Publications by authors named "Hocine Redjem"

45 Publications

Timing and Spectrum of Neurological Complications After Flow Diverter Implantation for Intracranial Aneurysms.

Front Neurol 2021 20;12:590383. Epub 2021 Apr 20.

Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France.

The aim of this study was to characterize neurological complications after flow diverter (FD) treatment on a long follow-up cohort and identify predictive factors associated with these complications. This study was conducted on a monocentric cohort of patients treated for intracranial aneurysms by FD. Between September 2008 and July 2018, 413 patients were treated for 514 aneurysms: 18% of the patients presented with at least one neurological complication during a median follow-up of 446 days (IQR 186-1,210). Sixty-one patients presented with ischemic complications, 13 with hemorrhagic ones and 10 with compressive processes. Among 89 neurological complications 64.5% were peri-operative (occurring within the 30 days following the procedure) and 35.5% were delayed after 1 month. Overall, neurological complications after FD implantation were overrepresented by cerebrovascular ischemic events occurring during the peri-operative period, but also in a delayed manner after 1 year. Long-term follow-up is relevant after aneurysm intervention using FD.
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http://dx.doi.org/10.3389/fneur.2021.590383DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8093792PMC
April 2021

Intravenous abciximab as a rescue therapy for immediate reocclusion after successful mechanical thrombectomy in acute ischemic stroke patients.

Platelets 2021 Apr 11:1-6. Epub 2021 Apr 11.

Rothschild Foundation Hospital, Interventional Neuroradiology Department, Paris, France.

- Immediate reocclusion after mechanical thrombectomy (MT) for acute ischemic stroke (AIS) is a rare but devastating condition associated with poor functional outcome. - The aim of this study was to gain insights into the mechanisms underlying immediate reocclusion, and to evaluate the efficacy and safety of the glycoprotein IIb/IIIa antagonist abciximab, for its treatment. - Clinical data were collected from April 2015 to April 2019 in a monocentric prospective registry of AIS patients treated by MT. All patients with immediate reocclusion were retrospectively selected and subdivided into 2 groups according to abciximab treatment status. , the separate and combined effects of abciximab and alteplase on clot formation in whole blood under flow conditions were further investigated in microfluidic chambers. - From 929 MT-treated patients, 21 had post-MT immediate reocclusion. Abciximab treatment in reocclusion patients (n = 10) led to higher rate of final recanalization ( < .001) while it did not increase bleeding complications. Flow chamber experiments revealed that, in contrast to alteplase, abciximab efficiently limits thrombus accretion from flowing blood by blocking platelet aggregation. - Our results underscore a key role for platelet aggregation and the potential of Glycoprotein IIb/IIIa antagonists as a rescue therapy in post-MT immediate reocclusion.
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http://dx.doi.org/10.1080/09537104.2021.1894326DOI Listing
April 2021

Safety and efficacy of intensive blood pressure lowering after successful endovascular therapy in acute ischaemic stroke (BP-TARGET): a multicentre, open-label, randomised controlled trial.

Lancet Neurol 2021 04 26;20(4):265-274. Epub 2021 Feb 26.

Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France; Laboratory of Vascular Translational Science, INSERM, Paris, France; FHU NeuroVasc, Assistance Publique-Hôpitaux de Paris, Paris, France.

Background: High systolic blood pressure after successful endovascular therapy for acute ischaemic stroke is associated with increased risk of intraparenchymal haemorrhage. However, no randomised controlled trials are available to guide optimal management. We therefore aimed to assess whether an intensive systolic blood pressure target resulted in reduced rates of intraparenchymal haemorrhage compared with a standard systolic blood pressure target.

Methods: We did a multicentre, open-label, randomised controlled trial at four academic hospital centres in France. Eligible individuals were adults (aged ≥18 years) with an acute ischaemic stroke due to a large-vessel occlusion that was successfully treated with endovascular therapy. Patients were randomly assigned (1:1) to either an intensive systolic blood pressure target group (100-129 mm Hg) or a standard care systolic blood pressure target group (130-185 mm Hg), by means of a central web-based procedure, stratified by centre and intravenous thrombolysis use before endovascular therapy. In both groups, the target systolic blood pressure had to be achieved within 1 h after randomisation and maintained for 24 h with intravenous blood pressure lowering treatments. The primary outcome was the rate of radiographic intraparenchymal haemorrhage at 24-36 h and the primary safety outcome was the occurrence of hypotension. Analyses were done on an intention-to-treat basis. BP-TARGET is registered with ClinicalTrials.gov, number NCT03160677, and the trial is closed at all participating sites.

Findings: Between June 21, 2017, and Sept 27, 2019, 324 patients were enrolled in the four participating stroke centres: 162 patients were randomly assigned to the intensive target group and 162 to the standard target group. Four (2%) of 162 patients were excluded from the intensive target group and two (1%) of 162 from the standard target group for withdrawal of consent or legal reasons. The mean systolic blood pressure during the first 24 h after reperfusion was 128 mm Hg (SD 11) in the intensive target group and 138 mm Hg (17) in the standard target group. The primary outcome was observed in 65 (42%) of 154 patients in the intensive target group and 68 (43%) of 157 in the standard target group on brain CT within 24-36 h after reperfusion] (adjusted odds ratio 0·96, 95% CI 0·60-1·51; p=0·84). Hypotensive events were not significantly different between both groups and occurred in 12 (8%) of 158 patients in the intensive target and five (3%) of 160 in the standard target group. Mortality within the first week after randomisation occurred in 11 (7%) of 158 patients in the intensive target group and in seven (4%) of 160 in the standard target group.

Interpretation: An intensive systolic blood pressure target of 100-129 mm Hg after successful endovascular therapy did not reduce radiographic intraparenchymal haemorrhage rates at 24-36 h as compared with a standard care systolic blood pressure target of 130-185 mm Hg. Notably, these results are applicable to patients with successful reperfusion and systolic blood pressures of more than 130 mm Hg at the end of procedure. Further studies are needed to understand the association between blood pressure and outcomes after reperfusion.

Funding: French Health Ministry.
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http://dx.doi.org/10.1016/S1474-4422(20)30483-XDOI Listing
April 2021

Corrigendum to 'Antiplatelet Therapy During Emergent Extracranial Internal Carotid Artery Stenting: Comparison of Three Intravenous Antiplatelet Perioperative Strategies' [Journal of Stroke and Cerebrovascular Diseases, Vol. 30, No. 2, (2020) 105521].

J Stroke Cerebrovasc Dis 2021 Mar 22;30(3):105560. Epub 2020 Dec 22.

Interventional Neuroradiology Department, Rothschild Foundation Hospital, Paris, France; Laboratory of Vascular Translational Sci- ence, U1148 INSERM, Universit'e de Paris, 46 rue Henri Huchard 75018 Paris, France; Universit'e de Paris, France; FHU Neurovasc, France. Electronic address:

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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.105560DOI Listing
March 2021

Antiplatelet Therapy During Emergent Extracranial Internal Carotid Artery Stenting: Comparison of Three Intravenous Antiplatelet Perioperative Strategies.

J Stroke Cerebrovasc Dis 2021 Feb 9;30(2):105521. Epub 2020 Dec 9.

Interventional Neuroradiology Department, Rothschild Foundation Hospital, Paris, France; Laboratory of Vascular Translational Science, U1148 INSERM, Université de Paris, 46 rue Henri Huchard 75018 Paris, France; Université de Paris, France; FHU Neurovasc, France. Electronic address:

Introduction: Guidelines for antiplatelet therapy administration, during emergent stenting for extra-cranial internal carotid artery (EC-ICA) occlusion in the setting of acute ischemic stroke (AIS) are lacking. Different antiplatelet regimen are used in association to endovascular therapy (EVT) for the treatment of EC-ICA lesions. We aimed to compare the clinical and radiological effects of three intravenous antiplatelet agents used during emergent EC-ICA stenting.

Material And Methods: Clinical data were collected from January 2015 to December 2019 in a monocentric prospective registry of AIS patients treated by EVT. All patients who underwent emergent EC-ICA stenting were sorted regarding the intravenous antiplatelet agent used during the procedure.

Results: Among 218 patients treated by EVT for an EC-ICA occlusion of the anterior circulation during the study period, 70 underwent an emergent stenting of the EC-ICA. 60 were included in the present study, 9 received intravenous (IV) Cangrelor, 8 IV abciximab and 43 Aspirin. The rate of favorable neurological outcome, defined as modified Rankin Scale (mRS) ≤ 2 at three months were better in the Cangrelor and Aspirin groups (66,7% and 58,1%, respectively) than in the Abciximab group (37,5%), as well as, the rate of any intracranial ICH (22,2% and 37,2% vs 62,5%). The rate of acute stent reocclusion was similar between groups.

Conclusion: When used as a rescue treatment during emergent stenting of EC-ICA, Cangrelor and Aspirin present a better safety profile than Abciximab, with less intracranial hemorrhages and a higher rate of good clinical outcome. Additional studies are needed to confirm these findings.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.105521DOI Listing
February 2021

Corrigendum to 'Benefits and Safety of Periprocedural Heparin During Thrombectomy in Patients Contra-Indicated for Alteplase' [Journal of Stroke and Cerebrovascular Diseases, Vol. 29, No. 10 (October), 2020: 105052].

J Stroke Cerebrovasc Dis 2021 Feb 9;30(2):105465. Epub 2020 Dec 9.

Interventional Neuroradiology Unit, Fondation Rothschild Hospital, Paris, France; Laboratory of Vascular Translational Science, U1148 Institut National de la Sant'e et de la Recherche M'edicale (INSERM), Paris, France; Universit'e Paris Denis Diderot, Sorbonne Paris Cite, France.

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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.105465DOI Listing
February 2021

Impact of Blood Pressure After Successful Endovascular Therapy for Anterior Acute Ischemic Stroke: A Systematic Review.

Front Neurol 2020 29;11:573382. Epub 2020 Oct 29.

Interventional Neuroradiology Department, Fondation Rothschild, Paris, France.

Optimal blood pressure (BP) targets after endovascular therapy (EVT) for acute ischemic stroke (AIS) still need to be assessed, especially according to the recanalization status. Facing the lack of randomized controlled trials addressing this question, we performed a systematic review of studies assessing the post-EVT BP impact on functional outcome and symptomatic intracranial hemorrhage (sICH). Studies published after January 1, 2012 were included in the systematic review. The PRISMA checklist and flow diagram were followed for the design and reporting of this work. Five studies were included in the present analysis. Despite a significant heterogeneity among studies which precluded a meta-analysis, systolic BP (SBP) was the most frequently used parameter to describe BP. BP variability (standard deviation, successive variability) after EVT was associated with worse functional outcome, especially in studies without specific BP targets after successful EVT. Lower BP values after successful EVT were associated with lower odds of sICH. Four studies evaluated the post-EVT BP impact on recanalized patients solely, with only one specifically addressing the impact of a TICI 2B vs. 2C. Interestingly, SBP reduction was inversely associated with worse outcomes in TICI 3 patients but not in TICI 2B patients, pointing to the potential value of BP management according to the exact TICI. BP post-EVT seems to be associated with worse functional outcomes and sICH. However, given the important heterogeneity depicted among the included studies, no decisive conclusion can be made from this systematic review, thus underlying the urgent need of randomized controlled trials evaluating this question.
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http://dx.doi.org/10.3389/fneur.2020.573382DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7659685PMC
October 2020

Rescue carotid puncture for ischemic stroke treated by endovascular therapy: a multicentric analysis and systematic review.

J Neurointerv Surg 2020 Oct 19. Epub 2020 Oct 19.

Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France.

Background: Endovascular therapy (EVT) for acute ischemic stroke (AIS) can be challenging in older patients with supra-aortic tortuosity. Rescue carotid puncture (RCP) can be an alternative in case of supra-aortic catheterization failure by femoral access, but data regarding RCP are scarce. We sought to investigate the feasibility, effectiveness and safety of RCP for AIS treated by EVT.

Methods: Patients treated by EVT with RCP were included from January 2012 to December 2019 in the Endovascular Treatment in Ischemic Stroke (ETIS) multicentric registry. Main outcomes included reperfusion rates (≥TICI2B), 3 month functional outcome (modified Rankin Scale) and 3 month mortality. We also performed an additional systematic review of the literature according to the PRISMA checklist to summarize previous studies on RCP.

Results: 25 patients treated by EVT with RCP were included from the ETIS registry. RCP mainly concerned elderly patients (median age 85 years, range 73-92) with supra-aortic tortuosity (n=16 (64%)). Intravenous thrombolysis (IVT) was used for nine patients (36%). Successful reperfusion was achieved in 64%, 87.5% of patients were dependent at 3 months, and 3 month mortality was 45.8%. The systematic review yielded comparable results. In pooled individual data, there was a shift toward better functional outcome in patients with successful reperfusion (median (IQR) 4 (2-6) vs 6 (4-6), p=0.011).

Conclusion: RCP mainly concerned elderly patients admitted for AIS with anterior LVO with supra-aortic tortuosity. The procedure seemed feasible, notably for patients treated with IVT, and led to significant reperfusion rates at the end of procedure, but with pronounced unfavorable outcomes at 3 months. RCP should be performed under general anesthesia to avoid life-threatening complications and ensure airways safety. Finally, RCP led to low rates of closure complications, emphasizing that this concern should not withhold RCP, if indicated.
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http://dx.doi.org/10.1136/neurintsurg-2020-016725DOI Listing
October 2020

Endovascular treatment as the main approach for Spetzler-Martin grade III brain arteriovenous malformations.

J Neurointerv Surg 2021 Mar 28;13(3):241-246. Epub 2020 Sep 28.

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

Background: Because Spetzler-Martin (SM) grade III brain arteriovenous malformations (bAVMs) constitute a heterogeneous group of lesions with various combination of sizes, eloquence, and venous drainage patterns, their management is usually challenging. The aim of this study is to evaluate the clinical/imaging outcomes and the procedural safety of endovascular approach as the main treatment for the cure of SM grade III bAVMs.

Methods: In this retrospective study, prospectively collected data of SM grade III bAVMs treated by endovascular techniques between 2010 and 2018 at our hospital were reviewed. Patients older than 16 years with angiographic follow-up of at least 6 months after endovascular treatment were entered in the study. The patients had a mean follow-up of 12 months. The data were assessed for clinical outcome (modified Rankin Scale), permanent neurological deficit, post-operative complications, and optimal imaging outcome, defined by complete exclusion of AVM. The independent predictive variables of poor outcome or hemorrhagic complication were assessed using binary logistic regression.

Results: Sixty-five patients with 65 AVMs were included in the study. Mean age of the patients was 40.0±14.4. Most common presentation was hemorrhage (61.5%). The patients underwent one to eight endovascular procedures (median=2). Mean nidus diameter was 30.2±13.0. A complete obliteration of AVM was achieved in 57 patients (87.7%). Post-procedure significant hemorrhagic and ischemic complications were seen in 13 (20%) and five (7.7%) patients respectively, leading to five (7.7%) transient and four (6.2%) permanent neurological deficits. Eight patients (12.3%) experienced worsening of mRS after embolization. Ten patients (15.4%) had poor outcome (mRS 3-5) at follow-up and two (3%) died.

Conclusions: Endovascular treatment can achieve a high rate of complete exclusion of grade III AVM but may be associated (as in other treatment modalities) with significant important complications.

Clinical Trial Registration Number: NCT02879071.
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http://dx.doi.org/10.1136/neurintsurg-2020-016450DOI Listing
March 2021

Benefits and Safety of Periprocedural Heparin During Thrombectomy in Patients Contra-Indicated for Alteplase.

J Stroke Cerebrovasc Dis 2020 Oct 18;29(10):105052. Epub 2020 Jul 18.

Interventional Neuroradiology Unit, Fondation Rothschild Hospital, Paris, France; Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France; Université Paris Denis Diderot, Sorbonne Paris Cite, France.

Backround And Purpose: Role of peri-procedural heparin as an adjuvant treatment during mechanical thrombectomy (MT) for patients contra-indicated for alteplase remains a source of debate.

Methods: We included patients from the multicenter French register ETIS that underwent MT without administration of alteplase, and compared patients who received heparin during MT with patients who did not. Heparin impact on outcome were analyzed regarding final TICI score, NIHSS at day one, modified rankin scale (mRS) and intracranial hemorrhagic transformation on imaging at day one.

Results: Over 1031 patients, 751 were included between January 2015 and June 2018 in 6 different centers, and 223 (26.69%) received heparin. Heparin administration was associated with a significant deleterious effect on NIHSS at 24h [adjusted OR = 1.2; p = 0.02], mRS at 3 months [adjusted OR 1.58; p = 0.03], and on complete reperfusion [TICI 3 adjusted OR 0.68; p = 0.02]. Heparin administration was associated with a significant reduction of hemorrhagic transformation [adjusted OR 0.48; p = 0.00005].

Conclusions: Heparin administration during MT seems deleterious for reperfusion and functional outcome. Randomized trials are needed to identify the role of antithrombotic treatments, such as heparin, in the setting of acute ischemic stroke management.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.105052DOI Listing
October 2020

Early Brain Imaging Shows Increased Severity of Acute Ischemic Strokes With Large Vessel Occlusion in COVID-19 Patients.

Stroke 2020 11 19;51(11):3366-3370. Epub 2020 Aug 19.

Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France (S.E., H.R., F.D., S.H., S.S., G.C., J.-P.D., M.M., R.B., B.M., M.P.).

Background And Purpose: Reports are emerging regarding the association of acute ischemic strokes with large vessel occlusion and coronavirus disease 2019 (COVID-19). While a higher severity of these patients could be expected from the addition of both respiratory and neurological injury, COVID-19 patients with strokes can present with mild or none respiratory symptoms. We aimed to compare anterior circulation large vessel occlusion strokes severity between patients with and without COVID-19.

Methods: We performed a comparative cohort study between patients with COVID-19 who had anterior circulation large vessel occlusion and early brain imaging within 3 hours from onset, in our institution during the 6 first weeks of the COVID-19 outbreak and a control group admitted during the same calendar period in 2019.

Results: Twelve COVID-19 patients with anterior circulation large vessel occlusion and early brain imaging were included during the study period and compared with 34 control patients with anterior circulation large vessel occlusion and early brain imaging in 2019. Patients in the COVID-19 group were younger (=0.032) and had a history of diabetes mellitus more frequently (=0.039). Patients did not significantly differ on initial National Institutes of Health Stroke Scale nor time from onset to imaging (=0.18 and =0.6, respectively). Patients with COVID-19 had more severe strokes than patients without COVID-19, with a significantly lower clot burden score (median: 6.5 versus 8, =0.016), higher rate of multivessel occlusion (50% versus 8.8%, =0.005), lower DWI-ASPECTS (Diffusion-Weighted Imaging-Alberta Stroke Program Early CT Scores; median: 5 versus 8, =0.006), and higher infarct core volume (median: 58 versus 6 mL, =0.004). Successful recanalization rate was similar in both groups (=0.767). In-hospital mortality was higher in the COVID-19 patients' group (41.7% versus 11.8%, =0.025).

Conclusions: Early brain imaging showed higher severity large vessel occlusion strokes in patients with COVID-19. Given the massive number of infected patients, concerns should be raised about the coming neurovascular impact of the pandemic worldwide.
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http://dx.doi.org/10.1161/STROKEAHA.120.031011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7446979PMC
November 2020

Visual Field Defect Before and After Endovascular Treatment of Occipital Arteriovenous Malformations.

Neurosurgery 2020 Jul 6. Epub 2020 Jul 6.

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

Background: Occipital arteriovenous malformations (AVMs) carry a high risk of postoperative morbidity because of their anatomic relation to the visual cortex and optic radiations. Data regarding endovascular management of these lesions are scant.

Objective: To report our single-center experience with occipital AVMs, most of which were treated endovascularly, with a special interest for postoperative visual impairment.

Methods: From a prospective database, we assessed the clinical and radiological data of all patients with an occipital AVM managed between 1997 and 2018. The extension of the nidus to the primary visual cortex was assessed and correlated to the pre- and postintervention visual symptomatology. Modified Rankin Scale and visual fields (VFs) were assessed pre- and post-treatment and at the last follow-up.

Results: A total of 83 patients (47 males [56.6%]) with an occipital AVM were included in the study. Mean age at presentation was 33.5 ± 15.0 yr (min-max = 7-76). A total of 34 patients (41%) presented with hemorrhage related to the AVM. A total of 57 patients (68.7%) underwent endovascular treatment (EVT) alone, 20 (24.1%) underwent embolization and surgery, 3 (3.6%) underwent embolization and radiosurgery, and 3 (3.6%) were conservatively managed. A complete obliteration of the AVM was achieved in 53 patients (66.3%). A post-treatment worsening of the VF was found in 24 of the treated patients (30%), 3 patients (9%) for ruptured AVMs, and in 21 patients (46%) for unruptured AVMs. Morbidity rate was 3.7% and mortality rate was 2.5%.

Conclusion: EVT of occipital AVM carries a non-negligible rate of complications, especially regarding visual functions.
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http://dx.doi.org/10.1093/neuros/nyaa280DOI Listing
July 2020

Recent advances in devices for mechanical thrombectomy.

Expert Rev Med Devices 2020 Jul 25;17(7):697-706. Epub 2020 Jun 25.

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

Introduction: Acute ischemic stroke (AIS) secondary to the occlusion of a large intracranial vessel (LVO) is a recognized public health problem. Mechanical thrombectomy (MT) has gained full acceptance: Class A, Level 1 in 2015 after the publication of numerous trials. Further meta-analyses have scrutinized extensively those results and international recommendations and guidelines have been given. Nevertheless, multiple-specific points remain to be clarified and are or will be under investigations.

Areas Covered: This review of the most recent literature (mostly publications after 2015) will cover the actual common practice for MT, especially focusing on the devices available (and their validation), how they are commonly used, relate the most relevant results, and detail some emerging technologies.

Expert Opinion: The authors will express their own view on the current practice and emphasize on the areas where questions remain and hypothesize what specific improvements are necessary and prone to occur.
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http://dx.doi.org/10.1080/17434440.2020.1784004DOI Listing
July 2020

Direct aspiration stroke thrombectomy: a comprehensive review.

J Neurointerv Surg 2020 Nov 12;12(11):1099-1106. Epub 2020 Jun 12.

Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France

Mechanical thrombectomy is now the standard of care for acute ischemic stroke patients with large vessel occlusions, and can be performed with several devices and techniques. One of these techniques, direct aspiration (DA), consists of navigating a large-bore catheter up to the face of the clot and initiating forceful suction. This comprehensive review has three objectives: (1) to describe the direct aspiration technique; (2) to present the available evidence regarding predictive factors of DA success and performance compared with other techniques; and (3) to discuss the forthcoming improvements in distal aspiration.
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http://dx.doi.org/10.1136/neurintsurg-2019-015508DOI Listing
November 2020

Treatment of Acute Ischemic Stroke due to Large Vessel Occlusion With COVID-19: Experience From Paris.

Stroke 2020 08 29;51(8):2540-2543. Epub 2020 May 29.

From the Interventional Neuroradiology Department, Rothschild Foundation Hospital, Paris, France.

Background And Purpose: Higher rates of strokes have been observed in patients with coronavirus disease 2019 (COVID-19), but data regarding the outcomes of COVID-19 patients suffering from acute ischemic stroke due to large vessel occlusion (LVO) are lacking. We report our initial experience in the treatment of acute ischemic stroke with LVO in patients with COVID-19.

Methods: All consecutive patients with COVID-19 with acute ischemic stroke due to LVO treated in our institution during the 6 first weeks of the COVID-19 outbreak were included. Baseline clinical and radiological findings, treatment, and short-term outcomes are reported.

Results: We identified 10 patients with confirmed COVID-19 treated for an acute ischemic stroke due to LVO. Eight were men, with a median age of 59.5 years. Seven had none or mild symptoms of COVID-19 at stroke onset. Median time from COVID-19 symptoms to stroke onset was 6 days. All patients had brain imaging within 3 hours from symptoms onset. Five patients had multi-territory LVO. Five received intravenous alteplase. All patients had mechanical thrombectomy. Nine patients achieved successful recanalization (mTICI2B-3), none experienced early neurological improvement, 4 had early cerebral reocclusion, and a total of 6 patients (60%) died in the hospital.

Conclusions: Best medical care including early intravenous thrombolysis, and successful and prompt recanalization achieved with mechanical thrombectomy, resulted in poor outcomes in patients with COVID-19. Although our results require further confirmation, a different pharmacological approach (antiplatelet or other) should be investigated to take in account inflammatory and coagulation disorders associated with COVID-19.
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http://dx.doi.org/10.1161/STROKEAHA.120.030574DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7282400PMC
August 2020

Effect of Steady and Dynamic Blood Pressure Parameters During Thrombectomy According to the Collateral Status.

Stroke 2020 04 11;51(4):1199-1206. Epub 2020 Mar 11.

From the Interventional Neuroradiology Department, Fondation Rothschild, Paris, France (B.M., J.-P.D., W.B., R.F., H.R., S.S., G.C., S.E., R.B., M.P., M.M.).

Background and Purpose- Guidelines regarding blood pressure (BP) management during endovascular therapy (EVT) for anterior circulation strokes are questionable since the optimal BP target is a matter of debate. To evaluate the importance of hemodynamic control during EVT, we investigated the impact of dynamic and steady BP parameters during EVT on functional outcome (part 1) and according to the collateral status (CS; part 2). Methods- We performed a post hoc analysis of the ASTER trial (Contact Aspiration Versus Stent Retriever for Successful Recanalization). BP was measured noninvasively during EVT and CS assessed on the angiographic run before EVT. We studied dynamic BP parameter using BP variability (coefficient of variation) and steady BP parameter (hypotension time defined as systolic BP <140 mm Hg and mean arterial pressure <90 mm Hg). The primary outcome was favorable outcome defined as a 3-month modified Rankin Scale score between 0 and 2. Results- Among the 381 patients of the ASTER study, 172 patients were included in part 1 and 159 in part 2. Systolic BP, diastolic BP, and mean arterial pressure variability were negatively associated with favorable outcome regardless of CS: per 10-unit increase, adjusted odds ratios were 0.45 (95% CI, 0.20-0.98), 0.37 (95% CI, 0.19-0.72), and 0.35 (95% CI, 0.16-0.76), respectively. According to CS, the hypotension time with periprocedural mean arterial pressure <90 mm Hg was negatively associated with favorable outcome in patients with poor CS (adjusted odds ratio, 0.88 [95% CI, 0.72-1.09]) but not in patients with good CS (adjusted odds ratio, 1.24 [95% CI, 0.91-1.67]; =0.047). Conclusions- The CS did not modify the association between dynamic parameters and functional outcomes, but some findings suggest that the CS modifies the association between steady parameter and functional outcomes. Hypotension time according to the CS was not statistically predictive of poor outcomes but displayed a trend toward worse outcomes for patients with poor CS only.
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http://dx.doi.org/10.1161/STROKEAHA.119.026769DOI Listing
April 2020

Predictors of Parenchymal Hematoma After Mechanical Thrombectomy: A Multicenter Study

Stroke 2019 09 22;50(9):2364-2370. Epub 2019 Jul 22.

Interventional Neuroradiology Unit, Fondation Rothschild Hospital, Paris, France (W.B., R.F., J.-P.D., K.Z., B.M., H.R., G.C., S.S., S.E., M.M., M.P., R.B.).

Background And Purpose: Parenchymal hematoma (PH) is a rare but dreadful complication of acute ischemic stroke with unclear underlying mechanisms. We aimed to study the incidence and predictors of PH after mechanical thrombectomy.

Methods: Data from a prospective observational multicenter registry was screened to identify acute ischemic stroke patients with an anterior circulation large vessel occlusion who underwent mechanical thrombectomy. Clinical, imaging, and procedural characteristics were used for the analysis, including brain imaging systematically performed at 24 hours. PH occurrence was assessed according to ECASS (European Collaborative Acute Stroke Study) criteria. Univariate and multivariable analyses were performed to identify predictors of PH.

Results: A total of 1316 patients were included in the study. PH occurred in 153 out of 1316 patients (11.6%) and was associated with a lower rate of favorable outcome and increased mortality. On multivariable analysis, age (per 1 year increase, odds ratio [OR], 1.01; 95% CI, 1.00–1.03; P=0.05), current smoking (OR, 2.02; 95% CI, 1.32–3.09; P<0.01), admission Alberta Stroke Program Early CT Score (per a decrease of 1 point, OR, 1.70; 95% CI, 1.18–2.44; P<0.01), general anesthesia (OR, 1.98; 95% CI, 1.36–2.90; P<0.001), angiographic poor collaterals (OR, 2.13; 95% CI, 1.36–3.33; P<0.001) and embolization in new territory (OR, 2.94; 95% CI, 1.70–5.10; P<0.001) were identified as independent predictors of PH.

Conclusions: PH occurred at a rate of 11.6% after mechanical thrombectomy, with high morbidity and mortality. Our study identified clinical, radiological, and procedural predictors of PH occurrence that can serve as the focus of future periprocedural management studies with the aim of reducing its occurrence.
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http://dx.doi.org/10.1161/STROKEAHA.118.024512DOI Listing
September 2019

Double stent assisted coiling of intracranial bifurcation aneurysms in Y and X configurations with the Neuroform ATLAS stent: immediate and mid term angiographic and clinical follow-up.

J Neurointerv Surg 2019 Dec 27;11(12):1239-1242. Epub 2019 Jul 27.

Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France.

Purpose: Self-expandable stents have broadened the spectrum of endovascular treatment of intracranial aneurysms. However, procedures involving double stenting in Y/X configurations carry a relatively high risk of procedural complications. The Neuroform ATLAS, the evolution of Neuroform EZ, is a nitinol self-expanding hybrid/open cell stent which can be delivered through a low profile 0.017 inch catheter. We present our experience in the treatment of intracranial aneurysms with this stent in Y and X configurations.

Materials And Methods: We prospectively maintained a database from consecutive patients who underwent double stent assisted coiling with the Neuroform ATLAS, from July 2015 to February 2019. Clinical and angiographic results were analyzed.

Results: 55 patients harboring 55 bifurcation aneurysms were treated with double stenting: 52 'Y' configurations, 3 'X' configurations. Deployment was successful in all cases. Post-treatment control angiography showed complete occlusion in 33 cases (60%), neck remnant in 8 cases (14.5%), and incomplete occlusion in 14 cases (25.4%). The overall symptomatic periprocedural complication rate was 12.7%. 38 aneurysms underwent follow-up (69%, mean duration 16 months): 33 aneurysms (87%) were completely occluded, 3 aneurysms (8%) had a neck remnant, and 2 aneurysms (5%) were incompletely occluded.

Conclusion: The Neuroform ATLAS is an effective device for treatment of bifurcation aneurysms, allowing good conformability, a high level of navigability, and easy mesh crossing to perform Y/X stenting procedures. The rate of procedural complications remains non-negligible, and an indication for a double stenting procedure should be carefully discussed in a multidisciplinary meeting.
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http://dx.doi.org/10.1136/neurintsurg-2019-015175DOI Listing
December 2019

Neutrophil count predicts poor outcome despite recanalization after endovascular therapy.

Neurology 2019 07 25;93(5):e467-e475. Epub 2019 Jun 25.

From the Departments of Interventional Neuroradiology (W.B., J.-P.D., R.F., B.M., D.B., S.E., G.C., S.S., H.R., M.P., M.M., R.B.), Clinical Research (K.Z., M.B.M.), Neurology (C.S.), and Intensive Care (G.T.), Rothschild Foundation Hospital; Université Paris Diderot (J.-P.D., M.M.), Sorbonne Paris Cite; Laboratory of Vascular Translational Science (J.-P.D., M.P., M.M., R.B.), U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Paris; and Department of Clinical Research (M.K.), CHRU Lille, Lille, France.

Objective: To identify early prognostic factors of poor clinical outcome in patients treated by endovascular therapy (EVT) with successful recanalization.

Methods: We reviewed our monocentric prospectively collected EVT database of patients with anterior circulation acute ischemic stroke (AIS) from January 2016 to April 2018 who had achieved successful recanalization (Thrombolysis in Cerebral Infarction score ≥ 2b) at the end of the procedure. A poor outcome was defined as a 3-month modified Rankin Scale score of ≥3.

Results: A total of 324 patients were included, among whom 186 (57.4%) had a poor outcome. Multivariate logistic regression indicated that age (per 10-year increase, odds ratio [OR] 1.34, 95% confidence interval [CI] 1.12-1.60), baseline NIH Stroke Scale score (per 1-unit increase, OR 1.09, 95% CI 1.04-1.15), initial infarct volume (per a log+1 increase, OR 1.34, 95% CI 1.05-1.67), blood glucose level (per a log+1 increase, OR 2.60, 95% CI 1.01-6.66), and neutrophil count (per 1,000-unit increase, OR 1.08, 95% CI 1.01-1.17) were all associated with poor clinical outcome.

Conclusions: In addition to baseline severe AIS criteria, high neutrophil count and high blood glucose, known from experimental studies to be associated with downstream microvascular thromboinflammation, are independently associated with poor outcome. These findings support a deleterious role of thromboinflammation in patient recovery despite successful recanalization.
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http://dx.doi.org/10.1212/WNL.0000000000007859DOI Listing
July 2019

Visual assessment of diffusion weighted imaging infarct volume lacks accuracy and reliability.

J Neurointerv Surg 2019 Sep 2;11(9):947-954. Epub 2019 Feb 2.

Unit of Clinical Research, Fondation Rothschild Hospital, Paris, France.

Purpose: The DAWN trial (Diffusion weighted imaging or CT perfusion Assessment with clinical mismatch in the triage of Wake-up and late presenting strokes undergoing Neurointervention with Trevo) has demonstrated the benefits of thrombectomy in patients with unknown or late onset strokes, using automated software (RAPID) for measurement of infarct volume. Because RAPID is not available in all centers, we aimed to assess the accuracy and repeatability of visual infarct volume estimation by clinicians and the consequences for thrombectomy decisions based on the DAWN criteria.

Materials And Methods: 18 physicians, who routinely depend on MRI for acute stroke imaging, assessed 32 MR scans selected from a prospective databaseover two independent sessions. Raters were asked to visually estimate the diffusion weighted imaging (DWI) infarct volume for each case. Sensitivity, specificity, and accuracy of the estimated volumes were compared with the available RAPID measurements for various volume cut-off points. Thrombectomy decisions based on DAWN criteria with RAPID measurements and raters' visual estimates were compared. Inter-rater and intra-rater agreement was measured using kappa statistics.

Results: The mean accuracy of raters was <90% for all volume cut-points. Inter-rater agreement was below substantial for each DWI infarct volume cut-off points. Intra-rater agreement was substantial for 55-83% of raters, depending on the selected cut-off points. Applying DAWN criteria with visual estimates instead of RAPID measurements led to 19% erroneous thrombectomy decisions, and showed a lack of reproducibility.

Conclusion: The visual assessment of DWI infarct volume lacks accuracy and repeatability, and could lead to a significant number of erroneous decisions when applying the DAWN criteria.
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http://dx.doi.org/10.1136/neurintsurg-2018-014613DOI Listing
September 2019

Gadolinium-Enhanced Extracranial MRA Prior to Mechanical Thrombectomy Is Not Associated With an Improved Procedure Speed.

Front Neurol 2018 9;9:1171. Epub 2019 Jan 9.

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

To assess whether performing a pre-intervention gadolinium-enhanced extracranial magnetic resonance angiogram (MRA) in addition to intracranial vascular imaging is associated with improved thrombectomy time metrics. Consecutive patients treated by MT at a large comprehensive stroke center between January 2012 and December 2017 who were screened using pre-intervention MRI were included. Patients characteristics and procedural data were collected. Univariate and multivariate analysis were performed to compare MT speed, efficacy, complications, and clinical outcomes between patients with and without pre-intervention gadolinium-enhanced extracranial MRA. A total of 912 patients were treated within the study period, including 288 (31.6%) patients with and 624 (68.4%) patients without extracranial MRA. Multivariate analysis showed no significant difference between groups in groin puncture to clot contact time (RR = 0.93 [0.85-1.02], = 0.14) or to recanalization time (RR = 0.92 [0.83-1.03], = 0.15), rates of successful recanalization (defined as a mTICI 2b or 3, RR = 0.93 [0.62-1.42], = 0.74), procedural complications (RR = 0.81 [0.51-1.27], = 0.36), and good clinical outcome (defined by a mRS ≤ 2 at 3 months follow-up, RR = 1.05 [0.73-1.52], = 0.79). Performing a pre-intervention gadolinium-enhanced extracranial MRA in addition to non-contrast intracranial MRA at stroke onset does not seem to be associated with a delay or shortening of procedure times.
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http://dx.doi.org/10.3389/fneur.2018.01171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6333645PMC
January 2019

Prognostic Significance of Pulse Pressure Variability During Mechanical Thrombectomy in Acute Ischemic Stroke Patients.

J Am Heart Assoc 2018 09;7(18):e009378

1 Department of Interventional Neuroradiology Fondation Rothschild Paris France.

Background Studies on the role of blood pressure ( BP ) variability specifically during mechanical thrombectomy ( MT ) are sparse and limited. Moreover, pulse pressure ( PP ) has not been considered as a potent hemodynamic parameter to describe BP variability during MT . We assessed the impact of PP variability on functional outcome in acute ischemic stroke patients with large vessel occlusion during MT . Methods and Results Acute ischemic stroke patients presenting with large vessel occlusion from January 2012 to June 2016 were included. BP data during MT were prospectively collected in the ETIS (Endovascular Treatment in Ischemic Stroke) registry. Logistic regression models were used to assess the association between PP coefficients of variation and functional outcome at 3 months (modified Rankin Scale). Among the 343 included patients, PP variability was significantly associated with worse 3-month modified Rankin Scale in univariable (odds ratio [OR] =1.56, 95% confidence interval [CI]: 1.24-1.96 per 1-unit increase, P=0.0002) and multivariable ordinal logistic regression (adjusted OR =1.40, 95% CI : 1.09-1.79, P=0.008). PP variability was also associated with unfavorable outcome (modified Rankin Scale 3-6) in univariable ( OR =1.53, 95% CI : 1.17-2.01, P=0.002) and multivariable analysis (adjusted OR =1.42, 95% CI : 1.02-1.98, P=0.04). There was an association between PP variability and 3-month all-cause mortality in univariable analysis ( OR = 1.37, 95% CI : 1.01-1.85 per 1-unit increase of the coefficient of variation of the PP , P=0.04), which did not remain significant after adjustment for potential confounders. Conclusions PP variability during MT is an independent predictor of worse clinical outcome in acute ischemic stroke patients. These findings support the need for a close monitoring of BP variability during MT . Whether pharmacological interventions aiming at reducing BP variability during MT could impact functional outcome needs to be determined.
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http://dx.doi.org/10.1161/JAHA.118.009378DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6222945PMC
September 2018

Anterior cerebral artery embolism during thrombectomy increases disability and mortality.

J Neurointerv Surg 2018 Nov 8;10(11):1057-1062. Epub 2018 May 8.

Departement of Interventional Neuroradiology, Rothschild Foundation, Paris, France.

Objective: During thrombectomy, thromboembolic migration in previously unaffected territory may occur and is not systematically notified. We report our data on the incidence, predictors, and clinical outcome of anterior cerebral artery emboli (ACAE).

Methods: From a prospectively collected thrombectomy database of consecutive patients with anterior circulation stroke between January 2012 and December 2016, 690 angiographic images were analyzed to assess ACAE. The primary outcome was a favorable outcome, defined as a 3 month modified Rankin Scale score of 0-2 or equal to the pre-stroke score.

Results: ACAE occurred in 65 patients (9.4%; 95% CI 7.2% to 11.6%). Internal carotid artery occlusion (tandem or terminal), Alberta Stroke Program Early CT Score <7, increasing number of passes, and use of stent retriever alone (compared with distal aspiration alone or combined with stent retriever) were found to be independent predictors of ACAE. Compared with patients without ACAE, patients with ACAE had lower rates, with an adjusted OR (95% CI) of 0.48 (0.25 to 0.92; P=0.027) for favorable outcome and 0.49 (0.25 to 0.96; P=0.038) for early neurologic improvement. ACAE was significantly associated with a higher mortality (adjusted OR 1.93; 95% CI 1.03 to 3.61; P=0.039) and intracranial hemorrhagic complications (adjusted OR 2.45; 95% CI 1.33 to 4.47; P=0.004). Despite a successful reperfusion modified Thrombolysis in Cerebral Infarction score of 2b-3 at the end of the procedure, a favorable outcome was reached in 30% of patients with ACAE compared with 52.4% in the other patients (OR 0.39; 95% CI 0.19 to 0.78; P=0.008).

Conclusions: Procedural ACAE was not an uncommon condition, and was associated with increased mortality and disability rates, regardless of the success of reperfusion.
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http://dx.doi.org/10.1136/neurintsurg-2018-013793DOI Listing
November 2018

May the Inferior Petrosal Sinus Recanalization During Endovascular Treatment for Carotid-Cavernous Fistulas Increase the Risk of Sixth Nerve Palsy?

World Neurosurg 2018 Aug 3;116:e246-e251. Epub 2018 May 3.

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

Background: Sixth nerve palsy is a common complication of endovascular treatment for carotid-cavernous fistulas (CCF). Two hypotheses are evoked: the spontaneous venous congestion into the cavernous sinus and the direct compression of the nerve by the embolic agent into the cavernous sinus. Nevertheless, the evidence is still uncertain. Knowing the vicinity of the sixth nerve with the inferior petrosal sinus (IPS) in the Dorello canal, we hypothesized that the recanalization of the IPS increased the risk of nerve damage.

Methods: We analyzed a prospective database of patients treated for CCFs from March 2009 to April 2016. We excluded patients who did not need treatment, cases of high-flow CCF, and patients lost to follow-up, obtaining a homogeneous population of 82 patients with indirect CCFs. This population was divided in 2 groups: patients without new-onset/worsening of sixth nerve palsy and patients with this postprocedural complication.

Results: Our main endpoints were the potential differences between patients with or without recanalization of IPS and between those who underwent or not an embolization with Onyx-18. We did not find any statistically meaningful difference between the 2 groups concerning the necessity of IPS recanalization (P > 0.999, odds ratio 0.97, 95% confidence interval 0.32-2.96) or with the use of Onyx-18 as an embolic agent (P = 0.56; odds ratio 1.41, 95% confidence interval 0.41-2.45).

Conclusions: The recanalization of a thrombosed IPS does not increase the risk of procedural sixth nerve damage. The initial injury seems to relate with development/worsening of a sixth nerve palsy.
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http://dx.doi.org/10.1016/j.wneu.2018.04.182DOI Listing
August 2018

Predictors of favorable outcome after mechanical thrombectomy for anterior circulation acute ischemic stroke in octogenarians.

J Neuroradiol 2018 Jul 20;45(4):211-216. Epub 2018 Feb 20.

Department of Interventional Neuroradiology, Rothschild Foundation, 25 rue Manin, 75940 Paris, France.

Introduction: Mechanical thrombectomy for anterior circulation large vessel occlusion (LVO) improves functional outcome at three months. This therapeutic approach is the new gold standard, with a benefit being also observed in elderly patients. However, data are limited in this heterogeneous and fragile population. The objectives of this study were, first, to describe outcome after mechanical thrombectomy in a representative group of patients over 80. Second, to evaluate factors associated with a favorable functional outcome after thrombectomy for anterior circulation LVO in elderly patients (aged≥80 years).

Methods: A total of 169 patients with anterior circulation LVO referred for an endovascular treatment were included. Primary outcome evaluated functional outcome at three months. Multivariable analysis was performed to identify prognostic factors in elderly patients with pre-stroke mRS≤3.

Results: Overall, 25.34% of patients (43/169) were functionally independent at three months (mRS≤2) and 16.57% (28/169) had a moderate functional disability (mRS=3). Mortality rate was 33.14% (56/169). At 24h, 7.1% of patients (12/169) had symptomatic hemorrhage. Male gender (P=0.033), low initial NIHSS (P=0.037), higher DWI-ASPECTS (P=0.022) and use of intravenous thrombolysis (IVT) (P=0.0193) were associated with a better functional outcome.

Conclusions: There is no reason to withhold mechanical thrombectomy on the basis of age alone. Small infarct core, low NIHSS, male gender and use of IVT are associated with a better functional outcome.
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http://dx.doi.org/10.1016/j.neurad.2018.01.055DOI Listing
July 2018

Thrombus Neutrophil Extracellular Traps Content Impair tPA-Induced Thrombolysis in Acute Ischemic Stroke.

Stroke 2018 03 8;49(3):754-757. Epub 2018 Feb 8.

From the Université Paris Diderot, Sorbonne Paris Cite, Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), France (C. Ducroux, L.D.M., S.L., S.D., W.B., C. Deschildre, R.B., J.-B.M., M.P., M.M., B.H.-T.-N., J.-P.D.); Department of Interventional Neuroradiology (W.B., R.B., H.R., G.C., S.S., R.F., M.P., M.M., J.-P.D.) and Department of Clinical Research (M.B.M., L.S.), Rothschild Foundation Hospital, Paris, France; and DHU NeuroVasc, Paris, France (M.M.).

Background And Purpose: Neutrophil Extracellular Traps (NETs) are DNA extracellular networks decorated with histones and granular proteins produced by activated neutrophils. NETs have been identified as major triggers and structural factors of thrombosis. A recent study designated extracellular DNA threads from NETs as a potential therapeutic target for improving tissue-type plasminogen activator (tPA)-induced thrombolysis in acute coronary syndrome. The aim of this study was to assess the presence of NETs in thrombi retrieved during endovascular therapy in patients with acute ischemic stroke (AIS) and their impact on tPA-induced thrombolysis.

Methods: We analyzed thrombi from 108 AIS patients treated with endovascular therapy. Thrombi were characterized by hematoxylin/eosin staining, immunostaining, and ex vivo enzymatic assay. Additionally, we assessed ex vivo the impact of deoxyribonuclease 1 (DNAse 1) on thrombolysis of AIS thrombi.

Results: Histological analysis revealed that NETs contributed to the composition of all AIS thrombi especially in their outer layers. Quantitative measurement of thrombus NETs content was not associated with clinical outcome or AIS pathogenesis but correlated significantly with endovascular therapy procedure length and device number of passes. Ex vivo, recombinant DNAse 1 accelerated tPA-induced thrombolysis, whereas DNAse 1 alone was ineffective.

Conclusions: This study suggests that thrombus NETs content may be responsible for reperfusion resistance, including mechanical or pharmacological approaches with intravenous tPA, irrespectively of their etiology. The efficacy of a strategy involving an administration of DNAse 1 in addition to tPA should be explored in the setting of AIS.

Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02907736.
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http://dx.doi.org/10.1161/STROKEAHA.117.019896DOI Listing
March 2018

DWI-ASPECTS (Diffusion-Weighted Imaging-Alberta Stroke Program Early Computed Tomography Scores) and DWI-FLAIR (Diffusion-Weighted Imaging-Fluid Attenuated Inversion Recovery) Mismatch in Thrombectomy Candidates: An Intrarater and Interrater Agreement Study.

Stroke 2018 01 30;49(1):223-227. Epub 2017 Nov 30.

From the Interventional Neuroradiology Unit (R.F., C.D., V.C., D.B., W.B., B.M., H.R., G.C., S.S., J.-P.D., M.M., R.B., M.P.), Diagnostic Radiology Unit (A.L., L.D., D.C., P.K.), Neurovascular Unit (C.S., M.O., D.W.-L.), and Research and Biostatistics Unit (M.B.M., I.A., K.Z.), Fondation Rothschild Hospital, Paris, France; HSHS Neuroscience Center, HSHS St. John's Hospital, Springfield, IL (N.K.); Neuroradiology Unit, Henri Mondor Hospital, Creteil, France (E.K., A.B.); Radiology Unit, Cochin Hospital, Paris, France (H.K.); Neurovascular Unit, Foch Hospital, Suresnes, France (B.L., A.W.); and Interventional Neuroradiology Research Laboratory, CHUM Research Center, Notre-Dame Hospital, Montreal, Quebec, Canada (J.R.).

Background And Purpose: We aimed to study the intrarater and interrater agreement of clinicians attributing DWI-ASPECTS (Diffusion-Weighted Imaging-Alberta Stroke Program Early Computed Tomography Scores) and DWI-FLAIR (Diffusion-Weighted Imaging-Fluid Attenuated Inversion Recovery) mismatch in patients with acute ischemic stroke referred for mechanical thrombectomy.

Methods: Eighteen raters independently scored anonymized magnetic resonance imaging scans of 30 participants from a multicentre thrombectomy trial, in 2 different reading sessions. Agreement was measured using Fleiss κ and Cohen κ statistics.

Results: Interrater agreement for DWI-ASPECTS was slight (κ=0.17 [0.14-0.21]). Four raters (22.2%) had a substantial (or higher) intrarater agreement. Dichotomization of the DWI-ASPECTS (0-5 versus 6-10 or 0-6 versus 7-10) increased the interrater agreement to a substantial level (κ=0.62 [0.48-0.75] and 0.68 [0.55-0.79], respectively) and more raters reached a substantial (or higher) intrarater agreement (17/18 raters [94.4%]). Interrater agreement for DWI-FLAIR mismatch was moderate (κ=0.43 [0.33-0.57]); 11 raters (61.1%) reached a substantial (or higher) intrarater agreement.

Conclusions: Agreement between clinicians assessing DWI-ASPECTS and DWI-FLAIR mismatch may not be sufficient to make repeatable clinical decisions in mechanical thrombectomy. The dichotomization of the DWI-ASPECTS (0-5 versus 0-6 or 0-6 versus 7-10) improved interrater and intrarater agreement, however, its relevance for patients selection for mechanical thrombectomy needs to be validated in a randomized trial.
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http://dx.doi.org/10.1161/STROKEAHA.117.019508DOI Listing
January 2018

Mechanical Thrombectomy for Minor and Mild Stroke Patients Harboring Large Vessel Occlusion in the Anterior Circulation: A Multicenter Cohort Study.

Stroke 2017 12 31;48(12):3274-3281. Epub 2017 Oct 31.

From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch Hospital, Versailles Saint-Quentin-en-Yvelines University, Suresnes, France; Univ. Lille, CHU Lille, EA 2694-Santé Publique: Épidémiologie et Qualité des Soins, France (J.L., A.D.); and Department of Interventional Neuroradiology (H.R., G.C., S.S., J.-P.D., M.M., M.P., R.B.) and Department of Neurology (M.O.), Rothschild Foundation, Paris, France.

Background And Purpose: Proximal large vessel occlusion (LVO) is present in up to 30% of minor strokes. The effectiveness of mechanical thrombectomy (MT) in the subgroup of minor stroke with LVO in the anterior circulation is still open to debate. Data about MT in this subgroup of patients are sparse, and their optimal management has not yet been defined. The purpose of this multicenter cohort study was to evaluate the effectiveness of MT in patients experiencing acute ischemic stroke (AIS) because of LVO in the anterior circulation, presenting with minor-to-mild stroke symptoms (National Institutes of Health Stroke Scale score of <8).

Methods: Multicenter cohort study involving 4 comprehensive stroke centers having 2 therapeutic approaches (urgent thrombectomy associated with best medical treatment [BMT] versus BMT first and MT if worsening occurs) about management of patients with minor and mild acute ischemic stroke harboring LVO in the anterior circulation. An intention-to-treat analysis was conducted. The primary end point was the rate of excellent outcome defined as the achievement of a modified Rankin Scale score of 0 to 1 at 3 months.

Results: Three hundred one patients were included, 170 with urgent MT associated with BMT, and 131 with BMT alone as first-line treatment. Patients treated with MT were younger, more often received intravenous thrombolysis, and had shorter time to imaging. Twenty-four patients (18.0%) in the medical group had rescue MT because of neurological worsening. Overall, excellent outcome was achieved in 64.5% of patients, with no difference between the 2 groups. Stratified analysis according to key subgroups did not find heterogeneity in the treatment effect size.

Conclusions: Minor-to-mild stroke patients with LVO achieved excellent and favorable functional outcomes at 3 months in similar proportions between urgent MT versus delayed MT associated with BMT. There is thus an urgent need for randomized trials to define the effectiveness of MT in this patient subgroup.
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http://dx.doi.org/10.1161/STROKEAHA.117.018113DOI Listing
December 2017

Augmented 3D venous navigation for neuroendovascular procedures.

J Neurointerv Surg 2018 Jul 11;10(7):649-652. Epub 2017 Oct 11.

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

Background: Endovascular venous access is increasingly used for the treatment of many cerebrovascular diseases. The quality of venous roadmapping through arterial injection can be problematic because of contrast media dilution, slow flow velocity, and unilateral opacification of the venous system.

Objective: To describe our experience with the VesselNavigator (Philips Healthcare, Best, The Netherlands) in performing live 3D roadmapping for intracranial venous procedures.

Material And Methods: Live 3D roadmapping is an image-processing technique that allows dynamic roadmapping of vessels with immediate adaptation to the C-arm movements without the need for contrast injection. For this purpose, 3D MR venography is overlaid on live fluoroscopy images after semiautomatic coregistration. The technique was applied to cases of idiopathic venous stenosis and arteriovenous fistula.

Results: The process of coregistration was performed by the principal operator in <5 min, just before the treatment. The accuracy was controlled peroperatively and was judged satisfactory. Three illustrative cases demonstrate the use of this software for venous navigation and pressure measurement (case 1), venous stenting (case 2), and transvenous embolization of a carotid-cavernous fistula (case 3).

Conclusion: Our preliminary experience suggests that it is a feasible and safe technique for intracranial venous navigation and procedures. The potential lowering of overall radiation dose and contrast media use needs to be verified with further studies.
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http://dx.doi.org/10.1136/neurintsurg-2017-013365DOI Listing
July 2018