgery, University Hospital Pitié Salpêtrière, Paris, Île-de-France, France.

Surgery for spinal hypervascular lesions, such as hemangioma or metastases from thyroid or renal cancer, may be challenging because of the risk of massive blood loss.1 To overcome this limitation, presurgical embolization has gained acceptance to reduce this risk.2 However, some configurations, such as the origin of a radiculomedullary artery close to the vessels feeding the lesion or when the lesion is supplied by vessels feeding an eloquent territory, may limit the possibility of presurgical embolization, especially with microparticles.3 Direct percutaneous puncture of the spinal lesion and subsequent embolization with liquid embolic agent may be a valuable option in such challenging cases.4We present a case of presurgical embolization of a C2 metastasis from a thyroid cancer using Onyx-18 injected by direct puncture (video 1). In this technical video, we stress the technical aspects of the direct puncture technique and the safety rules to avoid neurological complications.neurintsurg;neurintsurg-2020-017180v1/V1F1V1Video 1.
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http://dx.doi.org/10.1136/neurintsurg-2020-017180DOI Listing
March 2021

Angiographic Anatomy of the Middle Meningeal Artery in Relation to Chronic Subdural Hematoma Embolization.

Clin Neuroradiol 2021 Feb 24. Epub 2021 Feb 24.

Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.

Purpose: Middle meningeal artery (MMA) embolization is emerging as a potential treatment of chronic subdural hematomas (CSDHs). The purpose of this study is to describe MMA angiographic anatomy in relation to CSDH embolization.

Methods: This retrospective monocentric study was performed on imaging data of MMA embolization procedures for CSDH treatment performed between March 15, 2018 and April 30, 2020. Imaging data, including digital subtraction angiography (DSA) were reviewed independently by two physicians. Discrepancies were resolved by consensus. The MMA bifurcation pattern was analyzed according to an extended Adachi classification. Relations of the MMA with the ophthalmic artery (OA) were also analyzed.

Results: In this study, 140 MMAs were analyzed. Dominance of the anterior branch (type I) was observed in only 57/140 (41%) MMAs with a moderate interobserver agreement for classifying MMA into type I against all other (κ = 0.53, 95% confidence interval, CI 0.39-0.67). The posterior branch presented a proximal origin (type A), at the point of emergence of the MMA from the foramen spinosum or its immediate vicinity, in 48/135 (36%) MMAs with a very good interobserver agreement for classifying MMAs into type A against all other (κ = 0.82, 95% CI 0.72-0.92). An angiographic relationship with the OA was observed in 26 MMAs (19%).

Conclusion: In the majority of CSDH patients both anterior and posterior branches of the MMA should be targeted to achieve extensive convexity devascularization. Frequent anatomical variations of the MMA with respect to emergence of the posterior branch and MMA orbital branches are expected to impact CSDH embolization strategy.
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http://dx.doi.org/10.1007/s00062-021-00996-5DOI Listing
February 2021

Interventional Neuroradiology Trainee-led Research Collaborative JENI, moving forward.

J Neuroradiol 2021 Mar 27;48(2):137-138. Epub 2021 Jan 27.

Neuroradiology Department, Regional University Hospital of Tours, Tours France, France. Electronic address:

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http://dx.doi.org/10.1016/j.neurad.2021.01.007DOI Listing
March 2021

Reliability and accuracy of time-resolved contrast-enhanced magnetic resonance angiography in hypervascular spinal metastases prior embolization.

Eur Radiol 2021 Jan 15. Epub 2021 Jan 15.

Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Neuroradiology, F75013, Paris, France.

Objectives: Preoperative embolization of hypervascular spinal metastases (HSM) is efficient to reduce perioperative bleeding. However, intra-arterial digital subtraction angiography (IA-DSA) must confirm the hypervascular nature and rule out spinal cord arterial feeders. This study aimed to evaluate the reliability and accuracy of time-resolved contrast-enhanced magnetic resonance angiography (TR-CE-MRA) in assessing HSM prior to embolization.

Methods: All consecutive patients referred for preoperative embolization of an HSM were prospectively included. TR-CE-MRA sequences and selective IA-DSA were performed prior to embolization. Two readers independently reviewed imaging data to grade tumor vascularity (using a 3-grade and a dichotomized "yes vs no" scale) and identify the arterial supply of the spinal cord. Interobserver and intermodality agreements were estimated using kappa statistics.

Results: Thirty patients included between 2016 and 2019 were assessed for 55 levels. Interobserver agreement was moderate (κ = 0.52; 95% CI [0.09-0.81]) for TR-CE-MRA. Intermodality agreement between TR-CE-MRA and IA-DSA was good (κ = 0.74; 95% CI [0.37-1.00]). TR-CE-MRA had a sensitivity of 97.9%, a specificity of 71.4%, a positive predictive value of 95.9%, a negative predictive value of 83.3%, and an overall accuracy of 94.6%, for differentiating hypervascular from non-hypervascular SM. The arterial supply of the spine was assessable in 2/30 (6.7%) cases with no interobserver agreement (κ < 0).

Conclusions: TR-CE-MRA can reliably differentiate hypervascular from non-hypervascular SM and thereby avoid futile IA-DSAs. However, TR-CE-MRA was not able to evaluate the vascular supply of the spinal cord at the target levels, thus limiting its scope as a pretherapeutic assessment tool.

Key Points: • TR-CE-MRA aids in distinguishing hypervascular from non-hypervascular spinal metastases. • TR-CE-MRA could avoid one-quarter of patients referred for HSM embolization to undergo futile conventional angiography. • TR-CE-MRA's spatial resolution is insufficient to replace IA-DSA in the pretherapeutic assessment of the spinal cord vascular anatomy.
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http://dx.doi.org/10.1007/s00330-020-07654-3DOI Listing
January 2021

Dural arteriovenous fistula formation following bilateral middle meningeal artery embolization for the treatment of a chronic subdural hematoma: a case report.

Acta Neurochir (Wien) 2021 04 2;163(4):1069-1073. Epub 2021 Jan 2.

Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France.

Here is reported a case of dural arteriovenous fistula (DAVF) formation following middle meningeal artery (MMA) embolization. A 64-year-old male patient was operated for a bilateral CSDH by burr-hole craniostomy. Prophylactic post-operative MMA embolization was performed with 300-500-μm calibrated microparticles. The patient was admitted 3 months later for a left CSDH recurrence. Digital subtraction angiography demonstrated formation of a superior sagittal sinus DAVF fed by both superficial temporal arteries. This case highlights the possible role of local tissue hypoxia as a significant component of DAVF pathogenesis. Moreover, it has potential implications for MMA embolization as a management strategy for CSDH.
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http://dx.doi.org/10.1007/s00701-020-04696-wDOI Listing
April 2021

Author Correction: Genome-wide association study of intracranial aneurysms identifies 17 risk loci and genetic overlap with clinical risk factors.

Nat Genet 2021 Feb;53(2):254

Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands.

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http://dx.doi.org/10.1038/s41588-020-00760-4DOI Listing
February 2021

Predictive score for complete occlusion of intracranial aneurysms treated by flow-diverter stents using machine learning.

J Neurointerv Surg 2021 Apr 20;13(4):341-346. Epub 2020 Nov 20.

Department of Neuroradiology, Pitié-Salpêtrière Hospital, AP-HP, Paris, France

Background: Complete occlusion of an intracranial aneurysm (IA) after the deployment of a flow-diverter stent is currently unpredictable. The aim of this study was to develop a predictive occlusion score based on pretreatment clinical and angiographic criteria.

Methods: Consecutive patients with ≥6 months follow-up were included from 2008 to 2019 and retrospectively analyzed. Each IA was evaluated using the Raymond-Roy occlusion classification (RROC) and dichotomized as occluded (A) or residual (B/C); 80% of patients were randomly assigned to the training sample. Feature selection and binary outcome prediction relied on logistic regression and threshold maximizing class separation selected by a CART tree algorithm. The feature selection was addressed by a genetic algorithm selected from the 30 pretreatment available variables.

Results: The study included 146 patients with 154 IAs. Feature selection yielded a combination of six variables with a good cross-validated accuracy on the test sample, a combination we labeled DIANES score (IA diameter, indication, parent artery diameter ratio, neck ratio, side-branch artery, and sex). A score of more than -6 maximized the ability to predict RROC=A with sensitivity of 87% (95% CI 79% to 95%) and specificity of 82% (95% CI 64% to 96%) in the training sample. Accuracy was 86% (95% CI 79% to 94%). In the test sample, sensitivity and specificity were 89% (95% CI 77% to 98%) and 60% (95% CI 33% to 86%), respectively. Accuracy was 81% (95% CI 69% to 91%).

Conclusion: A score was developed as a grading scale for prediction of the final occlusion status of IAs treated with a flow-diverter stent.
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http://dx.doi.org/10.1136/neurintsurg-2020-016748DOI Listing
April 2021

Genome-wide association study of intracranial aneurysms identifies 17 risk loci and genetic overlap with clinical risk factors.

Nat Genet 2020 12 16;52(12):1303-1313. Epub 2020 Nov 16.

Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands.

Rupture of an intracranial aneurysm leads to subarachnoid hemorrhage, a severe type of stroke. To discover new risk loci and the genetic architecture of intracranial aneurysms, we performed a cross-ancestry, genome-wide association study in 10,754 cases and 306,882 controls of European and East Asian ancestry. We discovered 17 risk loci, 11 of which are new. We reveal a polygenic architecture and explain over half of the disease heritability. We show a high genetic correlation between ruptured and unruptured intracranial aneurysms. We also find a suggestive role for endothelial cells by using gene mapping and heritability enrichment. Drug-target enrichment shows pleiotropy between intracranial aneurysms and antiepileptic and sex hormone drugs, providing insights into intracranial aneurysm pathophysiology. Finally, genetic risks for smoking and high blood pressure, the two main clinical risk factors, play important roles in intracranial aneurysm risk, and drive most of the genetic correlation between intracranial aneurysms and other cerebrovascular traits.
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http://dx.doi.org/10.1038/s41588-020-00725-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7116530PMC
December 2020

Secondary S100B Protein Increase Following Brain Arteriovenous Malformation Rupture is Associated with Cerebral Infarction.

Molecules 2020 Nov 6;25(21). Epub 2020 Nov 6.

Department of Neuroradiology, Pitié-Salpêtrière Hospital, 75013 Paris, France.

Early S100B protein serum elevation is associated with poor prognosis in patients with ruptured brain arteriovenous malformations (BAVM). The purpose of this study is to determine whether a secondary elevation of S100B is associated with early complications or poor outcome in this population. This is a retrospective study of patients admitted for BAVM rupture. A secondary increase of S100B was defined as an absolute increase by 0.1 μg/L within 30 days of admission. Fisher's and unpaired t tests followed by multivariate analysis were performed to identify markers associated with this increase. Two hundred and twenty-one ruptures met inclusion criteria. Secondary S100B protein serum elevation was found in 17.1% of ruptures and was associated with secondary infarction ( < 0.001), vasospasm-related infarction ( < 0.001), intensive care ( = 0.009), and hospital length of stay ( = 0.005), but not with early rebleeding ( = 0.07) or in-hospital mortality ( = 0.99). Secondary infarction was the only independent predictor of secondary increase of S100B (OR 9.9; 95% CI (3-35); < 0.001). Secondary elevation of S100B protein serum levels is associated with secondary infarction in ruptured brain arteriovenous malformations.
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http://dx.doi.org/10.3390/molecules25215177DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7664396PMC
November 2020

Idiopathic Intracranial Hypertension: Glymphedema of the Brain.

J Neuroophthalmol 2021 Mar;41(1):93-97

Department of Neuroradiology (PN), Toronto Western Hospital, Toronto, Canada; Department of Neuroradiology (AK, ES, NS, FC, SL), Groupe Hospitalier Pitié Salpêtrière, Paris, France; Department of Ophthalmology (SB, VT), Groupe Hospitalier Pitié Salpêtrière, Paris, France; Department of Neurosurgery (ALB), Groupe Hospitalier Pitié Salpêtrière, Paris, France; GRC 31 E-HTIC (ES, SB, ALB, NS, VT, SL), Sorbonne University, Paris, France; Sorbonne University (ES, SB, NS, FC, VT, SL), Paris, France; and GRC BioFast (FC), Paris VI University, Paris, France.

Background: During the last decade, our understanding of cerebrospinal fluid (CSF) physiology has dramatically improved, thanks to the discoveries of both the glymphatic system and lymphatic vessels lining the dura mater in human brains.

Evidence Acquisition: We detail the recent basic science findings in the field of CSF physiology and connect them with our current understanding of the pathophysiology of idiopathic intracranial hypertension (IIH).

Results: Transverse sinus (TS) stenoses seem to play a major causative role in the symptoms of IIH, as a result of a decrease in the pressure gradient between the venous system and the subarachnoid space. However, the intracranial pressure can be highly variable among different patients, depending on the efficiency of the lymphatic system to resorb the CSF and on the severity of TS stenoses. It is likely that there is a subclinical form of IIH and that IIH without papilledema is probably under-diagnosed among patients with chronic migraines or isolated tinnitus.

Conclusions: IIH can be summarized in the following pathological triad: restriction of the venous CSF outflow pathway-overflow of the lymphatic CSF outflow pathway-congestion of the glymphatic system. To better encompass all the stages of IIH, it is likely that the Dandy criteria need to be updated and that perhaps renaming IIH should be considered.
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http://dx.doi.org/10.1097/WNO.0000000000001000DOI Listing
March 2021

Outcome and recanalization rate of tandem basilar artery occlusion treated by mechanical thrombectomy.

J Neuroradiol 2020 Nov 8;47(6):404-409. Epub 2020 Sep 8.

Sorbonne University, Paris VI University, Paris, France; GRC-14 Biosfast, Paris VI University, Paris, France; Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France. Electronic address:

Background: Tandem basilar artery occlusions (tBAO) are defined as concomitant basilar artery and extracranial dominant vertebral artery occlusions. The prognosis of such tBAO treated by mechanical thrombectomy (MT) has been scantly reported. The purpose of our study was to compare the safety and effectiveness of MT for patients with tBAO compared to those with non-tandem basilar artery occlusions (ntBAO).

Patients And Methods: Retrospective analysis of a database of patients who underwent MT at two academic centres. All patients treated for BAO were retrieved. Patients with tBAO, defined as a concomitant BAO and extracranial vertebral artery (VA) occlusion or severe stenosis ≥70% (V1 or proximal V2 segment) were compared with patients with ntBAO.

Results: A total of 15 patients with tBAO and 74 patients with ntBAO were enrolled. Successful reperfusion (modified thrombolysis in cerebral infarction score ≥2b) was obtained in 73.3% versus 90.5% (OR = 0.29, 95%CI: 0.07-1.15), good clinical outcome (3-months modified Rankin scale ≤2) was reached by 26.7% versus 32.4% (OR = 0.76; 95% CI: 0.24-2.63) and mortality at 3-months was 46.7% versus 31% (OR = 1.94; 95%CI: 0.63-6) of patients with tBAO versus ntBAO, respectively. Two patients (13.3%) with tBAO and three (4%) with ntBAO had symptomatic intracranial haemorrhage (OR = 3.64; 95% CI: 0.55-24).

Conclusion: Mechanical thrombectomy for patients with tandem basilar artery occlusion tends to be associated with lower rates of successful reperfusion and good clinical outcome, and higher rate of mortality. Larger multicentre studies are warranted to better precise the proper selection and management of such patients.
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http://dx.doi.org/10.1016/j.neurad.2020.08.004DOI Listing
November 2020

Spinal epidural arteriovenous fistula embolization with ethylene vinyl alcohol (EVOH) copolymer using the Scepter Mini dual-lumen balloon.

J Neurointerv Surg 2021 May 28;13(5):492. Epub 2020 Aug 28.

Department of Neuroradiology, Pitié-Salpêtrière University Hospital, Paris, Île-de-France, France.

Left unattended, spinal epidural arteriovenous fistulas (EAVFs) have a potentially severe clinical course. Embolization using ethylene vinyl alcohol (EVOH) copolymers through regular dual-lumen balloons has emerged as a potential option for the treatment of spinal arteriovenous (AV) fistulas;1-3 the main issue with this technique is the navigability of these balloons. The Scepter Mini is a low-profile, dual-lumen balloon, which may be helpful for EVOH embolization of spinal AV fistulas, as it may help to overcome the navigation drawbacks. In this technical video, we present a case of EVOH embolization of a right T6 spinal EAVF through a Scepter Mini balloon. Of note, particular attention should be paid to radiculomedullary arteries arising at the same level or at adjacent levels to avoid severe neurologic complications related to uncontrolled migration of the liquid embolic agent. Moreover, excessive use of embolic material should be avoided to prevent spinal cord compression (video 1). neurintsurg;13/5/492/V1F1V1Video 1.
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http://dx.doi.org/10.1136/neurintsurg-2020-016395DOI Listing
May 2021

Direct puncture of the superficial temporal artery for ethylene vinyl alcohol embolization of a type 3 arteriovenous fistula with a dual lumen balloon.

J Neurointerv Surg 2021 May 31;13(5):493. Epub 2020 Jul 31.

Interventional Neuroradiology, University Hospital Pitié Salpêtrière, Paris, Île-de-France, France.

Intracranial dural arteriovenous fistulas (dAVFs) may be difficult to treat by endovascular means, especially when the arterial feeders to the fistula are tortuous. 1 The usual main feeder to intracranial dAVFs is the middle meningeal artery, which may present very tight loops that are often difficult to cross with a microcatheter. 2 Direct puncture of a subcutaneous artery feeding the fistula indirectly via transosseous branches may be a valuable strategic option to overcome this limitation. 3 4 We report here the successful embolization of a Cognard type 3 parietal dAVF by direct puncture of the superficial temporal artery under roadmap guidance. The dAVF was subsequently embolized with ethylene vinyl alcohol via a dual lumen balloon, under balloon inflation. We highlight in this technical video 1 the potential difficulties and risks of direct puncture of the superficial temporal artery. We also stress the risk of delayed scalp necrosis using this technique. neurintsurg;13/5/493/V1F1V1Video 1.
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http://dx.doi.org/10.1136/neurintsurg-2020-016351DOI Listing
May 2021

Acute Stroke Management During the COVID-19 Pandemic: Does Confinement Impact Eligibility for Endovascular Therapy?

Stroke 2020 08 1;51(8):2593-2596. Epub 2020 Jul 1.

Department of Interventional and Diagnostic Radiology, Lausanne University Hospital, Switzerland (S.D.H., F.P., B.B., G.S.).

During the coronavirus disease 2019 (COVID-19) pandemic, the World Health Organization recommended measures to mitigate the outbreak such as social distancing and confinement. Since these measures have been put in place, anecdotal reports describe a decrease in the number of endovascular therapy (EVT) treatments for acute ischemic stroke due to large vessel occlusion. The purpose of our study was to determine the effect on EVT for patients with acute ischemic stroke during the COVID-19 confinement. In this retrospective, observational study, data were collected from November 1, 2019, to April 15, 2020, at 17 stroke centers in countries where confinement measures have been in place since March 2020 for the COVID-19 pandemic (Switzerland, Italy, France, Spain, Portugal, Germany, Canada, and United States). This study included 1600 patients treated by EVT for acute ischemic stroke. Date of EVT and symptom onset-to-groin puncture time were collected. Mean number of EVTs performed per hospital per 2-week interval and mean stroke onset-to-groin puncture time were calculated before confinement measures and after confinement measures. Distributions (non-normal) between the 2 groups (before COVID-19 confinement versus after COVID-19 confinement) were compared using 2-sample Wilcoxon rank-sum test. The results show a significant decrease in mean number of EVTs performed per hospital per 2-week interval between before COVID-19 confinement (9.0 [95% CI, 7.8-10.1]) and after COVID-19 confinement (6.1 [95% CI, 4.5-7.7]), (<0.001). In addition, there is a significant increase in mean stroke onset-to-groin puncture time (<0.001), between before COVID-19 confinement (300.3 minutes [95% CI, 285.3-315.4]) and after COVID-19 confinement (354.5 minutes [95% CI, 316.2-392.7]). Our preliminary analysis indicates a 32% reduction in EVT procedures and an estimated 54-minute increase in symptom onset-to-groin puncture time after confinement measures for COVID-19 pandemic were put into place.
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http://dx.doi.org/10.1161/STROKEAHA.120.030794DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7340133PMC
August 2020

Neurological diseases of unknown etiology: Brain-biopsy diagnostic yields and safety.

Eur J Intern Med 2020 10 10;80:78-85. Epub 2020 Jul 10.

Sorbonne Université, UPMC Univ. Paris 06, F-75005, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-Phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, F-75013, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix, Institut de Cardiométabolisme et Nutrition (ICAN), Service de Médecine Intensive-Réanimation, F-75013, Paris, France.

Background: For nonneoplastic neurological diseases, no recommendation exists regarding the place or appropriate timing of brain biopsy. The aim of this study was to evaluate the diagnostic yield and safety of brain biopsies from patients with neurological diseases of unknown etiology.

Methods: We performed a retrospective cohort study from January 1, 2008 to December 31, 2018. We analyzed 1847 brain-biopsied patients, including 178 biopsies indicated for neurological diseases of unknown etiology. Specific histological and final diagnosis rates, positive diagnosis-associated factors, complication rate and complication-associated factors were assessed.

Results: Specific histological diagnosis and final diagnosis rates were 71.3% and 83.1%, respectively, leading to therapeutic management change(s) for 75.3% of patients. Brain- biopsy-related mortality and permanent neurological morbidity occurred in 1.1% and 0.6% of the patients, respectively. The multivariable logistic-regression model retained (odds ratio [95% CI] only immunodepression (2.2 [1.1-4.7]; P=.04) as being independently associated with specific histological diagnosis, while supratentorial biopsy-targeted lesions (4.1 [1.1-15.2]; P=.04) were independently associated with a final diagnosis. Biopsies obtained from comatose patients were less contributive to the diagnosis (0.2 [0.05-0.7]; P=.01). Prebiopsy platelet count <100 G/L (28.5 [1.8-447]; P=.02), hydrocephalus (6.3 [1.2-15.3]; P=.02) and targeted lesions <1 cm (4.3 [1.2-15.3]; P=.03) were independently associated with brain biopsy-related complications.

Conclusion: For highly selected patients with neurological diseases of unknown etiology, brain biopsy has a high diagnostic yield and low frequency of severe complications. We advocate that this procedure be considered early in the diagnosis algorithm of these patients.
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http://dx.doi.org/10.1016/j.ejim.2020.05.029DOI Listing
October 2020

Four-dimensional digital subtraction angiography for exploration of spinal cord vascular malformations: preliminary experience.

J Neurointerv Surg 2021 Jan 25;13(1):69-74. Epub 2020 Jun 25.

Neuroradiology, Hôpital Universitaire Pitié Salpêtrière, Paris, Île-de-France, France.

Background: The precise understanding of the angioarchitecture of spinal vascular malformations (SVMs) is often difficult to reach with conventional digital subtraction angiography (DSA). The purpose of our study was to evaluate the potential of four-dimensional DSA (4D-DSA) (Siemens Healthcare) in the exploration of SVMs.

Methods: We retrospectively studied all patients who underwent spinal DSA, including 4D-DSA acquisition, from July 2018 to June 2019 at a single institution. All spinal DSA acquisitions were performed under general anesthesia. 4D-DSA acquisitions were acquired with the protocol '12 s DSA Dyna4D Neuro'. 12 mL of iodixanol 320 mg iodine/mL were injected via a 5 F catheter (1 mL/s during the 12 s 4D-DSA acquisition). Inter-rater (three independent reviewers) and intermodality agreements were assessed.

Results: Nine consecutive patients (six men, three women, mean age 55.3±19.8 years) with 10 SVMs (spinal dural arteriovenous fistulas n=3, spinal epidural arteriovenous fistulas n=2, spinal pial arteriovenous fistulas n=2, and spinal arteriovenous malformations n=2; one patient had two synchronous pial fistulas) had spinal DSA, including 4D-DSA acquisition. Inter-rater agreement was good and moderate for the venous drainage pattern and the SVM subtype, respectively. In 9 of 10 cases, the quality of the acquisition was graded as good. Satisfactory concordance between 4D-DSA and the selective microcatheterization was observed in 90% of cases for the location of the shunt point.

Conclusion: 4D-DSA acquisition may be helpful for a better understanding of the angioarchitecture of SVMs. Larger series are warranted to confirm these preliminary results.
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http://dx.doi.org/10.1136/neurintsurg-2020-015909DOI Listing
January 2021

Roadmap-assisted V3 Vertebral Artery Interventional Approach to the Basilar Artery : Case Report and Systematic Search of the Literature.

Clin Neuroradiol 2020 Dec 16;30(4):869-873. Epub 2020 Jun 16.

Department of Neuroradiology, APHP. Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.

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http://dx.doi.org/10.1007/s00062-020-00918-xDOI Listing
December 2020

First clinical multicenter experience with the new Scepter Mini microballoon catheter.

J Neurointerv Surg 2021 Mar 16;13(3):261-266. Epub 2020 Jun 16.

Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany

Background: Balloon-assisted techniques can improve the endovascular treatment of cerebrospinal vascular malformations. The aim of this study was to report the first clinical multicenter experience with the new Scepter Mini dual-lumen microballoon catheter.

Methods: Patients with cerebral or spinal vascular malformations treated with the Scepter Mini at seven European neurovascular centers were retrospectively reviewed. Clinical data, angiographic features of the vascular malformations, procedural parameters including the type of application, navigability, technical failures, complications and embolization success were assessed.

Results: The usage of 34 Scepter Mini microballoon catheters in 20 patients was analyzed. Most treated malformations (80.0%) were cerebral arteriovenous malformations. Four different applications were reported: embolization via Scepter Mini (n=23, 67.6%), balloon-occlusion with simultaneous embolization via a second microcatheter (n=3, 8.8%), diagnostic angiography with simultaneous balloon-inflation for flow arrest (n=4, 11.8%), and navigation support (n=4, 11.8%). The mean diameter of the blood vessels in which the Scepter Mini was inflated was 1.9±0.5 mm. The navigability of the Scepter Mini was rated as 'easy' or 'very easy' in 88.2% of cases. Complete occlusion of the malformation was achieved in 60.9% of cases. Technical failures occurred in 4/23 embolization procedures, and all were related to insufficient stability of the balloon within the vessel. No complications related to the Scepter Mini were observed, while unrelated complications occurred in three patients (15.0%).

Conclusions: The Scepter Mini is a promising new device for balloon-assisted embolization of cerebrospinal vascular malformations via small feeders. Beyond embolization, the Scepter Mini can also be used for other applications, such as superselective flow arrest and navigation support.
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http://dx.doi.org/10.1136/neurintsurg-2020-016115DOI Listing
March 2021

Larger Middle Meningeal Arteries on Computed Tomography Angiography in Patients with Chronic Subdural Hematomas as Compared with Matched Controls.

J Neurotrauma 2020 12 10;37(24):2703-2708. Epub 2020 Jul 10.

Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France.

Chronic subdural hematomas (CSDHs) are one of the most prevalent head-trauma-related conditions. The middle meningeal artery (MMA) may participate in the pathophysiology of CSDHs. The aim of this study was to determine whether CSDHs are associated with large MMAs. Patients referred for CSDH embolization and having undergone a computed tomography angiography (CTA) before embolization were retrospectively included. For each CSDH patient, two age- and sex-matched controls with a CTA performed during the study period were selected. Size comparisons of the MMA were performed between MMAs ipsilateral to CSDHs, on the contralateral side, and in controls. Comparison was also made with angiographic measurements from CSDH embolization procedures. Seventy-five patients with CSDH with available CTAs prior to embolization were enrolled and 146 MMAs were measured. One hundred fifty controls were included and 288 MMAs were measured. The median diameter of the 94 MMAs ipsilateral to a CSDH (1.5 mm; interquartile range [IQR] 1.3-1.7) was significantly larger than that of control MMAs (1.28 mm; IQR 1.15-1.4) ( < 0.001). The median diameter of 52 MMAs on the side of a unilateral CSDH (1.6 mm; IQR 1.4-1.8) was larger than that of the 52 contralateral MMAs (1.4 mm; IQR 1.25-1.6) ( < 0.001). Among the characteristics of patients with CSDH, multiple surgeries were associated with significantly larger MMAs (>1.7 mm;  = 0.01). MMAs ipsilateral to CSDHs appear to be significantly larger as compared with contralateral MMAs and MMAs in a control population, suggesting the involvement of the MMA in the pathophysiology of CSDH.
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http://dx.doi.org/10.1089/neu.2020.7168DOI Listing
December 2020

Middle meningeal artery embolization reduces the post-operative recurrence rate of at-risk chronic subdural hematoma.

J Neurointerv Surg 2020 Dec 21;12(12):1209-1213. Epub 2020 May 21.

Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France.

Background: Embolization of the middle meningeal artery (MMA) has emerged as a potential treatment of chronic subdural hematomas (CSDHs).

Objective: To evaluate the impact on recurrence rate of postsurgical embolization of CSDH in patients with a higher than average risk of recurrence.

Methods: A monocentric retrospective study was performed on retrospectively collected data. From March 2018 to December 2019, embolization of the MMA was proposed as an adjunct postoperative treatment after burr-hole surgery in patients operated for a recurrent CSDH or a CSDH with an independent recurrence risk factor, including antiplatelet therapy, full anticoagulation therapy, coagulation disorder, hepatopathy, or chronic alcoholism. Patients who had undergone postoperative embolization were compared with a historic group of patients operated between March 2016 and March 2018, selected based on the same inclusion criteria.

Results: During the study period, 89 patients (with 74 unilateral and 15 bilateral CSDHs) were included and underwent an embolization procedure, leading to 91 out of a total of 104 MMA being embolized (88%). These were compared with 174 patients (138 unilateral and 36 bilateral CSDH) in the historic control group. One major procedure-related adverse event was registered. Four of the 89 patients (4%) required surgery for a CSDH recurrence in the embolization group, significantly less than the 24 of 174 patients (14%) in the control group (OR=0.28, 95% CI 0.07 to 0.86, p=0.02).

Conclusions: Postsurgical embolization of the MMA may reduce the recurrence rate of CSDHs with a risk factor of recurrence.
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http://dx.doi.org/10.1136/neurintsurg-2020-016048DOI Listing
December 2020

Mechanical Thrombectomy for Acute Ischemic Stroke Amid the COVID-19 Outbreak: Decreased Activity, and Increased Care Delays.

Stroke 2020 07 20;51(7):2012-2017. Epub 2020 May 20.

Neuroradiology Department, CH Sainte-Anne, Paris, France (B.K., W.B.H., G.B.).

Background And Purpose: The efficiency of prehospital care chain response and the adequacy of hospital resources are challenged amid the coronavirus disease 2019 (COVID-19) outbreak, with suspected consequences for patients with ischemic stroke eligible for mechanical thrombectomy (MT).

Methods: We conducted a prospective national-level data collection of patients treated with MT, ranging 45 days across epidemic containment measures instatement, and of patients treated during the same calendar period in 2019. The primary end point was the variation of patients receiving MT during the epidemic period. Secondary end points included care delays between onset, imaging, and groin puncture. To analyze the primary end point, we used a Poisson regression model. We then analyzed the correlation between the number of MTs and the number of COVID-19 cases hospitalizations, using the Pearson correlation coefficient (compared with the null value).

Results: A total of 1513 patients were included at 32 centers, in all French administrative regions. There was a 21% significant decrease (0.79; [95%CI, 0.76-0.82]; <0.001) in MT case volumes during the epidemic period, and a significant increase in delays between imaging and groin puncture, overall (mean 144.9±SD 86.8 minutes versus 126.2±70.9; <0.001 in 2019) and in transferred patients (mean 182.6±SD 82.0 minutes versus 153.25±67; <0.001). After the instatement of strict epidemic mitigation measures, there was a significant negative correlation between the number of hospitalizations for COVID and the number of MT cases ( -0.51; =0.04). Patients treated during the COVID outbreak were less likely to receive intravenous thrombolysis and to have unwitnessed strokes (both <0.05).

Conclusions: Our study showed a significant decrease in patients treated with MTs during the first stages of the COVID epidemic in France and alarming indicators of lengthened care delays. These findings prompt immediate consideration of local and regional stroke networks preparedness in the varying contexts of COVID-19 pandemic evolution.
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http://dx.doi.org/10.1161/STROKEAHA.120.030373DOI Listing
July 2020

Mechanical thrombectomy practices in France: Exhaustive survey of centers and individual operators.

J Neuroradiol 2020 Nov 13;47(6):410-415. Epub 2020 May 13.

Neuroradiology department, Dupuytren, university hospital of Limoges, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France; XLIM CNRS, UMR 7252, université de Limoges, Limoges, France.

Background And Purpose: Mechanical thrombectomy (MT) has dramatically changed the landscape of stroke care as well as stroke care organization. Public health institutions are faced with the challenge of swiftly providing equal access to this high technical level procedure with rapidly broadening indications, and constantly developing techniques. The aim of this study was to present a current nationwide overview of technical MT practices in France as well as local organizations.

Materials And Methods: Thrombectomy capable French stroke centers, and physicians performing MT were invited to participate to a nationwide survey, disseminated through an existing trainee-led research network (the JENI-RC) under the aegis of the French Society of Neuroradiology. The survey was composed of 64 questions to collect both individual practices and general center-based information.

Results: All French centers (100%) answered the survey, and 74% (110/148) of active interventional neuroradiologists (INR) performing MT completed individual questionnaires. The mean number of INR per center performing MT was 3.7±1.85, and 85% of the centers were organized for 24/7 continuity of care. MRI was the most commonly used imaging modality for stroke diagnosis and patients' selection, and perfusion imaging was routinely available in 85% of the centers. Half of centers performed yearly between 100 and 200 MT. Anesthesiologic, and technical considerations are also developed in the manuscript.

Conclusions: This nationwide survey highlights the impressive response to the challenge of reorganization of stroke care with regards to mechanical thrombectomy in France. Technical and management disparities remain. Most centers remain understaffed to properly function in the long term, but the inflow of INT trainees is substantial.
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http://dx.doi.org/10.1016/j.neurad.2020.05.001DOI Listing
November 2020

Long-term Kinetic Papilledema Improvement After Venous Sinus Stenting in Idiopathic Intracranial Hypertension.

Clin Neuroradiol 2020 May 12. Epub 2020 May 12.

Department of Ophthalmology, Pitié-Salpêtrière Hospital, APHP, 47, Bd de l'Hôpital, 75013, Paris, France.

Background And Purpose: The aim of this study was to assess the safety and effectiveness of lateral sinus stenosis (LSS) stenting in patients with idiopathic intracranial hypertension (IIH) who are refractory to medical treatment, particularly focusing on visual outcomes including papilledema.

Material And Methods: Retrospective study of consecutive patients with IIH refractory to medical treatment who underwent LSS stenting. Clinical features, visual fields and optical coherence tomography (OCT) retinal nerve fiber layer (RNFL) and ganglion cell layer (GCL) thicknesses were assessed before stenting, at 1 month poststenting and at last follow-up. Complications were also recorded.

Results: A total of 16 women were included, with a mean age of 39 ± 11 years. All patients had papilledema while 15/16 (94%) had headaches. Mean visual acuity was 0.036 logMAR, range (+0.4 to +0.0 logMAR). The mean RNFL thickness prior to stenting was 121.7 µm (±34.7 µm) and mean GCL thickness was 80.2 µm (±8.9 µm). Mean follow-up was 19.7 months (±11.8 months). After stenting, acetazolamide was discontinued in 15/16 (94%) patients. Papilledema improved in 14/16 (88%) of patients. The mean RNFL thickness was significantly decreased 1 month after stenting (96.3 ± 15.6 µm; p < 0.001) and at last visit (93.4 ± 15.3 µm; p < 0.001). The GCL thickness after LSS stenting was moderately decreased at the last visit examination: 80.2 ± 8.9 µm vs. 78.0 ± 10.7 µm; (p < 0.01). No stent-related complication occurred, while there was one case of restenosis.

Conclusion: Improvement of papilledema appears to occur relatively rapidly after the LSS stenting. The results further support the role of LSS stenting in the treatment of IIH, especially with respect to visual symptoms.
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http://dx.doi.org/10.1007/s00062-020-00908-zDOI Listing
May 2020

Cangrelor and Stenting in Acute Ischemic Stroke : Monocentric Case Series.

Clin Neuroradiol 2020 May 7. Epub 2020 May 7.

Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.

Purpose: Cangrelor is an intravenous P2Y12 receptor inhibitor with a rapid onset/offset of action and a short half-life (3-6 min). The objective was to present a preliminary experience regarding the safety and effectiveness using cangrelor, in combination with aspirin, in acute ischemic stroke patients requiring acute stenting.

Material And Methods: Retrospective analysis for patients who underwent stenting (intracranial and/or extracranial) in the setting of acute ischemic stroke with cangrelor and aspirin as antiplatelet therapy.

Results: Cangrelor was used in 12 patients, 4 (33%) with extracranial stenting, 6 (50%) with intracranial stenting and 2 (17%) with combined extracranial and intracranial stenting. The mean age was 67 years (44-88) and 9 patients (75%) were female. The median National Institutes of Health Stroke Score at admission was 15 (IQR: 8-22). Of the patients, six (50%) received intravenous thrombolysis. All patients (100%) obtained modified thrombolysis in cerebral infarction score ≥2b. Good clinical outcome, defined as modified Rankin scale score ≤2 at 3‑months follow-up, was observed in 7 patients (58%). None of the patients experienced intraprocedural thromboembolic complications. Postprocedural stent thrombosis after cessation of cangrelor infusion due to emergency craniotomy surgery to manage malignant cerebral infarction occurred in one patient (8%). Of the patients, two (17%) experienced asymptomatic intracranial hemorrhage (ICH), one patient (8%) experienced symptomatic ICH and one (8%) retroperitoneal hematoma was observed, which was managed conservatively.

Conclusion: Cangrelor might be a safe and effective antiplatelet medication owing to its on/off activity for acute stenting in the setting of acute ischemic stroke. Further investigations through randomized studies with larger samples are necessary.
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http://dx.doi.org/10.1007/s00062-020-00907-0DOI Listing
May 2020

Safety of vertebral augmentation with cranio-caudal expansion implants in vertebral compression fractures with posterior wall protrusion.

Eur Radiol 2020 Oct 4;30(10):5641-5649. Epub 2020 May 4.

Department of Neuroradiology, Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospitals, F75013, Paris, France.

Objectives: Vertebral augmentation (VA) has become routinely used in vertebral compression fractures (VCFs). VCFs are often associated with posterior wall protrusions (PWPs), which theoretically contraindicates vertebroplasty due to a higher risk of neurological complications. The latest generation of VA devices uses intravertebral cranio-caudal expandable implants to improve the correction of structural deformities but could also be used to prevent further PWP during cement injection. The aim of this study was to evaluate the safety of VA with expandable implant for VCFs with PWP.

Methods: All consecutive patients treated with expandable implants were considered eligible for inclusion if they met the following criteria: (1) non-neurological VCF, (2) considered unstable (A3-A4 in AOSpine classification), (3) significant PWP (> 2 mm), (4) back pain with a visual analogue scale (VAS) ≥ 4. PWPs were independently measured by two investigators; Pearson's statistics were used for interobserver reproducibility.

Results: Fifty-one consecutive patients, with a mean age of 75 ± 8.3 years (range, 50-92), were included. There was a slight decrease between mean preoperative (6.7 mm ± 2.2 mm) and postoperative (6.5 mm ± 2.2 mm) PWP (p = 0.02), with an excellent interobserver reproducibility (Pearson correlation coefficient = 0.92). A mean kyphosis reduction of 34.9% (± 28.4) was observed (p < 0.001). Forty-two patients (82.4%) had significant pain improvements (mean preoperative VAS = 6.9 [± 1.7] versus 3.1 [± 2.0] postoperatively [p < 0.001]). Secondary adjacent level fractures were noted in 16 patients (31.4%), with a reduction of that risk down to 18.8% if a preventive adjacent vertebroplasty was performed, without reaching the significance threshold (p = 0.14).

Conclusions: VA with expandable implants appeared safe for non-neurological VCFs with PWP, while allowing satisfactory pain relief.

Key Points: • Vertebral augmentation with cranio-caudal expandable implants is safe for non-neurological vertebral compression fractures with posterior wall protrusions. • Vertebral augmentation with cranio-caudal expandable implants might increase the occurrence of secondary adjacent level fractures. • Adjacent level vertebroplasty might be helpful to prevent secondary adjacent level fractures.
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http://dx.doi.org/10.1007/s00330-020-06889-4DOI Listing
October 2020

Transoral vertebroplasty for the C1 lateral mass.

J Neurointerv Surg 2020 Sep 30;12(9):879-885. Epub 2020 Apr 30.

Sorbonne Université, Paris, France.

Background: Osteolytic lesions of the atlas (C1) are challenging to treat by vertebroplasty due to the vicinity of the vertebral artery and the spinal cord.

Objective: To present our experience with transoral vertebroplasty (TOV) for osteolytic lesions of the lateral mass of the atlas.

Methods: Retrospective case series involving 15 consecutive patients (nine male, six female, mean age 63 years) who underwent TOV for the treatment of an osteolytic lesion of the lateral mass of the atlas. Among the osteolytic lesions, 10/15 (67%) were bone metastases from various cancers; 4/15 (27%) were lesions related to multiple myeloma; and one lesion (7%) was an aggressive hemangioma. All the TOVs were performed under general anesthesia and in most cases (10/15; 67%) in a hybrid angiosuite combining a C-arm flat panel and a CT scan. The remaining five patients were treated under biplane fluoroscopic guidance.

Results: Vertebroplasty of the lateral mass of C1 through a transoral route was feasible in all cases. Significant pain relief was obtained in most cases (1 month average decrease in Numeric Rating Scale: 4.9±4.1). No major complication was recorded. In 7/15 cases (47%), cement leakage surrounding the C1 lateral mass was seen; none of these leakages had a significant clinical consequence. No additional spine surgery was required in any of the patients.

Conclusion: TOV of osteolytic lesions of the lateral mass of the atlas is feasible and seems safe and effective, providing pain relief and bone stabilization.
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http://dx.doi.org/10.1136/neurintsurg-2020-015853DOI Listing
September 2020

Letter to the editor regarding "Safety and Effectiveness of Cervical Vertebroplasty: Report of a Large Cohort and Systematic Review".

Eur Radiol 2020 09 24;30(9):5209-5210. Epub 2020 Apr 24.

Department of Neuroradiology, APHP-Pitié-Salpêtrière Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France.

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http://dx.doi.org/10.1007/s00330-020-06857-yDOI Listing
September 2020

Is Anatomical Variations a Risk Factor for Cerebral Vasospasm in Anterior Communicating Complex Aneurysms Rupture?

Stroke 2020 03 22;51(3):998-1001. Epub 2020 Jan 22.

Department of Neuroradiology (E.S., N.-A.S., K.P., S.L., F.C.), Pitié-Salpêtrière Hospital, France.

Background and Purpose- One-third of ruptured aneurysms are located on the anterior communicating complex with high prevalence of anatomic variations of this arterial segment. In this study, we hypothesized that anatomic variations of the anterior communicating complex increase the risk of angiographic vasospasm. Methods- Retrospective study of prospectively collected data from a monocentric subarachnoid hemorrhage cohort of patients admitted to neurointensive care between 2002 and 2018. Univariate followed by multivariate logistic regression analysis was used to identify factors associated with angiographic vasospasm. Results- One thousand three hundred seventy-four patients with aneurismal subarachnoid hemorrhage were admitted to our institution; 29.8% (n=410) were related to an anterior communicating complex aneurysm rupture; 9.2% (n=38) of them showed an anterior communicating artery variation. Angiographic vasospasm was diagnosed in 55.6% of this subgroup (vs 28.1%, =0.003). In the multivariate analysis, external ventricular drain (2.2 [1.32-3.65], =0.003) and anterior communicating artery variation (2.40 [1.2-4.9], =0.04) were independently and significantly associated with angiographic vasospasm, while age above 60 years (0.3 [0.2-0.7]; =0.002) was a protective factor. However, anterior communicating artery variation was not statistically associated with ischemic vasospasm or poor neurological outcome after anterior communicating artery aneurysm rupture. Conclusions- Anatomic variation of anterior communicating artery could be a new biomarker to identify patients at risk to develop angiographic vasospasm post-subarachnoid hemorrhage. External validation cohorts are necessary to confirm these results.
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http://dx.doi.org/10.1161/STROKEAHA.119.026661DOI Listing
March 2020

Rescue stenting versus medical care alone in refractory large vessel occlusions: a systematic review and meta-analysis.

Neuroradiology 2020 May 11;62(5):629-637. Epub 2020 Jan 11.

Department of Interventional Neuroradiology, Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, 47-83 Boulevard de l'Hôpital, F75013, Paris, France.

Purpose: Mechanical thrombectomy (MT) failure is associated with very poor prognosis. Permanent intracranial stenting (PIS) may be useful in such refractory occlusions. However, this strategy requires an aggressive antithrombotic regimen that may be harmful in extended strokes. The aim of this study was to compare clinical outcomes between patients with refractory acute large vessel occlusions (LVOs) treated by PIS versus patients for whom the procedure was stopped without recanalization.

Methods: We conducted a systematic review by searching for articles in PubMed, the Cochrane Library, and ClinicalTrials.gov from January 2015 to September 2019. Two reviewers independently selected studies comparing PIS after failed MT in addition to usual care versus usual care only. A comparative meta-analysis was performed using random-effects models to estimate odds ratios of favorable clinical outcome at 90 days, defined as a modified Rankin scale 0-2, mortality and symptomatic intracranial hemorrhage (SICH).

Results: Four comparative studies were included for a total of 352 patients: 149 in the PIS group versus 203 in the control group. PIS was associated with significantly higher rates of 90-day favorable clinical outcome (odds ratio [OR], 2.87 [95% confidence interval (95% CI), 1.77-4.66]; p < 0.001; I, 0%) and lower mortality (OR, 0.39 [0.16-0.93]; p = 0.03; I, 43%), whereas SICH rates did not significantly differ (OR, 0.68 [0.37-1.27]; p = 0.23; I, 0%).

Conclusion: From observational study results, attempting PIS after failed MT seems to improve clinical outcomes without increasing the risk of intracranial bleeding. Randomized trials are needed to confirm these results.
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http://dx.doi.org/10.1007/s00234-020-02360-9DOI Listing
May 2020

Combined use of contact aspiration and the stent retriever technique versus stent retriever alone for recanalization in acute cerebral infarction: the randomized ASTER 2 study protocol.

J Neurointerv Surg 2020 May 8;12(5):471-476. Epub 2020 Jan 8.

Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France.

Rationale: Mechanical thrombectomy (MT) using a stent retriever (SR) device is currently the recommended treatment in ischemic stroke due to anterior circulation large vessel occlusion. Combining contact aspiration (CA) with SR is a promising new treatment, although it was not found to be superior to SR alone as first-line treatment for achieving successful reperfusion.

Aim: To determine whether endovascular treatment combining first-line use of CA and SR is more efficient than SR alone.

Methods: The ASTER 2 clinical trial is a prospective, randomized, multicenter, open-label trial with a blinded endpoint. We included patients admitted with suspected anterior circulation ischemic stroke secondary to large vessel occlusion <8 hours from symptom onset. They were randomly allocated in a 1:1 ratio to one of two treatment groups (combined CA and SR or SR alone). In the case of failure of the assigned technique after three attempts, other adjunctive techniques were applied.

Study Outcome: The primary outcome is the rate of successful/complete reperfusion (modified Thrombolysis In Cerebral Infarction (mTICI) score 2c/3) after the entire endovascular procedure. Secondary outcomes include reperfusion rates after the assigned first-line intervention alone and at the end of the procedure, procedural times, change in NIH Stroke Scale score at 24 hours, intracerebral hemorrhage at 24 hours, procedure-related serious adverse events, the modified Rankin Scale score, and all-cause mortality at 90 days and 1 year. The cost effectiveness of the two procedures will also be analyzed.

Discussion: This is the first head-to-head randomized trial to directly compare the efficacy of the combined use of CA and SR versus SR alone. This prospective trial aims to demonstrate the synergistic effects of CA and SR devices in first-line endovascular treatment.
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http://dx.doi.org/10.1136/neurintsurg-2019-014735DOI Listing
May 2020