Publications by authors named "Laurent Pierot"

127 Publications

Susceptibility Vessel Sign in Relation With Time From Onset to Magnetic Resonance Imaging.

Stroke 2021 May 8;52(5):1839-1842. Epub 2021 Apr 8.

Université Caen-Normandie, INSERM UMR-S U1237, Cyceron, Caen, France (S.S., M.G., M.Z., E.T.).

[Figure: see text].
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http://dx.doi.org/10.1161/STROKEAHA.120.032198DOI Listing
May 2021

Intracranial aneurysm treatment with WEB and adjunctive stent: preliminary evaluation in a single-center series.

J Neurointerv Surg 2021 Mar 30. Epub 2021 Mar 30.

Department of Neuroradiology, Hôpital Maison-Blanche, CHU Reims, Reims, France

Background: Intrasaccular flow disruption with WEB is a safe and efficacious technique that has significantly changed endovascular management of wide-neck bifurcation aneurysms (WNBAs). Use of stent in combination with WEB is occasionally required. We analyzed the frequency of use, indications, safety, and efficacy of the WEB-stent combination.

Methods: All aneurysms treated with WEB and stent were extracted from a prospectively maintained database. Patient and aneurysm characteristics, complications, and anatomical results were independently analyzed by a physician independent of the procedures.

Results: From June 2011 to January 2020, 152 patients with 157 aneurysms were treated with WEB. Of these, 17/152 patients (11.2%) with 19/157 aneurysms (12.1%) were treated with WEB device and stent. Indications were very wide neck with a branch emerging from the neck in 1/19 (5.2%) aneurysms and WEB protrusion in 18/19 (94.7%). At 1 month, no morbimortality was reported. At 6 months, anatomical results were complete aneurysm occlusion in 15/17 aneurysms (88.2%), neck remnant in 1/17 (5.9%), and aneurysm remnant in 1/17 (5.9%). At 12 months, there was complete aneurysm occlusion in 13/14 aneurysms (92.9%) and neck remnant in 1/14 (7.1%).

Conclusions: Combining WEB and stent is a therapeutic strategy to manage WNBA. In our series, this combination was used in 11.2% of patients treated with WEB, resulting in no morbidity or mortality with a high efficacy at 6 and 12 months (complete aneurysm occlusion in 88.2% and 92.9%, respectively).
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http://dx.doi.org/10.1136/neurintsurg-2021-017379DOI Listing
March 2021

Wide neck bifurcation aneurysms: what is the optimal endovascular treatment?

J Neurointerv Surg 2021 May 15;13(5):e9. Epub 2021 Mar 15.

Neurointerventions, National Institute of Clinical Neurosciences, Budapest, Budapest, Hungary.

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http://dx.doi.org/10.1136/neurintsurg-2021-017459DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8053325PMC
May 2021

Direct transfer to angiosuite for patients with severe acute stroke treated with thrombectomy: the multicentre randomised controlled DIRECT ANGIO trial protocol.

BMJ Open 2021 Mar 15;11(3):e040522. Epub 2021 Mar 15.

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

Introduction: Mechanical thrombectomy (MT) increases functional independence in patients with acute ischaemic stroke with anterior circulation large vessel occlusion (LVO), and the probability to achieve functional independence decreases by 20% for each 1-hour delay to reperfusion. Therefore, we aim to investigate whether direct angiosuite transfer (DAT) is superior to standard imaging/emergency department-based management in achieving 90-day functional independence in patients presenting with an acute severe neurological deficit likely due to LVO and requiring emergent treatment with MT.

Methods And Analysis: DIRECT ANGIO (Effect of DIRECT transfer to ANGIOsuite on functional outcome in patient with severe acute stroke treated with thrombectomy: the randomised DIRECT ANGIO Trial) trial is an investigator-initiated, multicentre, prospective, randomised, open-label, blinded endpoint (PROBE) study. Eligibility requires a patient ≤75 years, pre-stroke modified Rankin Scale (mRS) 0-2, presenting an acute severe neurological deficit and admitted within 5 hours of symptoms onset in an endovascular-capable centre. A total of 208 patients are randomly allocated in a 1:1 ratio to DAT or standard management. The primary outcome is the rate of patients achieving a functional independence, assessed as mRS 0-2 at 90 days. Secondary endpoints include patients presenting confirmed LVO, patients eligible to intravenous thrombolysis alone, patients with intracerebral haemorrhage and stroke-mimics, intrahospital time metrics, early neurological improvement (reduction in National Institutes of Health Stroke Scale by ≥8 points or reaching 0-1 at 24 hours) and mRS overall distribution at 90 days and 12 months. Safety outcomes are death and intracerebral haemorrhage transformation. Medico-economics analyses include health-related quality of life and cost utility assessment.

Ethics And Dissemination: The DIRECT ANGIO trial was approved by the ethics committee of Ile de France 1. Study began in April 2020. Results will be published in an international peer-reviewed medical journal.

Trial Registration Number: NCT03969511.
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http://dx.doi.org/10.1136/bmjopen-2020-040522DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7970280PMC
March 2021

The Woven Endobridge as a treatment for acutely ruptured aneurysms: A review of the literature.

Interv Neuroradiol 2021 Jan 28:1591019921991397. Epub 2021 Jan 28.

Department of diagnostic and therapeutic neuroradiology, Centre Hospitalier Universitaire de Reims, Reims, France.

The Woven Endobridge (WEB; Microvention, Aliso Viejo, California, USA) is a relatively new device which has been shown to be safe and effective for the treatment of wide necked bifurcation aneurysms in multiple prospective Good Clinical Practice studies. However, the vast majority of aneurysms included in these studies have been unruptured. The aim of this review is to summarise the current evidence available on the treatment of ruptured aneurysms with the WEB.
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http://dx.doi.org/10.1177/1591019921991397DOI Listing
January 2021

Bridging May Increase the Risk of Symptomatic Intracranial Hemorrhage in Thrombectomy Patients With Low Alberta Stroke Program Early Computed Tomography Score.

Stroke 2021 Mar 28;52(3):1098-1104. Epub 2021 Jan 28.

Department of Neurology (T.R.M., M.G., D.S., M.R.H., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland.

Background And Purpose: Whether intravenous thrombolysis (IVT) increases the risk for symptomatic intracranial hemorrhage (sICH) in patients treated with mechanical thrombectomy (MT) is a matter of debate. Purpose of this study was to evaluate the extent of early ischemia as a possible factor influencing the risk for sICH after IVT+MT versus direct MT.

Methods: An explorative analysis of the BEYOND-SWIFT (Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the SOLITAIRE FR With the Intention for Thrombectomy) multicenter cohort was performed. We hypothesized that the sICH risk between IVT+MT versus direct MT differs across the strata of Alberta Stroke Program Early CT Scores (ASPECTS). For this purpose, all patients with ICA, M1, and M2 vessel occlusions and available noncontrast computed tomography or diffusion-weighed imaging ASPECTS (n=2002) were analyzed. We used logistic regression analysis in subgroups, as well as interaction terms, to address the risk of sICH in IVT+MT versus direct MT patients across the ASPECTS strata.

Results: In 2002 patients (median age, 73.7 years; 50.7% women; median National Institutes of Health Stroke Scale score, 16), the overall rate of sICH was 6.5% (95% CI, 5.5%-7.7%). Risk of sICH differed across ASPECTS groups (9-10: 6.3%; 6-8: 5.6% and ≤5 9.8%; =0.042). With decreasing ASPECTS, the risks of sICH in the IVT+MT versus the direct MT group increased from adjusted odds ratio of 0.61 ([95% CI, 0.24-1.60] ASPECTS 9-10), to 1.72 ([95% CI, 0.69-4.24] ASPECTS 6-8) and 6.31 ([95% CI, 1.87-21.29] ASPECTS ≤5), yielding a positive interaction term (1.91 [95% CI, 1.01-3.63]). Sensitivity analyses regarding diffusion-weighed imaging versus noncontrast computed tomography ASPECTS did not alter the primary observations.

Conclusions: The extent of early ischemia may influence relative risks of sICH in IVT+MT versus direct MT patients, with an excess sICH risk in IVT+MT patients with low ASPECTS. If confirmed in post hoc analyses of randomized controlled trial data, IVT may be administered more carefully in patients with low ASPECTS eligible for and with direct access to MT.
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http://dx.doi.org/10.1161/STROKEAHA.120.030508DOI Listing
March 2021

Immediate post-operative aneurysm occlusion after endovascular treatment of intracranial aneurysms with coiling or balloon-assisted coiling in a prospective multicenter cohort of 1189 patients: Analysis of Recanalization after Endovascular Treatment of intracranial Aneurysm (ARETA) Study.

J Neurointerv Surg 2020 Dec 21. Epub 2020 Dec 21.

Interventional Neuroradiology, APHP, Paris, Île-de-France, France.

Background: Coiling, including balloon-assisted coiling (BAC), is the first-line therapy for ruptured and unruptured aneurysms. Its efficacy can be clinically evaluated by bleeding/rebleeding rate after coiling, and anatomically evaluated by aneurysm occlusion post-procedure and during follow-up. We aimed to analyze immediate post-coiling aneurysm occlusion and associated factors within the Analysis of Recanalization after Endovascular Treatment of intracranial Aneurysm (ARETA) population.

Methods: Between December 2013 and May 2015, 16 neurointerventional departments prospectively enrolled participants treated for ruptured and unruptured aneurysms (ClinicalTrials.gov: NCT01942512). Participant demographics, aneurysm characteristics, and endovascular techniques were recorded. In patients with aneurysms treated by coiling or BAC, immediate post-operative aneurysm occlusion was independently evaluated by a core lab using a 3-grade scale: complete occlusion, neck remnant, and aneurysm remnant.

Results: Of 1135 participants (age 53.8±12.8 years, 754 women (66.4%)), 1189 aneurysms were analyzed. Treatment modality was standard coiling in 645/1189 aneurysms (54.2%) and BAC in 544/1189 (45.8%). Immediate post-operative aneurysm occlusion was complete occlusion in 57.8%, neck remnant in 34.4%, and aneurysm remnant in 7.8%. Adequate occlusion (complete occlusion or neck remnant) was significantly more frequent in aneurysms with size <10 mm (93.1% vs 86.3%; OR 1.8, 95% CI 1.1 to 3.2; p=0.02) and in aneurysms with a narrow neck (95.8% vs 89.6%; OR 2.5, 95% CI 1.5 to 4.1; p=0.0004). Patients aged <70 years had significantly more adequate occlusion (92.7% vs 87.2%; OR 1.9, 95% CI 1.1 to 3.4; p=0.04).

Conclusions: Immediately after aneurysm coiling, including BAC, adequate aneurysm occlusion was obtained in 92.2%. Age <70 years, aneurysm size <10 mm, and narrow neck were factors associated with adequate occlusion.

Trial Registration Number: NCT01942512, http://www.clinicaltrials.gov.
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http://dx.doi.org/10.1136/neurintsurg-2020-017012DOI Listing
December 2020

Surface-modified flow diverter p48-MW-HPC: Preliminary clinical experience in 28 patients treated in two centers.

J Neuroradiol 2021 May 17;48(3):195-199. Epub 2020 Dec 17.

Hôpital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France.

Background And Purpose: Flow diversion is increasingly used for endovascular treatment of distal intracranial aneurysms and has led to the development of small diameter flow diverters such as p48-MW (phenox, Bochum, Germany). Use of flow diverters is limited, however, as patients require dual antiplatelet treatment to avoid thromboembolic complications. Hydrophilic Polymer Coating was developed to reduce platelet aggregation on the p48-MW (p48-MW-HPC). This study reports preliminary experience with p48-MW-HPC in aneurysm treatment in two centers.

Materials And Methods: Patients with ruptured, unruptured, and recanalized aneurysms treated with p48-MW-HPC were prospectively included and retrospectively analyzed for safety and efficacy. Safety was evaluated by analyzing intra- and postoperative complications as well as thromboembolic events depicted by DWI in the 72 h post-procedure. Efficacy was evaluated at 6 months based on aneurysm occlusion.

Results: From April 2019 to May 2020, 28 patients aged 25-82 years with 29 aneurysms were treated. Two thromboembolic events (7.1%) were reported with good clinical outcome. Final morbidity and mortality were both 0.0%. Post-operative DWI-MRI was depicting lesions in 70.0% of patients. Short-term (6 months) anatomical results were complete aneurysm occlusion in 87.0% of aneurysms, neck remnant in 8.7%, and aneurysm remnant in 4.3%.

Conclusion: This preliminary clinical evaluation conducted in a relatively small sample size shows high feasibility (100.0%) of p48-MW-HPC aneurysm treatment, without morbidity or mortality, and high efficacy (complete occlusion in 90.0%). Additional larger comparative studies are needed to confirm these results and optimize perioperative antiplatelet treatment.
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http://dx.doi.org/10.1016/j.neurad.2020.11.006DOI Listing
May 2021

Effect of Pre- and In-Hospital Delay on Reperfusion in Acute Ischemic Stroke Mechanical Thrombectomy.

Stroke 2020 10 16;51(10):2934-2942. Epub 2020 Sep 16.

Department of Neurology (B.M., T.R.M., M.G., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland.

Background And Purpose: Post hoc analyses of randomized controlled clinical trials evaluating mechanical thrombectomy have suggested that admission-to-groin-puncture (ATG) delays are associated with reduced reperfusion rates. Purpose of this analysis was to validate this association in a real-world cohort and to find associated factors and confounders for prolonged ATG intervals.

Methods: Patients included into the BEYOND-SWIFT cohort (Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the Solitaire FR With the Intention for Thrombectomy; https://www.clinicaltrials.gov; Unique identifier: NCT03496064) were analyzed (n=2386). Association between baseline characteristics and ATG was evaluated using mixed linear regression analysis. The effect of increasing symptom-onset-to-admission and ATG intervals on successful reperfusion (defined as Thrombolysis in Cerebral Infarction [TICI] 2b-3) was evaluated using logistic regression analysis adjusting for potential confounders.

Results: Median ATG was 73 minutes. Prolonged ATG intervals were associated with the use of magnetic resonance imaging (+19.1 [95% CI, +9.1 to +29.1] minutes), general anesthesia (+12.1 [95% CI, +3.7 to +20.4] minutes), and borderline indication criteria, such as lower National Institutes of Health Stroke Scale, late presentations, or not meeting top-tier early time window eligibility criteria (+13.8 [95% CI, +6.1 to +21.6] minutes). There was a 13% relative odds reduction for TICI 2b-3 (adjusted odds ratio [aOR], 0.87 [95% CI, 0.79-0.96]) and TICI 2c/3 (aOR, 0.87 [95% CI, 0.79-0.95]) per hour ATG delay, while the reduction of TICI 2b-3 per hour increase symptom-onset-to-admission was minor (aOR, 0.97 [95% CI, 0.94-0.99]) and inconsistent regarding TICI 2c/3 (aOR, 0.99 [95% CI, 0.97-1.02]). After adjusting for identified factors associated with prolonged ATG intervals, the association of ATG delay and lower rates of TICI 2b-3 remained tangible (aOR, 0.87 [95% CI, 0.76-0.99]).

Conclusions: There is a great potential to reduce ATG, and potential targets for improvement can be deduced from observational data. The association between in-hospital delay and reduced reperfusion rates is evident in real-world clinical data, underscoring the need to optimize in-hospital workflows. Given the only minor association between symptom-onset-to-admission intervals and reperfusion rates, the causal relationship of this association warrants further research. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03496064.
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http://dx.doi.org/10.1161/STROKEAHA.120.030208DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7523579PMC
October 2020

Retreatments are part of the evaluation of device performance … but have to be analyzed separately.

J Neurointerv Surg 2021 Apr 14;13(4):e6. Epub 2020 Sep 14.

Interventional Neuroradiology, CHU Bicêtre, Le Kremlin-Bicetre, Île-de-France, France.

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http://dx.doi.org/10.1136/neurintsurg-2020-016773DOI Listing
April 2021

Delayed thromboembolic events after coiling of unruptured intracranial aneurysms in a prospective cohort of 335 patients.

J Neurointerv Surg 2020 Sep 7. Epub 2020 Sep 7.

Neuroradiology, APHP, Le Kremlin-Bicetre, Île-de-France, France.

Background: Coiling is the first-line treatment for the management of unruptured intracranial aneurysms (UIAs), but delayed thromboembolic events (TEEs) can occur after such treatment. ARETA (Analysis of Recanalization after Endovascular Treatment of Intracranial Aneurysm) is a prospective multicenter study conducted to analyze aneurysm recanalization. We analyzed delayed TEEs in the UIA subgroup.

Methods: Sixteen neurointerventional departments prospectively enrolled patients treated for ruptured and unruptured aneurysms between December 2013 and May 2015. Participant demographics, aneurysm characteristics, and endovascular techniques were recorded. Data were analyzed from participants with UIA treated by coiling or balloon-assisted coiling. We assessed the rates, timing, management, clinical outcomes, and risk factors for delayed TEEs using univariable and multivariable analyses.

Results: The rate of delayed TEEs was 2.4% (95% CI 1.0% to 4.6%) in patients with unruptured aneurysms, with all events occurring in the week following the procedure. In multivariate analysis, two factors were associated with delayed TEEs: autosomal dominant polycystic kidney disease (ADPKD): 20.0% in patients with ADPKD vs 1.9% in patients without ADPKD (OR 27.3 (95% CI 3.9 to 190.2), p=0.0008) and post-procedure aneurysm remnant: 9.4% in patients with post-procedure aneurysm remnant vs 1.6% in patients with adequate occlusion (OR 9.9 (95% CI 1.0 to 51.3), p=0.006). We describe modalities of management as well as clinical outcomes.

Conclusions: Delayed TEE is a relatively rare complication after coiling of UIAs. In this series, all occurred in the week following the initial procedure. Two factors were associated with delayed TEE: ADPKD and aneurysm remnant at procedure completion.

Clinical Trial Registration: NCT01942512.
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http://dx.doi.org/10.1136/neurintsurg-2020-016654DOI Listing
September 2020

Association of initial imaging modality and futile recanalization after thrombectomy.

Neurology 2020 10 26;95(17):e2331-e2342. Epub 2020 Aug 26.

From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada.

Objective: To test the hypothesis that selection by initial imaging modality (MRI vs CT) is associated with rate of futile recanalizations (FRs) after mechanical thrombectomy (MT), we assessed this association in a multicenter, retrospective observational registry (BEYOND-SWIFT [Registry for Evaluating Outcome of Acute Ischemic Stroke Patients Treated With Mechanical Thrombectomy], NCT03496064).

Methods: In 2,011 patients (49.7% female, median age 73 years [61-81]) included between 2009 and 2017, we performed univariate and multivariate analyses regarding the occurrence of FR. FRs were defined as 90-day modified Rankin Scale (mRS) score 4-6 despite successful recanalization in patients selected by MRI (n = 690) and CT (n = 1,321) with a sensitivity analysis considering only patients with mRS 5-6 as futile.

Results: MRI as compared to CT resulted in similar rates of subsequent MT (adjusted odds ratio [aOR] 1.048, 95% confidence interval [CI] 0.677-1.624). Rates of FR were as follows: 571/1,489 (38%) FR mRS 4-6 including 393/1,489 (26%) FR mRS 5-6. CT-based selection was associated with increased rates of FRs compared to MRI (44% [41%-47%] vs 29% [25%-32%], < 0.001; aOR 1.77 [95% CI 1.25-2.51]). These findings were robust in sensitivity analysis. MRI-selected patients had a delay of approximately 30 minutes in workflow metrics in real-world university comprehensive stroke centers. However, functional outcome and mortality were more favorable in patients selected by MRI compared to patients selected with CT.

Conclusions: CT selection for MT was associated with an increased risk of FRs as compared to MRI selection. Efforts are needed to shorten workflow delays in MRI patients. Further research is needed to clarify the role of the initial imaging modality on FR occurrence and to develop a reliable FR prediction algorithm.
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http://dx.doi.org/10.1212/WNL.0000000000010614DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7682915PMC
October 2020

Safety and efficacy of the Silk flow diverter: Insight from the DIVERSION prospective cohort study.

J Neuroradiol 2020 Jun 29. Epub 2020 Jun 29.

Department of Neuroradiology, University Hospital of Bordeaux, Bordeaux, France. Electronic address:

Background And Purpose: Flow diverters are considered as an essential tool in the stent-based treatment of complex intracranial aneurysms. We report here a subgroup analysis of the nationwide prospective DIVERSION study to investigate the safety and efficacy of the Silk flow diverter at 12 months follow-up.

Methods: We performed a subgroup analysis of patients included in the DIVERSION, a national prospective cohort study including all flow diverters placement between 2012 and 2014 in France, and treated with the Silk. The primary outcome was the morbi-mortality at 12 months, including death, morbidity event and aneurysm retreatment within 12 months post-treatment. All reported serious events were adjudicated by an independent Data Safety and Monitoring Board. Satisfactory occlusion was defined as 3 or 4 on Kamran's scale by an independent imaging core laboratory during follow-up.

Results: A total of 102 procedures involving 101 patients (mean age±standard deviation, 54.3±13.5 years) harbouring 118 aneurysms (113/118 located in the anterior circulation; mean size 8.2±7.1mm) were included. During the 12-month follow-up, 34 (33.3%) procedures experienced at least one morbi-mortality event: 3 deaths, 27 morbidity events and 4 retreatments. Overall, 1/3 deaths and 10/27 morbidity events were related to the device and/or the procedure, leading to a specific survival rate and a specific free-morbidity survival rate at 12 months of 98.98% [95% confidence interval, 92.98%-99.86%] and 89.73% [95%CI, 81.71%-94.36%], respectively. The rate of permanent-related neurological deficit was 5.9% within 12 months. One year follow-up imaging showed satisfactory occlusion in 82.2% of cases.

Conclusion: Flow diversion with the Silk device has a reasonable safety and effectiveness profile for the endovascular treatment of intracranial aneurysms.
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http://dx.doi.org/10.1016/j.neurad.2020.06.006DOI Listing
June 2020

Rebleeding and bleeding in the year following intracranial aneurysm coiling: analysis of a large prospective multicenter cohort of 1140 patients-Analysis of Recanalization after Endovascular Treatment of Intracranial Aneurysm (ARETA) Study.

J Neurointerv Surg 2020 Dec 16;12(12):1219-1225. Epub 2020 Jun 16.

Interventional Neuroradiology, CHU Bicêtre, Le Kremlin-Bicetre, Île-de-France, France.

Background: Endovascular treatment is the first line therapy for the management of ruptured and unruptured intracranial aneurysms, but delayed aneurysm rupture leading to bleeding/rebleeding can occur subsequently. ARETA (Analysis of Recanalization after Endovascular Treatment of intracranial Aneurysm) is a prospective, multicenter study conducted to analyze aneurysm recanalization. We analyzed delayed bleeding and rebleeding in this large cohort.

Methods: 16 neurointerventional departments prospectively enrolled patients treated for ruptured and unruptured aneurysms between December 2013 and May 2015 (ClinicalTrials.gov: NCT01942512). Participant demographics, aneurysm characteristics and endovascular techniques were recorded. Data were analyzed from participants with ruptured or unruptured aneurysms treated by coiling or balloon-assisted coiling. Rates of bleeding and rebleeding were analyzed and associated factors were studied using univariable and multivariable analyses.

Results: The bleeding rate was 0.0% in patients with unruptured aneurysms and 1.0% (95% CI 0.3% to 1.7%) in patients with ruptured aneurysms. In multivariate analysis, two factors were associated with rebleeding occurrence: incomplete aneurysm occlusion after initial treatment (2.0% in incomplete aneurysm occlusion vs 0.2% in complete aneurysm occlusion, OR 10.2, 95% CI 1.2 to 83.3; p=0.03) and dome-to-neck ratio (1.5±0.5 with rebleeding vs 2.2±0.9 without rebleeding, OR 0.2, 95% CI 0.04 to 0.8; p=0.03). Modalities of management of aneurysm rebleeding as well as clinical outcomes are described.

Conclusions: Aneurysm coiling affords good protection against bleeding (for unruptured aneurysms) and rebleeding (for ruptured aneurysms) at 1 year with rates of 0.0% and 1.0%, respectively. Aneurysm occlusion and dome-to-neck ratio are the two factors that appear to play a role in the occurrence of rebleeding.
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http://dx.doi.org/10.1136/neurintsurg-2020-015971DOI Listing
December 2020

Aneurysm treatment with WEB in the cumulative population of two prospective, multicenter series: 3-year follow-up.

J Neurointerv Surg 2021 Apr 12;13(4):363-368. Epub 2020 Jun 12.

Department of Neuroradiology, Nuffield Department of Surgical Sciences, Oxford University, Oxford, Oxfordshire, UK.

Background: WEB treatment is an endovascular approach for wide-neck bifurcation aneurysms that has demonstrated high safety and good efficacy in mid-term follow-up. While evaluating safety in the long term is important to determine if delayed adverse events occur affecting late morbidity and mortality, the most important point to evaluate is the long-term stability of aneurysm occlusion. The current analysis reports the 3-year clinical and anatomical results of WEB treatment in the combined population of two European trials (WEBCAST (WEB Clinical Assessment of Intrasaccular Aneurysm Therapy) and WEBCAST-2).

Methods: Aneurysm occlusion was evaluated using a 3-grade scale: complete occlusion, neck remnant, and aneurysm remnant.

Results: The safety population comprised 79 patients. The efficacy population comprised 61 aneurysms. Aneurysm locations were middle cerebral artery in 32/61 aneurysms (52.5%), anterior communicating artery in 13/61 (21.3%), basilar artery in 9/61 (14.8%), and internal carotid artery terminus in 7/61 (11.5%). No adverse events related to the device or procedure occurred between 2 and 3 years. At 3 years, complete occlusion was observed in 31/61 (50.8%) aneurysms, neck remnant in 20/61 (32.8%), and aneurysm remnant in 10/61 (16.4%). Between 1 year and 3 years, aneurysm occlusion was improved or stable in 53/61 (86.9%) aneurysms and worsened in 8/61 (13.1%). Worsening was mostly from complete occlusion to neck remnant in 6/61 (9.8%) aneurysms. The retreatment rate at 3 years was 11.4%.

Conclusions: This analysis confirms the high safety profile of WEB. Moreover, evidence demonstrates the great stability of aneurysm occlusion with adequate occlusion (complete occlusion or neck remnant) in 83.6% of aneurysms.

Clinical Trial Registration: URL: http://www.clinicaltrials.gov. WEBCAST and WEBCAST-2: Unique identifier: NCT01778322.
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http://dx.doi.org/10.1136/neurintsurg-2020-016151DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7982938PMC
April 2021

Massive Dissecting Aneurysm in the Basilar Tip Artery Treated with Intra-aneurysm and Basilar Artery Coiling.

Med Arch 2020 Feb;74(1):61-64

Department of Neuroradiology, Hôpital Maison-Blanche, France.

Introduction: Deconstructive versus reconstructive technique remains controversial on the management of acute basilar tip artery dissection.

Aim: We introduced a case report of massive dissecting aneurysm in the basilar tip artery treated with intra-aneurysm and basilar artery coiling.

Results: A 30-year-old male presented with sudden headache and severe vomiting. Radiographic study showed a large unruptured dissecting aneurysm in the basilar tip artery involving bilateral P1 segment. This aneurysm was treated with intra-aneurysm and basilar artery coiling. Patient was discharge after 7 days without any neurological deficits. Post-operatively, the patient received 75 mg aspirin and 75 mg clopidogrel PO per day for 3 months - then 75 mg aspirin per day for up to 1 year. Angiographic follow-up at 3 months showed a complete occlusion of aneurysmal sac and basilar tip artery without any deficits (mRS 0). Cerebral arteriography at 6 months follow-up confirmed a stable occlusion of aneurysmal sac with a minor recurrence of aneurysm in left P1 segment.

Conclusion: Intra-aneurysm and basilar artery coiling is valuable alternative technique to treat complex basilar tip dissecting aneurysm in case of infeasible reconstructive technique. Clinical presentation, aneurysm characteristics and collateral circulation have to be investigated on each case to adopt this technique.
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http://dx.doi.org/10.5455/medarh.2020.74.61-64DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7164739PMC
February 2020

In Reply: Aneurysm Treatment With Woven EndoBridge in the Cumulative Population of 3 Prospective, Multicenter Series: 2-Year Follow-up.

Authors:
Laurent Pierot

Neurosurgery 2020 07;87(1):E78-E79

Department of Neuroradiology Hôpital Maison-Blanche Université Reims-Champagne-Ardenne Reims, France.

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http://dx.doi.org/10.1093/neuros/nyaa089DOI Listing
July 2020

Intraoperative Complications of Endovascular Treatment of Intracranial Aneurysms with Coiling or Balloon-assisted Coiling in a Prospective Multicenter Cohort of 1088 Participants: Analysis of Recanalization after Endovascular Treatment of Intracranial Aneurysm (ARETA) Study.

Radiology 2020 05 25;295(2):381-389. Epub 2020 Feb 25.

From the Departments of Neuroradiology, Hôpital Maison-Blanche, Université Reims-Champagne-Ardenne, 45 Rue Cognacq-Jay, 51092 Reims, France (L.P., H.A.N., S.S., M.G.); Department of Research and Public Health, Hôpital Robert Debré, CHU Reims, Reims, France (C.B.); CHU Tours, Tours, France (D.H.); CHU Rennes, Rennes, France (J.Y.G.); CHU Toulouse, Toulouse, France (A.C.J.); CHU Lille, Lille, France (F.B.); CHU Dijon, Dijon France (P.O.C.); CHU Nantes, Nantes, France (H.D.); CHU Poitiers, Poitiers, France (S.V.); CHU Saint-Etienne, Saint-Etienne, France (M.A.); CHU Clermont-Ferrand, Clermont-Ferrand, France (E.C.); CHU Nice, Nice, France (J.S.); Centre Hospitalier Sainte-Anne, Paris, France (D.T.); CHU Bordeaux, Bordeaux, France (G.M.); CHU Créteil, Créteil, France (S.G.); Hôpital Foch, Suresnes, France (G.R.); CHU Pitié-Salpêtrière, Paris, France (F.C.); Interventional Neuroradiology, NEURI Center, Hopital Bicêtre, Le Kremlin-Bicêtre, France (L.S.); Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom (P.W.).

Background Thromboembolic events and intraoperative rupture are the most frequent neurologic complications of intracranial aneurysm coiling. Their frequency has not been evaluated in recent series. Purpose To provide an analysis of complications, clinical outcome, and participant and aneurysm risk factors after aneurysm coiling or balloon-assisted coiling within the Analysis of Recanalization after Endovascular Treatment of Intracranial Aneurysm, or ARETA, cohort. Materials and Methods Sixteen neurointerventional departments prospectively enrolled participants treated for ruptured and unruptured aneurysms between December 2013 and May 2015. Participant demographics, aneurysm characteristics, and endovascular techniques were recorded. Data were analyzed from participants within the overall cohort treated with coiling or balloon-assisted coiling for a single aneurysm. Rates of neurologic complications were analyzed, and associated factors were studied by using univariable analyses (Student test, χ test, or Fisher exact test, as appropriate) and multivariable analyses (logistic regressions). Results A total of 1088 participants (mean age ± standard deviation, 54 years ± 13; 715 women [65.7%]) were analyzed. Thromboembolic events and intraoperative rupture were reported in 113 of 1088 participants (10.4%) and 34 of 1088 participants (3.1%), respectively. Poor clinical outcome (defined as modified Rankin Scale score of 3-6) was reported in 29 of 113 participants (25.7%) with thromboembolic events and in 11 of 34 participants (32.4%) with intraoperative rupture ( = .44). Factors associated with thromboembolic events were female sex (odds ratio [OR], 1.7; 95% confidence interval [CI]: 1.1, 2.8; = .02) and middle cerebral artery location (OR, 1.9; 95% CI: 1.2, 3.0; = .008). Factors associated with intraoperative rupture were anterior communicating artery location (OR, 2.2; 95% CI: 1.1, 4.7; = .03) and small aneurysm size (OR, 3.0; 95% CI: 1.5, 6.3; = .003). Conclusion During aneurysm coiling or balloon-assisted coiling, thromboembolic events were more frequent than were intraoperative rupture. Both complications were associated with poor clinical outcome in a similar percentage of participants. Risk factors for thromboembolic events were female sex and middle cerebral artery location. Risk factors for intraoperative rupture were small aneurysm size and anterior cerebral or communicating artery location. © RSNA, 2020.
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http://dx.doi.org/10.1148/radiol.2020191842DOI Listing
May 2020

How to WEB: a practical review of methodology for the use of the Woven EndoBridge.

J Neurointerv Surg 2020 May 31;12(5):512-520. Epub 2020 Jan 31.

Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA

Wide-necked bifurcation aneurysms (WNBAs) make up 26-36% of all brain aneurysms. Treatments for WNBAs pose unique challenges due to the need to preserve major bifurcation vessels while achieving a durable occlusion of the aneurysm. Intrasaccular flow disruption is an innovative technique for the treatment of WNBAs. The Woven EndoBridge (WEB) device is the only United States Food and Drug Administration approved intrasaccular flow disruption device. In this review article we discuss various aspects of treating WNBAs with the WEB device, including indications for use, aneurysm/device selection strategies, antiplatelet therapy requirement, procedural technique, potential complications and bailouts, and management strategies for residual/recurrent aneurysms after initial WEB treatment.
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http://dx.doi.org/10.1136/neurintsurg-2019-015506DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7231463PMC
May 2020

Endovascular Stroke Treatment and Risk of Intracranial Hemorrhage in Anticoagulated Patients.

Stroke 2020 03 29;51(3):892-898. Epub 2020 Jan 29.

Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.K.).

Background and Purpose- We aimed to determine the safety and mortality after mechanical thrombectomy in patients taking vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs). Methods- In a multicenter observational cohort study, we used multiple logistic regression analysis to evaluate associations of symptomatic intracranial hemorrhage (sICH) with VKA or DOAC prescription before thrombectomy as compared with no anticoagulation. The primary outcomes were the rate of sICH and all-cause mortality at 90 days, incorporating sensitivity analysis regarding confirmed therapeutic anticoagulation. Additionally, we performed a systematic review and meta-analysis of literature on this topic. Results- Altogether, 1932 patients were included (VKA, n=222; DOAC, n=98; no anticoagulation, n=1612); median age, 74 years (interquartile range, 62-82); 49.6% women. VKA prescription was associated with increased odds for sICH and mortality (adjusted odds ratio [aOR], 2.55 [95% CI, 1.35-4.84] and 1.64 [95% CI, 1.09-2.47]) as compared with the control group, whereas no association with DOAC intake was observed (aOR, 0.98 [95% CI, 0.29-3.35] and 1.35 [95% CI, 0.72-2.53]). Sensitivity analyses considering only patients within the confirmed therapeutic anticoagulation range did not alter the findings. A study-level meta-analysis incorporating data from 7462 patients (855 VKAs, 318 DOACs, and 6289 controls) from 15 observational cohorts corroborated these observations, yielding an increased rate of sICH in VKA patients (aOR, 1.62 [95% CI, 1.22-2.17]) but not in DOAC patients (aOR, 1.03 [95% CI, 0.60-1.80]). Conclusions- Patients taking VKA have an increased risk of sICH and mortality after mechanical thrombectomy. The lower risk of sICH associated with DOAC may also be noticeable in the acute setting. Improved selection might be advisable in VKA-treated patients. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT03496064. Systematic Review and Meta-Analysis: CRD42019127464.
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http://dx.doi.org/10.1161/STROKEAHA.119.026606DOI Listing
March 2020

Aneurysm Treatment With Woven EndoBridge in the Cumulative Population of 3 Prospective, Multicenter Series: 2-Year Follow-Up.

Neurosurgery 2020 08;87(2):357-367

Department of Neuroradiology, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris, France.

Background: Woven EndoBridge (WEB; Sequent Medical) treatment is an innovative endovascular approach for treatment of wide-neck bifurcation aneurysms. Initial studies have shown high safety with good efficacy at short term confirmed by trials conducted in United States (WEB-Intrasaccular Therapy) and in Europe (WEB Clinical Assessment of Intrasaccular Aneurysm Therapy [WEBCAST], French Observatory, and WEBCAST-2).

Objective: To report the 2-yr clinical and anatomical results of WEB treatment in the combined population of 3 European trials.

Methods: In a French Observatory, 2-yr clinical and anatomical data were collected. In WEBCAST and WEBCAST-2, 2-yr follow-up was optional, and data were collected when follow-up was performed. Aneurysm occlusion was evaluated using a 3-grade scale: complete occlusion, neck remnant, and aneurysm remnant.

Results: The population for safety was 138/168 patients (82.1%), including 89 females (64.5%), with mean age of 55.5 ± 10.2 yr. The population for efficacy was 121/169 aneurysms (71.6%). Aneurysm locations were middle cerebral artery in 65/121 aneurysms (53.7%), anterior-communicating artery in 25/121 (20.7%), basilar artery in 17/121 (14.0%), and internal carotid artery terminus in 14/121 (11.6%). No clinically relevant adverse events occurred between years 1 and 2. At 2 yr, complete occlusion was observed in 62/121 (51.2%) aneurysms, neck remnant in 36/121 (29.8%) aneurysms, and aneurysm remnant in 23/121 (19.0%) aneurysms. The global retreatment rate at 2 yr was 9.3%.

Conclusion: This analysis confirms the high safety profile of WEB treatment at 2 yr. Aneurysm occlusion is generally stable at 2 yr, and the retreatment rate between 1 yr and 2 yr is low (2.0%).
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http://dx.doi.org/10.1093/neuros/nyz557DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534535PMC
August 2020

Flow Diverters for Intracranial Aneurysms: The DIVERSION National Prospective Cohort Study.

Stroke 2019 12 7;50(12):3471-3480. Epub 2019 Oct 7.

Department of Interventional Neuroradiology (F.T.), Hospices Civils de Lyon, France.

Background and Purpose- Flow diverters are used for endovascular therapy of intracranial aneurysms. We did a nationwide prospective study to investigate the safety and effectiveness of flow diversion at 12 months. Methods- DIVERSION was a national prospective cohort study including all flow diverters placement between October 2012 and February 2014 in France. The primary end point was the event-free survival rate at 12 months, defined as the occurrence of morbidity (intracranial hemorrhage, ischemic stroke, noncerebral hemorrhage, or neurological deficit due to mass effect), retreatment, or death within 12 months post-treatment. A quality control was carried out on 100% of the collected data and of at least 10% of the included patients in each center, chosen at random. All reported serious events were adjudicated by an independent Data Safety and Monitoring Board. Satisfactory occlusion was defined as 3 or 4 on Kamran scale by an independent imaging core laboratory at 12 months. Results- We enrolled 398 patients harboring 477 intracranial aneurysms. At least 1 morbidity-mortality event was noted in 95 of 408 interventions representing an event-free survival rate of 75.7% (95% CI, 71.1-79.7). The rate of permanent-related serious events and mortality was 5.9% and 1.2% at 12 months, respectively. Multivariate analysis showed that high baseline blood pressure (hazard ratio, 2.54; 95% CI, 1.35-4.79; =0.039), diabetes mellitus (hazard ratio, 3.70; 95% CI, 1.60-8.6; =0.0022), and larger aneurysms (hazard ratio, 1.07; 95% CI, 1.04-1.11; <0.0001) were associated with the occurrence of a neurological deficit. The satisfactory occlusion rate at 12 months was 79.9%, and the absence of high baseline blood pressure (odds ratio, 2.01; 95% CI, 1.12-3.71; =0.0193) and postprocedural satisfactory occlusion (odds ratio, 2.75; 95% CI, 1.49-5.09; =0.0012) were associated with a 12-month satisfactory occlusion. Conclusions- A satisfactory occlusion was achieved in almost 80% of cases after flow diverter treatment with a permanent-related serious event and mortality rates of 5.9% and 1.2% at 12 months, respectively.
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http://dx.doi.org/10.1161/STROKEAHA.119.024722DOI Listing
December 2019

Do we still need coils for the endovascular treatment of intracranial aneurysms?

Authors:
Laurent Pierot

J Neurointerv Surg 2019 12;11(12):1173

Department of Radiology, University Hospital Reims, 51092 Reims, France

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http://dx.doi.org/10.1136/neurintsurg-2019-015588DOI Listing
December 2019

Patient and aneurysm factors associated with aneurysm rupture in the population of the ARETA study.

J Neuroradiol 2020 Jun 17;47(4):292-300. Epub 2019 Sep 17.

NEURI Center, hôpital Bicêtre, 94270 Le Kremlin-Bicêtre, France.

Background And Purpose: Identifying patients with intracranial aneurysms (IA) who have a high risk of rupture is critical to determine optimal management. ARETA (Analysis of Recanalization after Endovascular Treatment of intracranial Aneurysm) is a prospective, multicenter study, dedicated to evaluating endovascular treatment of IA. We aimed to identify factors associated with ruptured status, using this very large series of patients with ruptured and unruptured aneurysms.

Methods: Several analyses were conducted in the ARETA population: univariate and multivariate analyses in the whole population of patients and aneurysms to determine patient and aneurysm factors associated with aneurysm rupture, as well as a matched pair analysis (based on aneurysm size) conducted in the subgroup of patients with only one aneurysm to analyze the patient and aneurysm factors simultaneously.

Results: From December 2013 to May 2015, 1289 patients with 1761 aneurysms were included in ARETA. The multivariate analysis identified four patient factors: elevated blood pressure (EBP), no familial history, single IA, and active smoking, and four aneurysm factors: size≥5mm, narrow neck, irregular shape, and ACA/Acom location, associated with rupture status. In the matched pair analysis, five risk factors of rupture were identified: no familial history of aneurysm, narrow neck, active smoking, ACA/Acom location, and irregular shape.

Conclusions: The most important patient factors associated with IA rupture are smoking and EBP. Given that size is a well-identified aneurysm factor, narrow neck also seems to be associated with aneurysm rupture. Further studies are needed to confirm this factor and determine underlying mechanisms. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01942512.
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http://dx.doi.org/10.1016/j.neurad.2019.07.007DOI Listing
June 2020

Mechanical thrombectomy for basilar artery occlusion: efficacy, outcomes, and futile recanalization in comparison with the anterior circulation.

J Neurointerv Surg 2019 Dec 25;11(12):1174-1180. Epub 2019 Jun 25.

Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.

Background: Performing mechanical thrombectomy (MT) in patients with basilar artery occlusion (BAO) is currently not evidence-based.

Objective: To compare patients' outcome, relative merits of achieving recanalization, and predictors of futile recanalization (FR) between BAO and anterior circulation large vessel occlusion (ACLVO) MT.

Methods: In the multicenter BEYOND-SWIFT registry (NCT03496064), univariate and multivariate (displayed as adjusted Odds Ratios, aOR and 95% confidence intervals, 95%-CI) outcome comparisons between BAO (N=165) and ACLVO (N=1574) were performed. The primary outcome was favorable outcome at 90 days (modified Rankin Scale, mRS 0-2). Secondary outcome included mortality, symptomatic intracranial hemorrhage (sICH) and FR. The relative merits of achieving successful recanalization between ACLVO and BAO were evaluated with interaction terms.

Results: MT in BAO was more often technically effective and equally safe in regards to mortality and sICH when compared to ACLVO. When adjusting for baseline differences, there was no significant difference between BAO vs ACLVO regarding rates of favorable outcome (aOR 0.986, 95%-CI 0.553 - 1.758). However, BAO were associated with increased rates of FR (aOR 2.146, 95%-CI 1.267 - 3.633). Predictors for FR were age, stroke severity, maneuver count and intracranial stenting. No significant heterogeneity on the relative merits of achieving successful recanalization on several outcome parameters were observed when comparing BAO and ACLVO.

Conclusions: In selected patients, similar outcomes can be achieved in BAO and ACLVO patients treated with MT. Randomized controlled trials comparing patient selection and interventional strategies seem warranted to avoid FR.

Trial Registration Number: NCT03496064.
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http://dx.doi.org/10.1136/neurintsurg-2018-014516DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6902072PMC
December 2019

Endosaccular flow disruption: where are we now?

J Neurointerv Surg 2019 Oct 13;11(10):1024-1025. Epub 2019 Jun 13.

Radiology, University Hospital Reims, Reims, France.

Endosaccular flow disruption is an innovative method of treating wide-necked complex aneurysms. Currently four types of devices have obtained the CE mark for use within Europe. These are the Woven EndoBridge device (WEB), the Luna Aneurysm Embolization System, the Medina Embolic Device (Medtronic), and the Contour Neurovascular System. The aim of this article is to provide an overview of these devices and to summarize the evidence in the literature pertaining to the treatment of intracranial aneurysms with them.
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http://dx.doi.org/10.1136/neurintsurg-2018-014623DOI Listing
October 2019

[Place of interventional neuroradiology in the prevention of hemorrhagic stroke].

Authors:
Laurent Pierot

Presse Med 2019 Jun 30;48(6):672-683. Epub 2019 May 30.

Hôpital Maison-Blanche, service de neuroradiologie, 45, rue Cognacq-Jay, 51092 Reims cedex, France. Electronic address:

The risk of bleeding of unruptured aneurysms is increasing with aneurysm size. Small unruptured aneurysms can be treated conservatively with a regular MRI/MRA follow-up to detect a potential increase in size. If coiling is still the main endovascular technique for the treatment of unruptured aneurysms, several other techniques are now available including stent-assisted coiling, flow diversion, and flow disruption. After ARUBA study, there is no recommendation to treat unruptured brain AVMs. According to their hemorrhagic risk, dural arteriovenous fistulas with cortical venous drainage have to be treated, generally by endovascular approach through an arterial route.
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http://dx.doi.org/10.1016/j.lpm.2019.05.006DOI Listing
June 2019

Clipping of recanalized intracerebral aneurysms initially treated by the Woven EndoBridge device.

J Neurointerv Surg 2019 Aug 14;11(8):807-811. Epub 2019 May 14.

Neurosurgery, University Hospital Reims, Reims, France.

Background And Purpose: Intrasaccular flow disruption using the Woven EndoBridge (WEB) is a safe and effective method to treat intracranial aneurysms, particularly wide neck bifurcation aneurysms. However mid term and long term follow-up imaging can show aneurysm remnant or recanalization, and retreatment is therefore sometimes necessary. In most cases, retreatment is performed using an endovascular approach. The present series reports and analyzes aneurysm clipping of recanalized or incompletely occluded aneurysms following WEB treatment.

Methods: All patients treated with the WEB device since the beginning of our experience in June 2011 were prospectively collected in a local database. Among them, patients who were retreated by clipping for aneurysm remnants were included in the present series.

Results: In the cumulative population of 130 patients with aneurysms treated by the WEB device from June 2011 to February 2019, 4 patients (3.1%) were retreated with surgical clipping due to incomplete occlusion (2 patients) and aneurysm recanalization (2 patients). Three of the four aneurysms retreated (75%) were located in the middle cerebral artery and one in the anterior communicating artery (25.0%). The aneurysm was ruptured in 1 of 4 patients (25%). Clipping was performed 10-54 months after initial treatment with the WEB. Surgical exposure showed that the WEB device was inside the aneurysm sac in all cases. Clipping was easily performed in all but 1 case. Control DSA showed complete occlusion in two aneurysms and a neck remnant in two.

Conclusion: Clipping is a feasible option for treating aneurysm remnants following initial treatment with intrasaccular flow disruption using the WEB.
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http://dx.doi.org/10.1136/neurintsurg-2019-014903DOI Listing
August 2019

Outcome, efficacy and safety of endovascular thrombectomy in ischaemic stroke according to time to reperfusion: data from a multicentre registry.

Ther Adv Neurol Disord 2019 27;12:1756286419835708. Epub 2019 Mar 27.

Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, CH-3010, Switzerland.

Background And Purpose: In acute ischaemic stroke (AIS) of the anterior circulation (AC) treated with mechanical thrombectomy (MT), data point to a decline of treatment effect with increasing time from symptom onset to treatment. However, the magnitude of the decline will depend on the clinical setting and imaging selection used. The aims of this study were (1) to evaluate the clinical effect of time to reperfusion (TTR); and (2) to assess the safety and technical efficacy of MT according to strata of TTR.

Methods: Using the retrospective multicentre BEYOND-SWIFT registry data (ClinicalTrials.gov identifier: NCT03496064), we compared safety and efficacy of MT in 1461 patients between TTR strata of 0-180 min ( = 192), 180-360 min ( = 876) and >360 min ( = 393). Clinical effect of TTR was evaluated using multivariable logistic regression analyses adjusting for pre-specified confounders [adjusted odds ratios (aOR) and 95% confidence intervals (95% CI)]. Primary outcome was good functional outcome (modified Rankin Scale: mRS 0-2) at day 90.

Results: Every hour delay in TTR was a significant factor related to mRS 0-2 (aOR 0.933, 95% CI 0.887-0.981) with an estimated 1.5% decreased probability of good functional outcome per hour delay of reperfusion, and mRS 0-1 (aOR 0.929, 95% CI 0.877-0.985). Patients with late TTR had lower rates of successful and excellent reperfusion, higher complication rates and number of passes.

Conclusions: TTR is an independent factor related to long-term functional outcome. With increasing TTR, interventional procedures become technically less effective. Efforts should be made to shorten TTR through optimized prehospital and in-hospital pathways.
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http://dx.doi.org/10.1177/1756286419835708DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6437320PMC
March 2019