Publications by authors named "Jean-Francois Hak"

24 Publications

  • Page 1 of 1

Evaluation of Multiple Embolic Agents for Embolization of the Superior Rectal Artery in an Animal Model.

Cardiovasc Intervent Radiol 2022 Jan 5. Epub 2022 Jan 5.

Department of Interventional Radiology, Marseille Public University Hospital System (APHM), La Timone University Hospital, 264 Rue Saint Pierre, 13385, Marseille, Cedex 05, France.

Objective: To prospectively compare the safety of transcatheter embolization of superior rectal arteries in healthy pigs with multiple agents such as coils, spheres and liquids.

Materials And Methods: Nine adult domestic pigs (three males, mean weight: 60 kg [50-70]) were randomly assigned to the embolization group: copolymer of ethylene vinyl alcohol (EVOH)-Onyx® (group 1, n = 3), microspheres 500 µ (group 2, n = 3), 2-mm micro-coils (group 3, n = 3). After a selective angiogram has been acquired, the embolic agent was infused at the distal part of rectal arteries. An angio-CT was performed before and after each embolization. After one week, angiography was repeated prior to euthanasia. At necropsy, the anorectal juncture was removed for histopathologic examination.

Results: At necropsy, 100% of animals embolized with Onyx developed a significant necrosis zone of the distal part of the rectum. Histological examination revealed a mural infarction. For the micro-coil and microsphere groups, gross examination of the intestines did not reveal any evidence of ischaemia. The coils were found in the distal arterial vasculature of the meso-rectum, allowing a downstream revascularization by collaterals. The microspheres and onyx in the rectal wall, more distally.

Conclusion: Microspheres appear to induce fewer histologic complications than the liquid embolic agent and provide a more distal occlusion than micro-coils. These results suggest that, for superior rectal artery embolization, a super-selective embolization using spheres in human clinical conditions should be more effective and as safe as coil embolization. EVOH might be an unsafe embolization agent for haemorrhoids.
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http://dx.doi.org/10.1007/s00270-021-03041-7DOI Listing
January 2022

Upfront and Repeated Gamma-Knife Radiosurgery for Small (≤5 mL) Unruptured Brain Arteriovenous Malformation: A Cohort of 249 Consecutive Patients.

World Neurosurg 2021 Nov 27. Epub 2021 Nov 27.

Department of Functional Neurosurgery, Timone University Hospital, Aix-Marseille University, Marseille, France.

Objective: According to A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA), conservative treatment seems to be superior to any intervention for unruptured brain arteriovenous malformations (AVMs). This study aims to evaluate safety and efficacy of upfront and repeated Gamma-Knife Radiosurgery (GKRS) in patients harboring small AVMs fulfilling the inclusion criteria of ARUBA.

Methods: A retrospective study was conducted to evaluate outcomes of unruptured naive brain AVM with a volume ⩽ 5 mL eligible to ARUBA treated by GKRS with at least 3 years of follow-up.

Results: From 1992 to 2014, 249 patients fulfilled the inclusion criteria of this study. The median age was 36 years (range: 18-78 years). The median treated volume of the nidus was 1.3 mL (range: 0.4-5 mL) and 63% of the AVM were in eloquent areas. Radiosurgery-based AVM score was 1-1.8 (76%), the Spetzler-Martin grade was II-III (73%), and the Virginia Radiosurgery AVM scale was ≤1 point (75%). The overall AVM obliteration rate was 77.1% after up to 3 GKRS sessions. The median dose at the margin was 24 Gy (15-25 Gy) and the median follow-up was 45 months (range: 36-205 months). Eight patients (3.2%) experienced hemorrhage after GKRS, corresponding to a post-GKRS hemorrhage annual rate of 1.03%. Permanent symptomatic radio-induced changes rate was 2% (4 increased seizures, 1 neurologic deficit).

Conclusions: The very low toxicity rate and the high occlusion rate suggest in favor of upfront and repeated GKRS for unruptured small AVMs (⩽5 mL).
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http://dx.doi.org/10.1016/j.wneu.2021.11.091DOI Listing
November 2021

Relevance of Brain Regions' Eloquence Assessment in Patients With a Large Ischemic Core Treated With Mechanical Thrombectomy.

Neurology 2021 11 14;97(20):e1975-e1985. Epub 2021 Oct 14.

From INSERM U1266 (B.K., J.B., W.B.H., C.O., O.N.), Institut of Psychiatry and Neuroscience (IPNP), UMR_S1266, INSERM, Université de Paris, GHU Paris Psychiatrie et Neurosciences, Site Sainte-Anne; Diagnostic and Therapeutic Neuroradiology (K.J., G.B.), CHRU de Tours; Department of Interventional Neuroradiology (C.D., D.D.E.), University Hospital Center of Montpellier, Gui de Chauliac Hospital; Department of Diagnostic and Therapeutic Neuroradiology, CHRU-Nancy (F.Z., B.G.), IADI, INSERM U1254 (F.Z., B.G.), and ADI U1254 (F.Z., G.B.) Université de Lorraine, Nancy; Department of Diagnostic and Interventional Neuroradiology (J.-F.H.) and Neurology Department (C.P.), APHM, Cedex, Timone Hospital, Aix Marseille University; Department of Diagnostic and Interventional Neuroradiology (L.D., R.B.), Guillaume et René Laennec University Hospital, Nantes; Department of Interventional Neuroradiology (R.A., G.F.), Dupuytren University Hospital, Limoges; Department of Diagnostic and Interventional Neuroradiology (G.M., F.G.), Pellegrin Hospital-University Hospital of Bordeaux, France; Institute of Diagnostic, Interventional and Pediatric Radiology and Institute of Diagnostic and Interventional Neuroradiology (P.M., J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland; Neurology Department (P.S.), Fondation Rothschild Hospital, Paris; Neurology Department (G.T.), GHU Paris Psychiatrie et Neurosciences, Université de Paris, INSERM U1266, FHU NeuroVasc; and Neuroradiology Department (G.B.), Université de Paris, des Neurosciences Psychiatrie de Paris, France.

Objective: Individualized patient selection for mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) and large ischemic core (LIC) at baseline is an unmet need. We tested the hypothesis that assessing the functional relevance of both infarcted and hypoperfused brain tissue would improve the selection framework of patients with LIC for MT.

Methods: We performed a multicenter, retrospective study of adults with LIC (ischemic core volume >70 mL on MRI diffusion-weighted imaging) with MRI perfusion treated with MT or best medical management (BMM). Primary outcome was 3-month modified Rankin Scale (mRS), favorable if 0-3. Global and regional eloquence-based core perfusion mismatch ratios were derived. The predictive accuracy for clinical outcome of eloquent regions involvement was compared in multivariable and bootstrap random forest models.

Results: A total of 138 patients with baseline LIC were included (MT n = 96 or BMM n = 42; mean age ± SD, 72.4 ± 14.4 years; 34.1% female; mRS 0-3: 45.1%). Mean core and critically hypoperfused volume were 100.4 mL ± 36.3 mL and 157.6 ± 56.2 mL, respectively, and did not differ between groups. Models considering the functional relevance of the infarct location showed a better accuracy for the prediction of mRS 0-3 with a c statistic of 0.76 and 0.83 for logistic regression model and bootstrap random forest testing sets, respectively. In these models, the interaction between treatment effect of MT and the mismatch was significant ( = 0.04). In comparison, in the logistic regression model disregarding functional eloquence, the c statistic was 0.67 and the interaction between MT and the mismatch was insignificant.

Conclusions: Considering functional eloquence of hypoperfused tissue in patients with a large infarct core at baseline allows for a more precise estimation of treatment expected benefit.

Classification Of Evidence: This study provides Class II evidence that, in patients with AIS and LIC, considering the functional eloquence of the infarct location improves prediction of disability status at 3 months.
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http://dx.doi.org/10.1212/WNL.0000000000012863DOI Listing
November 2021

Mechanical Thrombectomy in Patients with a Large Ischemic Volume at Presentation: Systematic Review and Meta-Analysis.

J Stroke 2021 Sep 30;23(3):358-366. Epub 2021 Sep 30.

Department of Neuroradiology, GHU Paris, Sainte Anne Hospital Pscyhiatry and Neurosciences Institute (IPNP), UMR_S1266, INSERM, University of Paris, Tours, France.

The benefits of mechanical thrombectomy (MT) for patients with acute ischemic stroke (AIS) and a large ischemic core (LIC) at presentation are uncertain. We aimed to obtain up-to-date aggregate estimates of the outcomes following MT in patients with volumetrically assessed LIC. We conducted a Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA)-conformed, PROSPERO-registered, systematic review and meta-analysis of studies that included patients with AIS and a baseline LIC treated with MT, reported ischemic core volume quantitatively, and included patients with a LIC defined as a core volume ≥50 mL. The search was restricted to studies published between January 2015 and June 2020. Random-effects-meta-analysis was used to assess the effect of MT on 90-day unfavorable outcome (i.e., modified Rankin Scale [mRS] 3-6), mortality, and symptomatic intracranial hemorrhage (sICH) occurrence. Sensitivity analyses were performed for imaging-modality (computed tomography-perfusion or magnetic resonance-diffusion weighted imaging) and LIC-definition (≥50 or ≥70 mL). We analyzed 10 studies (954 patients), including six (682 patients) with a control group, allowing to compare 332 patients with MT to 350 who received best-medical-management alone. Overall, after MT the rate of patients with mRS 3-6 at 90 days was 74% (99% confidence interval [CI], 67 to 84; Z-value=7.04; I2=92.3%) and the rate of 90-day mortality was 36% (99% CI, 33 to 40; Z-value=-7.07; I2=74.5). Receiving MT was associated with a significant decrease in mRS 3-6 odds ratio (OR) 0.19 (99% CI, 0.11 to 0.33; P<0.01; Z-value=-5.92; I2=62.56) and in mortality OR 0.60 (99% CI, 0.34 to 1.06; P=0.02; Z-value=-2.30; I2=58.72). Treatment group did not influence the proportion of patients experiencing sICH, OR 0.96 (99% CI, 0.2 to 1.49; P=0.54; Z-value=-0.63; I2=64.74). Neither imaging modality for core assessment, nor LIC definition influenced the aggregated outcomes. Using aggregate estimates, MT appeared to decrease the risk of unfavorable functional outcome in patients with a LIC assessed volumetrically at baseline.
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http://dx.doi.org/10.5853/jos.2021.00724DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8521249PMC
September 2021

The white test for intraoperative screening of bile leakage: a potential trigger factor for acute pancreatitis after liver resection-a case series.

BMC Surg 2021 Oct 2;21(1):356. Epub 2021 Oct 2.

Department of Digestive Surgery and Liver Transplantation, Hôpital la Timone, 264 rue Saint-Pierre, 13385, Marseille Cedex 05, France.

Background: Acute pancreatitis after liver resection is a rare but serious complication, and few cases have been described in the literature. Extended lymphadenectomy, and long ischemia due to the Pringle maneuver could be responsible of post-liver resection acute pancreatitis, but the exact causes of AP after hepatectomy remain unclear.

Cases Presentation: We report here three cases of AP after hepatectomy and we strongly hypothesize that this is due to the bile leakage white test. 502 hepatectomy were performed at our center and 3 patients (0.6%) experienced acute pancreatitis after LR and all of these three patients underwent the white test at the end of the liver resection. None underwent additionally lymphadenectomy to the liver resection. All patient had a white-test during the liver surgery. We identified distal implantation of the cystic duct in these three patients as a potential cause for acute pancreatitis.

Conclusion: The white test is useful for detection of bile leakage after liver resection, but we do not recommend a systematic use after LR, because severe acute pancreatitis can be lethal for the patient, especially in case of distal cystic implantation which may facilitate reflux in the main pancreatic duct.
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http://dx.doi.org/10.1186/s12893-021-01354-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8487543PMC
October 2021

Pediatric brain arteriovenous malformation recurrence: a cohort study, systematic review and meta-analysis.

J Neurointerv Surg 2021 Sep 28. Epub 2021 Sep 28.

Department of Pediatric Radiology UMR 1163, Institut Imagine, INSERM U1000, APHP, Necker Sick Children Hospital, Paris, Paris, France.

Background: Recurrence following obliteration of brain arteriovenous malformations (AVMs) is common in children surgically treated, but recurrences following endovascular (EVT) and radiosurgical approaches are scantily reported.

Objective: To analyze the rates and risk factors for AVM recurrence after obliteration in a single-center cohort of children with ruptured AVMs treated with multimodal approaches, and to carry out a comprehensive review and meta-analysis of current data.

Methods: Children with ruptured AVMs between 2000 and 2019 enrolled in a prospective registry were retrospectively screened and included after angiographically determined obliteration to differentiate children with/without recurrence. A complementary systematic review and meta-analysis of studies investigating AVM recurrence in children between 2000 and 2020 was aggregated to explore the overall recurrence rates across treatment modalities by analyzing surgery versus other treatments.

Results: Seventy children with obliterated AVMs were included. AVM recurrences (n=10) were more commonly treated with EVT as final treatment (60% in the recurrence vs 13.3% in the no-recurrence group, p=0.018). Infratentorial locations were associated with earlier and more frequent recurrences (adjusted relative risk=4.62, 95% CI 1.08 to 19.04; p=0.04).In the aggregate analysis, the pooled rate of AVM recurrence was 10.9% (95% CI 8.7% to 13.5%). Younger age at presentation was associated with more frequent recurrences (RR per year increase, 0.97, 95% CI 0.93 to 0.99; p=0.046).

Conclusion: Location of infratentorial AVMs and younger age at presentation may be associated with earlier and more frequent recurrences. The higher rates of recurrence in patients with AVMs obliterated with EVT questions its role in an intent-to-cure approach and reinforces its position as an adjunct to surgery and/or radiosurgery.
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http://dx.doi.org/10.1136/neurintsurg-2021-017777DOI Listing
September 2021

Transient Perivascular Inflammation of the Carotid Artery (TIPIC) Syndrome: An Uncommon Cause of Anterior Neck Pain.

Pain Med 2022 Jan;23(1):212-213

Radiology Department, CHU La Conception, Marseille, France.

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http://dx.doi.org/10.1093/pm/pnab286DOI Listing
January 2022

Arterial Spin Labeling for the Etiological Workup of Intracerebral Hemorrhage in Children.

Stroke 2022 01 14;53(1):185-193. Epub 2021 Sep 14.

Department of Pediatric Radiology UMR 1163, Institut Imagine, INSERM U1000, (J.F.H., G.B., B.K., F.G., L.G., N.B., V.D.R., F.B., O.N.), University hospital Necker-Enfants-malades, Paris, France.

Background And Purpose: Pediatric nontraumatic intracerebral hemorrhage accounts for half of stroke in children. Early diagnostic of the causative underlying lesion is the first step toward prevention of hemorrhagic recurrence. We aimed to investigate the performance of arterial spin labeling sequence (ASL) in the acute phase etiological workup for the detection of an arteriovenous shunt (AVS: including malformation and fistula), the most frequent cause of pediatric nontraumatic intracerebral hemorrhage.

Methods: Children with a pediatric nontraumatic intracerebral hemorrhage between 2011 and 2019 enrolled in a prospective registry were retrospectively included if they had undergone ASL-magnetic resonance imaging before any etiological treatment. ASL sequences were reviewed using cerebral blood flow maps by 2 raters for the presence of an AVS. The diagnostic performance of ASL was compared with admission computed tomography angiography, other magnetic resonance imaging sequences including contrast-enhanced sequences and subsequent digital subtraction angiography.

Results: A total of 121 patients with pediatric nontraumatic intracerebral hemorrhage were included (median age, 9.9 [interquartile range, 5.8-13]; male sex 48.8%) of whom 76 (63%) had a final diagnosis of AVS. Using digital subtraction angiography as an intermediate reference, visual ASL inspection had a sensitivity and a specificity of, respectively, 95.9% (95% CI, 88.5%-99.1%) and 79.0% (95% CI, 54.4%-94.0%). ASL had a sensitivity, specificity, and accuracy of 90.2%, 97.2%, and 92.5%, respectively for the detection of the presence of an AVS, with near perfect interrater agreement (κ=0.963 [95% CI, 0.912-1.0]). The performance of ASL alone was higher than that of other magnetic resonance imaging sequences, individually or combined, and higher than that of computed tomography angiography.

Conclusions: ASL has strong diagnostic performance for the detection of AVS in the initial workup of intracerebral hemorrhage in children. If our findings are confirmed in other settings, ASL may be a helpful diagnostic imaging modality for patients with pediatric nontraumatic intracerebral hemorrhage.

Registration: URL: https://www.clinicaltrials.gov; Unique identifiers: 3618210420, 2217698.
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http://dx.doi.org/10.1161/STROKEAHA.120.032690DOI Listing
January 2022

Percutaneous lung and liver CT-guided ablation on swine model using microwave ablation to determine ablation size for clinical practice.

Int J Hyperthermia 2021 ;38(1):1140-1148

Department of Interventional Imaging, Assistance Publique Hopitaux de Marseille, Marseille, France.

Purpose: Microwave ablation (MWA) provides an effective treatment of lung and liver tumors but suffers from a lack of reproducibility of ablation size among currently available technologies. evaluations are far removed from clinical practices because of uninfused tissue. This study is preclinical testing of a new MWA system on swine lungs and liver.

Materials And Methods: All ablations were performed under CT guidance and multiple algorithms were tested with a power of 50, 75, and 100 W for durations of 3, 5, 8, 10, and 15 min. A 3 D-evaluation of the ablation zone was carried out using enhanced-CT. The sphericity index, coefficients of variation, and energy efficiency (which corresponds to the volume yield according to the power supplied) were calculated.

Results: Fifty liver and 48 lung ablations were performed in 17 swine. The sphericity index varies from 0.50 to 0.80 for liver ablations and from 0.40 to 0.69 for lung ablations. The coefficient of variation was below 15% for 4/5 and 4/8 protocols for lung and liver ablations, respectively. The energy efficiency seems to decrease with the duration of the ablation from 0.60 × 10 cm/J (75 W, 3 min) to 0.26 × 10 cm/J (100 W, 15 min) in the liver and from 0.57 × 10 cm/J (50 W, 10 min) to 0.42 × 10 cm/J (100 W, 12 min) in the lungs.

Conclusion: A shorter treatment time provides the best energy efficiency, and the best reproducibility is obtained for a 10 min treatment duration. The system tested provides an interesting reproducibility in both lung and liver measurements. Our results may help interventional radiologists in the optimal selection of treatment parameters.
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http://dx.doi.org/10.1080/02656736.2021.1961883DOI Listing
August 2021

Late Pediatric Mechanical Thrombectomy for Embolic Stroke as Bridge Reinforcement From LVAD to Heart Transplantation.

JACC Case Rep 2021 Apr 24;3(4):686-689. Epub 2021 Feb 24.

Department of Neuroradiology, University of Paris, INSERM UMR 1266 IMA-BRAIN, University Hospital Group, GHU Paris, Paris, France.

Although the left ventricular assist device is an important bridge to heart transplantation for patients with end-stage heart failure, it can also be a source of embolic stroke. We present a case of late intracranial mechanical thrombectomy performed for embolic stroke beyond the recommended 6 h, thus allowing for heart transplantation 4 days after intracranial mechanical thrombectomy. ().
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http://dx.doi.org/10.1016/j.jaccas.2020.10.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8302778PMC
April 2021

Description of morphological evolution of lung tumors treated by percutaneous radiofrequency ablation: long term follow-up of 100 lesions with chest CT.

Int J Hyperthermia 2021 ;38(1):786-794

Department of Medical Imaging, La Timone Hôpital, Marseille, France.

Purpose: Radiofrequency ablation (RFA) is a safe and effective minimally invasive treatment for pulmonary tumors. Patterns on chest computed tomography (CT) after RFA are classified into five types; however, the follow-up has not been fully described. The objectives of this study were to describe (1) the CT pattern 3 years after RFA and (2) its evolution over 7 years.

Materials And Methods: Lesions treated with RFA between 2009 and 2017 and with ≥3 years of follow-up CT data were included. Lesions with local recurrences were excluded from the study. The morphology of the ablation zone was classified as nodular, fibrotic, atelectatic, cavitary, and disappeared. Other initial anatomical parameters were recorded. Kruskal-Wallis or Chi-square tests were used to compare the groups.

Results: One hundred lung RFA scars were included, and a retrospective longitudinal study was performed. Three years after RFA, nodular, fibrotic, atelectatic, and cavitary scars, and disappearance were observed in 49%, 36%, 5%, 3%, and 6% of the scars, respectively. Evolution over 7 years showed that the fibrosis, atelectasis, and disappearance remained stable over time, whereas 28% of nodular scars evolved into fibrotic scars. Additionally, 45% of cavitary scars evolved into nodular scars. Pleural contact was associated with disappearance, and the use of a 20-mm needle was associated with atelectasis.

Conclusion: Follow-up after RFA showed that fibrosis, disappearance, and atelectasis remained stable over time. Nodular scars could evolve into fibrotic scars, and cavitary scars could evolve into nodular scars.
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http://dx.doi.org/10.1080/02656736.2021.1928773DOI Listing
July 2021

EASY score (Eloquent, Age and baseline SYmptoms score) for outcome prediction in patients with acute ischemic stroke.

Clin Neurol Neurosurg 2021 Apr 1;205:106626. Epub 2021 Apr 1.

Department of Neuroradiology, University Hospital of Southampton, Tremona Rd, Southampton, UK.

Objective: A pragmatic tool for the early and reliable prediction of recovery in patients with acute ischemic stroke is needed. We aimed to test the addition of brain eloquent areas involvement in variables predicting poor outcome, using a simple scoring system.

Methods: Retrospective study of patients with anterior circulation acute ischemic stroke treated with best medical treatment and/or endovascular reperfusion. Primary outcome measure was 3-months poor outcome (mRs 3-6). We developed a prognostic model based on clinical data and a quantitative scoring system of the main eloquent brain areas involved on early follow-up CT, and analyzed its accuracy to predict poor outcome comparatively to three other prognostic models. The final model was used to develop a score for outcome prediction based on the multivariable analysis.

Results: A total of 197 patients were included (poor outcome = 62; mean age 67 ± 15.1 years; 44% females). Independent predictors of poor outcome were increasing age (p < 0.001), baseline NIHSS (p = 0.03), and the involvement of two brain areas: posterior limb of internal capsule (p < 0.001) and postero-superior corona radiata (p < 0.001). This model showed to be the most accurate to predict poor outcome (Balance Accuracy = 77.74%; C-Statistic = 0.891). The derived risk score attributing points for each of these variables (EASY score) showed similar performances (Balance Accuracy = 82.11%; C-Statistic = 0.90).

Conclusion: The EASY score is an easy-to-apply and accurate tool to predict the 3-months functional outcome after ischemic stroke, relying on simple clinical features and the assessment of two key eloquent brain areas on early follow-up CT.
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http://dx.doi.org/10.1016/j.clineuro.2021.106626DOI Listing
April 2021

Mortality and functional outcome after pediatric intracerebral hemorrhage: cohort study and meta-analysis.

J Neurosurg Pediatr 2021 Apr 9:1-7. Epub 2021 Apr 9.

1Service d'imagerie Morphologique et Fonctionnelle, GHU Paris Psychiatrie et Neurosciences, Hospitalier Sainte Anne, Institut de Psychiatrie et Neurosciences de Paris, UMR_S1266, INSERM, Université de Paris.

Objective: The clinical outcome of pediatric intracerebral hemorrhage (pICH) is rarely reported in a comprehensive way. In this cohort study, systematic review, and meta-analysis of patients with pICH, the authors aimed to describe the basic clinical outcomes of pICH.

Methods: Children who received treatment for pICH at the authors' institution were prospectively enrolled in the cohort in 2008; data since 2000 were retrospectively included, and data through October 2019 were analyzed. The authors then searched PubMed and conducted a systematic review of relevant articles published since 1990. Data from the identified populations and patients from the cohort study were pooled into a multicategory meta-analysis and analyzed with regard to clinical outcomes.

Results: Among 243 children screened for inclusion, 231 patients were included. The median (IQR) age at ictus was 9.6 (4.6-12.5) years, and 128 patients (53%) were male. After a median (IQR) follow-up of 33 (13-63) months, 132 patients (57.4%) had a favorable clinical outcome, of whom 58 (44%) had no residual symptoms. Nineteen studies were included in the meta-analysis. Overall, the proportion of children with complete recovery was 27% (95% CI 19%-36%; Q = 49.6; I2 = 76%); of those with residual deficits, the complete recovery rate was 48.1% (95% CI 40%-57%; Q = 75.3; I2 = 81%). When pooled with the cohort study, the aggregate case-fatality rate at the last follow-up was 17.3% (95% CI 12%-24%; Q = 101.6; I2 = 81%).

Conclusions: Here, the authors showed that 1 in 6 children died after pICH, and the majority of children had residual neurological deficits at the latest follow-up. Results from the cohort study also indicate that children with vascular lesions as the etiology of pICH had significantly better clinical functional outcomes.
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http://dx.doi.org/10.3171/2020.9.PEDS20608DOI Listing
April 2021

Acute surgical management of children with ruptured brain arteriovenous malformation.

J Neurosurg Pediatr 2021 Jan 22:1-9. Epub 2021 Jan 22.

1APHP, Necker Hospital.

Objective: Rupture of brain arteriovenous malformation (AVM) is the main etiology of intracerebral hemorrhage (ICH) in children. Ensuing intracranial hypertension is among the modifiable prognosis factors and sometimes requires emergency hemorrhage evacuation (HE). The authors aimed to analyze variables associated with HE in children with ruptured AVM.

Methods: This study was a single-center retrospective analysis of children treated for ruptured AVM. The authors evaluated the occurrence of HE, its association with other acute surgical procedures (e.g., nidal excision, decompressive hemicraniectomy), and clinical outcome. Variables associated with each intervention were analyzed using univariable and multivariable models. Clinical outcome was assessed at 18 months using the ordinal King's Outcome Scale for Childhood Head Injury.

Results: A total of 104 patients were treated for 112 episodes of ruptured AVM between 2002 and 2018. In the 51 children (45.5% of cases) who underwent HE, 37 procedures were performed early (i.e., within 24 hours after initial cerebral imaging) and 14 late. Determinants of HE were a lower initial Glasgow Coma Scale score (adjusted odds ratio [aOR] 0.83, 95% CI 0.71-0.97 per point increase); higher ICH/brain volume ratio (aOR 18.6, 95% CI 13-26.5 per percent increase); superficial AVM location; and the presence of a brain herniation (aOR 3.7, 95% CI 1.3-10.4). Concurrent nidal surgery was acutely performed in 69% of Spetzler-Martin grade I-II ruptured AVMs and in 25% of Spetzler-Martin grade III lesions. Factors associated with nidal surgery were superficial AVMs, late HE, and absent alteration of consciousness at presentation. Only 8 cases required additional surgery due to intracranial hypertension. At 18 months, overall mortality was less than 4%, 58% of patients had a favorable outcome regardless of surgical intervention, and 87% were functioning independently.

Conclusions: HE is a lifesaving procedure performed in approximately half of the children who suffer AVM rupture. The good overall outcome justifies intensive initial management.
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http://dx.doi.org/10.3171/2020.8.PEDS20479DOI Listing
January 2021

Hemorrhage Expansion After Pediatric Intracerebral Hemorrhage.

Stroke 2021 01 11;52(2):588-594. Epub 2021 Jan 11.

GHU Paris Psychiatrie et Neurosciences, Hospitalier Sainte Anne, Service d'imagerie Morphologique et Fonctionnelle, Institut de Psychiatrie et Neurosciences de Paris, Unité mixte de recherche S1266, Institut National de la Santé Et de la Recherche Médicale, Université de Paris, Paris, France (G.B., J.-F.H., B.K., F.G., L.G., O.N.).

Background And Purpose: Significant hemorrhage expansion (sHE) is a known predictor of poor outcome after an intracerebral hemorrhage (ICH) in adults but remains poorly reported in children. In a large inception cohort, we aimed to explore the prevalence of sHE, its associations with clinical outcomes, and its clinical-imaging predictors in children.

Methods: Children admitted between January 2000 and March 2020 at a quaternary care pediatric hospital were screened for inclusion. Sample was restricted to children with 2 computed tomography scans within 72 hours of ICH onset, and a minimal clinical follow-up of months. sHE was defined as an increase from baseline ICH volume by 6 cc or 33% on follow-up computed tomography. Clinical outcome was assessed at 12 months with the King's Outcome Scale for Childhood Head Injury score and defined as favorable for scores ≥5.

Results: Fifty-two children met inclusion criteria, among which 8 (15%) demonstrated sHE, and 18 (34.6%) any degree of expansion. Children with sHE had more frequent coagulation disorders (25.0% versus 2.3%; =0.022). After multivariable adjustment, only the presence of coagulation disorders at baseline remained independently associated with sHE (adjusted odds ratio, 14.4 [95% CI, 1.04-217]; =0.048). sHE was independently associated with poor outcome (King's Outcome Scale for Childhood Head Injury <5A, odds ratio, 5.77 [95% CI, 1.01-38.95]; =0.043).

Conclusions: sHE is a frequent phenomenon after admission for a pediatric ICH and more so in children with coagulation defects. As sHE was strongly associated with poorer clinical outcomes, these data mandate a baseline coagulation work up and questions the need for protocolized repeat head computed tomography in children admitted for pediatric ICH.
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http://dx.doi.org/10.1161/STROKEAHA.120.030592DOI Listing
January 2021

Etiology of intracerebral hemorrhage in children: cohort study, systematic review, and meta-analysis.

J Neurosurg Pediatr 2021 Jan 1:1-7. Epub 2021 Jan 1.

1Service d'imagerie Morphologique et Fonctionnelle, GHU Paris Psychiatrie et Neurosciences, Hospitalier Sainte Anne, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, INSERM, Université de Paris.

Objective: Understanding the etiological spectrum of nontraumatic pediatric intracerebral hemorrhage (pICH) is key to the diagnostic workup and care pathway. The authors aimed to evaluate the etiological spectrum of diseases underlying pICH.

Methods: Children treated at the authors' institution for a pICH were included in an inception cohort initiated in 2008 and retrospectively inclusive to 2000, which was analyzed in October 2019. They then conducted a systematic review of relevant articles in PubMed published between 1990 and 2019, identifying cohorts with pICH. Identified populations and patients from the authors' cohort were pooled in a multicategory meta-analysis.

Results: A total of 243 children with pICH were analyzed in the cohort study. The final primary diagnosis was an intracranial vascular lesion in 190 patients (78.2%), a complication of a cardiac disease in 17 (7.0%), and a coagulation disorder in 14 (5.8%). Hematological and cardiological etiologies were disproportionately more frequent in children younger than 2 years (p < 0.001). The systematic review identified 1309 children in 23 relevant records pooled in the meta-analysis. Overall, there was significant heterogeneity. The dominant etiology was vascular lesion, with an aggregate prevalence of 0.59 (95% CI 0.45-0.64; p < 0.001, Q = 302.8, I2 = 92%). In 18 studies reporting a detailed etiological spectrum, arteriovenous malformation was the dominant etiology (68.3% [95% CI 64.2%-70.9%] of all vascular causes), followed by cavernoma (15.7% [95% CI 13.0%-18.2%]).

Conclusions: The most frequent etiology of pICH is brain arteriovenous malformation. The probability of an underlying vascular etiology increases with age, and, conversely, hematological and cardiac causes are dominant causes in children younger than 2 years.
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http://dx.doi.org/10.3171/2020.7.PEDS20447DOI Listing
January 2021

Combination of Alcohol and EVOH as a New Embolic Agent: Midterm Tissue and Inflammatory Effects in a Swine Model.

Radiol Res Pract 2020 23;2020:8831060. Epub 2020 Oct 23.

Diagnostic and Interventional Radiology Section, Department of Medical Imaging, University Hospital Timone APHM, 278 Rue Saint-Pierre, Marseille 13005, France.

Objective: To evaluate the vascular occlusion and midterm tissue toxicity properties of a combination of ethylene-vinyl alcohol (EVOH) (Squid 18®) (75%) and alcohol (25%)-Alco-Squid 18-in a swine model.

Materials And Methods: Alco-Squid 18 (75% Squid 18® mixed with 25% alcohol) (AS18) was compared to embolization with 96% alcohol alone and to embolization with Squid 18® (S18®) alone. An arteriovenous malformation (AVM) model was created in group 1 ( = 2). Each AVM model was then embolized with AS18 or S18® alone with evaluation of a ratio between the volume of embolic agent divided by the volume of the AVM (evaluated by CT). For group 2 ( = 5), each agent was tested on three different kidneys (upper pole kidney artery). Pre- and postinterventional CTs, angiographies, blood alcohol content dosages, and histological studies (3 months postintervention) were performed.

Results: AS18 has better distal distribution than S18® alone, both in the kidneys (mean capsule-S18® distance: 3.9 mm (±0.23) and mean capsule-AS18 distance: 2.3 mm (±0.11) (=0.029) and in the AVM model. Histological exploration found a higher rate of tubular necrosis with AS18 compared with S18® alone and alcohol alone (3.78 ± 0.44 compared to 2.33 ± 1.22 ( = 0.012) and 1.22 ± 0.67 (  < 0 .0001)). The blood alcohol content was negligible in all cases.

Conclusion: AS18 can suggest a better distal sclerotic and embolic character as compared with S18® alone without systemic toxicity.
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http://dx.doi.org/10.1155/2020/8831060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7605951PMC
October 2020

FairEmbo Concept for Arterial Embolizations: In Vivo Feasibility and Safety Study with Suture-Based Microparticles Compared with Microspheres.

Cardiovasc Intervent Radiol 2021 Apr 25;44(4):625-632. Epub 2020 Oct 25.

Interventional Radiololy Section, Department of Medical Imaging, University Hospital Timone, APHM, Marseille, France.

Purpose: Microspheres are effective embolic agents, especially for the management of bleeding and oncologic lesions. The first FairEmbo study reported the effectiveness of embolization using suture fragments. The effectiveness and safety of arterial embolization with suture-based microparticles (SBM) were assessed in a swine model.

Materials And Methods: In this ethical-approved animal study, a polar artery in each kidney was embolized in four swine: one side with hand-cut non-absorbable SBM (Flexocrin 2®) and the contralateral side with Embozene® 900 for comparison. Swine were followed for 3 months (M3) to evaluate the effectiveness and the safety of SBM. Follow-up protocol included clinical monitoring, computed tomography (CT) control and digital subtraction angiography (DSA), followed by histological analyses. The SBM confection parameters were evaluated by automatic microscopic sizer. RStudio software and Mann-Whitney test (significance at P < 0.05) were used for statistics.

Results: The average size of SBM was 1002 μm (SD = 258). All targets were effectively embolized by SBM with an angiogram defect estimated at 45.6% (95% CI [35.9-55.2]), compared to 40.5% (95% CI [30.6-55.5]) for Embozene® group (P = 0.342). The average duration of SBM embolization procedure was significantly increased compared to Embozene® embolization (1202 s versus 222 s, P = 0.029). There were no statistical differences in M3 DSA and CT for SBM and Embozene®, with persistence of partial arterial occlusion and atrophic embolized area. No postoperative complications were observed on clinical and CT controls.

Conclusion: This experimental study suggests that embolization with SBM is feasible, safe and effective in short- and medium-term follow-up as compared to microspheres.
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http://dx.doi.org/10.1007/s00270-020-02678-0DOI Listing
April 2021

Perfusion Imaging to Select Patients with Large Ischemic Core for Mechanical Thrombectomy.

J Stroke 2020 May 31;22(2):225-233. Epub 2020 May 31.

Diagnostic and Therapeutic Neuroradiology, CHRU de Tours, Tours, France.

Background And Purpose: Patients with acute ischemic stroke, proximal vessel occlusion and a large ischemic core at presentation are commonly not considered for mechanical thrombectomy (MT). We tested the hypothesis that in patients with baseline large infarct cores, identification of remaining penumbral tissue using perfusion imaging would translate to better outcomes after MT.

Methods: This was a multicenter, retrospective, core lab adjudicated, cohort study of adult patients with proximal vessel occlusion, a large ischemic core volume (diffusion weighted imaging volume ≥70 mL), with pre-treatment magnetic resonance imaging perfusion, treated with MT (2015 to 2018) or medical care alone (controls; before 2015). Primary outcome measure was 3-month favorable outcome (defined as a modified Rankin Scale of 0-3). Core perfusion mismatch ratio (CPMR) was defined as the volume of critically hypo-perfused tissue (Tmax >6 seconds) divided by the core volume. Multivariable logistic regression models were used to determine factors that were independently associated with clinical outcomes. Outputs are displayed as adjusted odds ratio (aOR) and 95% confidence interval (CI).

Results: A total of 172 patients were included (MT n=130; Control n=42; mean age 69.0±15.4 years; 36% females). Mean core-volume and CPMR were 102.3±36.7 and 1.8±0.7 mL, respectively. As hypothesized, receiving MT was associated with increased probability of favorable outcome and functional independence, as CPMR increased, a difference becoming statistically significant above a mismatch-ratio of 1.72. Similarly, receiving MT was also associated with favorable outcome in the subgroup of 74 patients with CPMR >1.7 (aOR, 8.12; 95% CI, 1.24 to 53.11; P=0.028). Overall (prior to stratification by CPMR) 73 (42.4%) patients had a favorable outcome at 3 months, with no difference amongst groups.

Conclusion: s In patients currently deemed ineligible for MT due to large infarct ischemic cores at baseline, CPMR identifies a subgroup strongly benefiting from MT. Prospective studies are warranted.
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http://dx.doi.org/10.5853/jos.2019.02908DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7341008PMC
May 2020

COVID-19-White matter and globus pallidum lesions: Demyelination or small-vessel vasculitis?

Neurol Neuroimmunol Neuroinflamm 2020 07 22;7(4). Epub 2020 May 22.

From the APHM (G.B., J.-F.H., S.C., N.G., J.-P.S.), Neuroradiology Department, La Timone University Hospital; APHM (E.K.), Department of Neurology, La Timone University Hospital; APHM (J.C.), Intensive Care Unit, La Timone University Hospital; Aix-Marseille University (N.G.), UMR CNRS 7339; and APHM (J.-P.S.), La Timone University Hospital, CEMEREM, Marseille, France.

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http://dx.doi.org/10.1212/NXI.0000000000000777DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7286652PMC
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

[Central venous access in interventional radiology].

Presse Med 2019 Oct 25;48(10):1141-1145. Epub 2019 Oct 25.

AP-HM, hôpital La Timone, service de radiologie interventionnelle, 265, rue Saint-Pierre, 13005 Marseille, France; Aix-Marseille université, LIIE, Marseille, France; Aix-Marseille université, CERIMED, Marseille, France.

Some patients require iteratives intravenous administrations on a central catheter, for example in oncology or infectiology, which represents a challenge for ambulatory treatment. Interventional radiology could provide solutions with the implant and monitoring of PICC-lines and ports. These are implanted in sterile environment and under imaging guidance in an interventional radiology room by an operator and with a paramedical team that need to be experienced. This development focus on the interest of one method with respect to the other, as well as the differents ways to do, the complications that could arise and the monitoring of these devices.
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http://dx.doi.org/10.1016/j.lpm.2019.10.013DOI Listing
October 2019

Nontraumatic Pediatric Intracerebral Hemorrhage.

Stroke 2019 12 22;50(12):3654-3661. Epub 2019 Oct 22.

From the Pediatric Radiology Department, Necker Enfants Malades (NEM), INSERM UMR1266, Sainte-Anne (G.B., J.F.H., O.N.).

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http://dx.doi.org/10.1161/STROKEAHA.119.025783DOI Listing
December 2019

Short-term outcomes after major hepatic resection in patients with cirrhosis: a 75-case unicentric western experience.

HPB (Oxford) 2019 03 16;21(3):352-360. Epub 2018 Aug 16.

Department of Digestive Surgery, Hôpital de la Timone, Marseille, France; Université Aix-Marseille, 27 Boulevard Jean Moulin, 13385, Marseille, France.

Background: The benefit of performing major hepatic resection (MHR) for hepatocellular carcinoma (HCC) in patients with cirrhosis remains controversial because of its high risk of posthepatectomy liver failure (PHLF). This study was conducted to assess the risk of MHR for HCC in patients with cirrhosis.

Methods: Patients with Child-Pugh A or B cirrhosis and HCC who underwent MHR from January 2000 to June 2014 were retrospectively identified. Risk factors for postoperative morbidity and mortality using univariate and multivariate analyses were evaluated.

Results: Seventy patients with Child-Pugh A (93%) and 5 (7%) with Child-Pugh B cirrhosis underwent MHR for HCC. Thirteen (17%) had Barcelona Clinic Liver Cancer (BCLC) stage A, 39 (50%) had BCLC B, and 23 (32%) had BCLC C disease. A perioperative blood transfusion was performed in 18 patients (24%). Ninety-day postoperative mortality was 9% (n=7). Major complications occurred in 16 patients (21%), including PHLF in 9 patients (12%). A multivariate analysis showed that perioperative blood transfusion was the main independent factor associated with mortality (OR= 6.5) and major morbidity (OR=10).

Conclusion: In selected patients with HCC and cirrhosis, MHR is feasible and has acceptable mortality, but careful perioperative management and limiting blood loss are required.
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http://dx.doi.org/10.1016/j.hpb.2018.07.020DOI Listing
March 2019
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