Publications by authors named "Mikael Mazighi"

191 Publications

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

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

Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France.

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

Endovascular therapy with or without intravenous thrombolysis in acute stroke with tandem occlusion.

J Neurointerv Surg 2021 Apr 28. Epub 2021 Apr 28.

Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, Nancy, France

Background: Endovascular therapy (EVT) is effective and safe in patients with tandem occlusion. The benefit of intravenous thrombolysis (IVT) prior to EVT in acute tandem occlusion is debatable.

Objective: To compare EVT alone with EVT plus IVT in patients with acute ischemic stroke due to anterior circulation tandem occlusions.

Methods: This is an individual patient pooled analysis of the Thrombectomy In TANdem lesions (TITAN) and Endovascular Treatment in Ischemic Stroke (ETIS) Registries. Patients were divided into two groups based on prior IVT treatment: (1) IVT+ group, which included patients who received IVT prior to EVT, (2) IVT- group, which included patients who did not receive IVT prior to EVT. Propensity score (inverse probability of treatment weighting (IPTW)) was used to reduce baseline between-group differences. The primary outcome was favorable outcome-that is, modified Rankin Scale (mRS) score 0 to 2 at 90 days.

Results: Overall, 602 consecutive patients with an acute stroke with tandem occlusion were included (380 and 222 in the bridging therapy and EVT alone groups, respectively). Onset to imaging time was shorter in the IVT+ group (median 103 vs 140 min). In contrast, imaging to puncture time was longer in the IVT+ group (median 107 vs 91 min). In IPTW analysis, the IVT+ group had higher odds of favorable outcome, excellent outcome (90-day mRS score 0-1), and successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2b/3 at the end of EVT). There was no difference in the risk of significant hemorrhagic complications between groups. In secondary analysis of patients treated with acute cervical internal carotid artery stenting, bridging therapy was associated with higher odds of favorable outcome and lower odds of mortality at 90 days.

Conclusions: Our results suggest that bridging therapy in patients with acute ischemic stroke due to anterior tandem occlusion is safe and may improve functional outcome, even in the setting of acute cervical internal carotid artery stenting during EVT.
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http://dx.doi.org/10.1136/neurintsurg-2020-017202DOI Listing
April 2021

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

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

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

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

Clinical Outcome of Acute Ischemic Strokes in Patients with COVID-19.

Cerebrovasc Dis 2021 Mar 30:1-8. Epub 2021 Mar 30.

Neurology Department, Delafontaine Hospital, Saint Denis, France.

Introduction: Acute ischemic stroke (AIS) and thrombotic events (TEs) were reported in patients with COVID-19. Clinical outcome of AIS in the course of COVID-19 remains unknown. We compared early clinical outcome and mortality of COVID-positive (+) patients admitted for AIS with COVID-negative (-) ones. We hypothesized that COVID+ patients would have poorer clinical outcomes and present a higher rate of TEs and mortality compared with COVID- ones.

Methods: In this multicentric observational retrospective study, we enrolled patients over 18 years old admitted for AIS in 3 stroke units of the Parisian region during lockdown from March 17, 2020, to May 2, 2020. COVID-19 status as well as demographic, clinical, biological, and imaging data was collected retrospectively from medical records. Poor outcome was defined as modified Rankin score (mRS) 3-6 (3-6) at discharge. We also compared TE frequency and mortality rate through a composite criterion in both groups.

Results: Two hundred and sixteen patients were enrolled; mean age was 68 years old, and 63% were male. Forty patients were CO-VID+ (18.5%) and 176 were COVID-. Obesity was statistically more frequent in the COVID+ group (36 vs. 13% p < 0.01). The percentage of patients with mRS (3-6) at discharge was higher in the COVID+ group compared with the COVID- group (60 vs. 41%, p = 0.034). The main predictor of presenting a mRS (3-6) at discharge was high NIHSS score at admission (OR, CI 95%: 1.325, 1.22-1.43). Mortality rate was higher in the COVID+ group (12 vs. 3.4%, p = 0.033) as well as TE frequency (15 vs. 2.8%, p < 0.01).

Conclusion: In this study, patients with AIS infected by SARS-CoV-2 showed a poorer early outcome than COVID- ones. However, when compared to other factors, COVID-19 was not a significant predictor of poor outcome. Vascular morbidity and mortality rates were significantly higher in the COVID+ group compared with the COVID- group.
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http://dx.doi.org/10.1159/000514562DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8089450PMC
March 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

A Novel Mouse Model for Cerebral Venous Sinus Thrombosis.

Transl Stroke Res 2021 Mar 5. Epub 2021 Mar 5.

Laboratory for Vascular Translational Science (LVTS), INSERM UMR 1148, Université de Paris, 75018, Paris, France.

Cerebral venous sinus thrombosis (CVST) is an uncommon cause of stroke resulting in parenchymal injuries associated with heterogeneous clinical symptoms and prognosis. Therefore, an experimental animal model is required to further study underlying mechanisms involved in CVST. This study is aimed at developing a novel murine model suitable and relevant for evaluating injury patterns during CVST and studying its clinical aspects. CVST was achieved in C57BL/6J mice by autologous clot injection into the superior sagittal sinus (SSS) combined with bilateral ligation of external jugular veins. Clot was prepared ex vivo using thrombin before injection. On days 1 and 7 after CVST, SSS occlusion and associated-parenchymal lesions were monitored using different modalities: in vivo real-time intravital microscopy, magnetic resonance imaging (MRI), and immuno-histology. In addition, mice were subjected to a neurological sensory-motor evaluation. Thrombin-induced clot provided fibrin- and erythrocyte-rich thrombi that lead to reproducible SSS occlusion at day 1 after CVST induction. On day 7 post-CVST, venous occlusion monitoring (MRI, intravital microscopy) showed that initial injected-thrombus size did not significantly change demonstrating no early spontaneous recanalization. Microscopic histological analysis revealed that SSS occlusion resulted in brain edema, extensive fibrin-rich venular thrombotic occlusion, and ischemic and hemorrhagic lesions. Mice with CVST showed a significant lower neurological score on post-operative days 1 and 7, compared to the sham-operated group. We established a novel clinically CVST-relevant model with a persistent and reproducible SSS occlusion responsible for symptomatic ischemic and hemorrhagic lesions. This method provides a reliable model to study CVST physiopathology and evaluation of therapeutic new regimens.
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http://dx.doi.org/10.1007/s12975-021-00898-1DOI Listing
March 2021

Endovascular thrombectomy 2020: open issues.

Eur Heart J Suppl 2020 Nov 6;22(Suppl M):M13-M18. Epub 2020 Dec 6.

Department of Neuroradiology, University Hopital Pierre Paul Riquet, Toulouse, France.

Mechanical thrombectomy is now well - established first - line treatment for selected patients with large artery occlusions of the anterior circulation. However, number of technical and procedural issues remains open to assure optimal outcomes in majority of patients including those suffering from posterior circulation perfusion defects. This brief review addresses some of the open issues and refers to the ongoing trials to close the existing knowledge gaps.
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http://dx.doi.org/10.1093/eurheartj/suaa161DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7916414PMC
November 2020

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

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

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

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

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

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

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

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

Increased serum QUIN/KYNA is a reliable biomarker of post-stroke cognitive decline.

Mol Neurodegener 2021 02 15;16(1). Epub 2021 Feb 15.

Université de Paris, INSERM U1148, Laboratory for Vascular Translational Science, F-75018, Paris, France.

Background: Strokes are becoming less severe due to increased numbers of intensive care units and improved treatments. As patients survive longer, post-stroke cognitive impairment (PSCI) has become a major health public issue. Diabetes has been identified as an independent predictive factor for PSCI. Here, we characterized a clinically relevant mouse model of PSCI, induced by permanent cerebral artery occlusion in diabetic mice, and investigated whether a reliable biomarker of PSCI may emerge from the kynurenine pathway which has been linked to inflammatory processes.

Methods: Cortical infarct was induced by permanent middle cerebral artery occlusion in male diabetic mice (streptozotocin IP). Six weeks later, cognitive assessment was performed using the Barnes maze, hippocampi long-term potentiation using microelectrodes array recordings, and neuronal death, white matter rarefaction and microglia/macrophages density assessed in both hemispheres using imunohistochemistry. Brain and serum metabolites of the kynurenin pathway were measured using HPLC and mass fragmentography. At last, these same metabolites were measured in the patient's serum, at the acute phase of stroke, to determine if they could predict PSCI 3 months later.

Results: We found long-term spatial memory was impaired in diabetic mice 6 weeks after stroke induction. Synaptic plasticity was completely suppressed in both hippocampi along with increased neuronal death, white matter rarefaction in both striatum, and increased microglial/macrophage density in the ipsilateral hemisphere. Brain and serum quinolinic acid concentrations and quinolinic acid over kynurenic acid ratios were significantly increased compared to control, diabetic and non-diabetic ischemic mice, where PSCI was absent. These putative serum biomarkers were strongly correlated with degradation of long-term memory, neuronal death, microglia/macrophage infiltration and white matter rarefaction. Moreover, we identified these same serum biomarkers as potential predictors of PSCI in a pilot study of stroke patients.

Conclusions: we have established and characterized a new model of PSCI, functionally and structurally, and we have shown that the QUIN/KYNA ratio could be used as a surrogate biomarker of PSCI, which may now be tested in large prospective studies of stroke patients.
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http://dx.doi.org/10.1186/s13024-020-00421-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7885563PMC
February 2021

Cost-Effectiveness of Mechanical Thrombectomy for Treatment of Stroke: From Modeling to Real-World Implementation.

Stroke 2021 Jan 11;52(2):674-676. Epub 2021 Jan 11.

Department of Neurology, Lariboisière Hospital, Research and Training Center for Cerebrovascular Disease, Fondation Rothschild Hospital, Université de Paris, France (M.M.).

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http://dx.doi.org/10.1161/STROKEAHA.120.032112DOI Listing
January 2021

Intracranial Hemorrhage After Reperfusion Therapies in Acute Ischemic Stroke Patients.

Front Neurol 2020 11;11:599908. Epub 2020 Dec 11.

Interventional Neuroradiology Department, Hôpital Fondation Adolphe de Rothschild, Paris, France.

Reperfusion therapies are the mainstay of acute ischemic stroke (AIS) treatments and overall improve functional outcome. Among the established complications of intravenous (IV) tissue-type plasminogen activator (tPA), intracranial hemorrhage (ICH) is by far the most feared and has been extensively described by seminal works over the last two decades. Indeed, IV tPA is associated with increased odds of any ICH and symptomatic ICH responsible for increased mortality rate during the first week after an AIS. Despite these results, IV tPA has been found beneficial in several pioneering randomized trials and improves functional outcome at 3 months. Endovascular therapy (EVT) combined with IV tPA for AIS patients consecutive to an anterior circulation large-vessel occlusion does not increase ICH occurrence. Of note, EVT following IV tPA leads to significantly higher rates of early reperfusion than with IV tPA alone, with no difference in ICH, which challenges the paradigm of reperfusion as a major prognostic factor for ICH complications. However, several blood biomarkers (glycemia, platelet and neutrophil count), clinical factors (age, AIS severity, blood pressure management, diabetes mellitus), and neuroradiological factors (cerebral microbleeds, infarct size) have been identified as risk factors for ICH after reperfusion therapy. In the years to come, the ultimate goal will be to further improve either reperfusion rates and functional outcome, while reducing hemorrhagic complications. To this end, various approaches being investigated are discussed in this review, such as blood-pressure control after reperfusion or the use of new antiplatelet agents as an adjunct to IV tPA and exhibit reduced hemorrhagic potential during the early phase of AIS.
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http://dx.doi.org/10.3389/fneur.2020.599908DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759548PMC
December 2020

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

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

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

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

Mismatch Profile Influences Outcome After Mechanical Thrombectomy.

Stroke 2021 01 22;52(1):232-240. Epub 2020 Dec 22.

Department of Neuroradiology (A.G., J.D., A.-C.J., F.B., C.C.), Centre Hospitalier Universitaire de Toulouse, France.

Background And Purpose: Mechanical thrombectomy (MT) is the recommended treatment for acute ischemic stroke caused by anterior circulation large vessel occlusion. However, despite a high rate of reperfusion, the clinical response to successful MT remains highly variable in the early time window where optimal imaging selection criteria have not been established. We hypothesize that the baseline perfusion imaging profile may help forecast the clinical response to MT in this setting.

Methods: We conducted a prospective multicenter cohort study of patients with large vessel occlusion-related acute ischemic stroke treated by MT within 6 hours. Treatment decisions and the modified Rankin Scale evaluation at 3 months were performed blinded to the results of baseline perfusion imaging. Study groups were defined a posteriori based on predefined imaging profiles: target mismatch (TMM; core volume <70 mL/mismatch ratio >1.2 and mismatch volume >10 mL) versus no TMM or mismatch (MM; mismatch ratio >1.2 and volume >10 mL) versus no MM. Functional recovery (modified Rankin Scale, 0-2) at 3 months was compared based on imaging profile at baseline and whether reperfusion (modified Thrombolysis in Cerebral Infarction 2bc3) was achieved.

Results: Two hundred eighteen patients (mean age, 71±15 years; median National Institutes of Health Stroke Scale score, 17 [interquartile range, 12-21]) were enrolled. Perfusion imaging profiles were 71% TMM and 82% MM. The rate of functional recovery was 54% overall. Both TMM and MM profiles were independently associated with a higher rate on functional recovery at 3 months Adjusted odds ratios were 3.3 (95% CI, 1.4-7.9) for TMM and 5.9 (95% CI, 1.8-19.6) for MM. Reperfusion (modified Thrombolysis in Cerebral Infarction 2bc3) was achieved in 86% and was more frequent in TMM and MM patients. Reperfusion was associated with a higher rate of functional recovery in MM and TMM patients but not among those with no MM.

Conclusions: In this cohort study, about 80% of the patients with a large vessel occlusion-related acute ischemic stroke had evidence of penumbra, regardless of infarction volume. Perfusion imaging profiles predict the clinical response to MT.
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http://dx.doi.org/10.1161/STROKEAHA.120.031929DOI Listing
January 2021

Age and Outcome after Endovascular Treatment in Anterior Circulation Large-Vessel Occlusion Stroke: ETIS Registry Results.

Cerebrovasc Dis 2021 15;50(1):68-77. Epub 2020 Dec 15.

Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, Nancy, France.

Background: Increasing patient age has been identified in clinical trials as a poor prognostic factor for functional independence after endovascular treatment (EVT) for acute ischemic stroke. These findings may not be fully generalizable to clinical practice due to strict inclusion and exclusion criteria in these trials. We aim to assess and quantify the association of patient age, especially in patients >80 and >90 years old, with functional outcome after EVT in current, everyday clinical practice.

Methods: The ETIS (Endovascular Treatment in Ischemic Stroke) Registry is an ongoing, prospective, observational study of 6 comprehensive stroke centers in France. We analyzed 1,708 patients treated between January 2017 and December 2018 and assessed the association of patient age with functional outcome adjusting for demographic and procedural predictors of functional outcome.

Results: The positive effect of mechanical thrombectomy diminished significantly with increasing age: compared to the 18-80 years age group, the odds for achieving a good functional outcome at 90 days after the procedure decreased in the 80-90 and >90 years groups (multilevel OR: 0.38, 95% CI: 0.28-0.51 and OR: 0.2, 95% CI: 0.09-0.45, respectively, p < 0.001). Increasing age was associated with increased mortality (multilevel OR: 2.46, 95% CI: 1.72-3.54 for the 80-90 years group and multilevel OR: 5.49, 95% CI: 2.97-10.16 for the >90 years group).

Conclusion: Patient age is strongly associated with functional outcome after EVT for acute ischemic stroke. The positive effect of thrombectomy persists in older age groups, even after adjustment for prognostic factors related to poor functional outcome. Stroke physicians should provide EVT irrespective of the patient's age.
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http://dx.doi.org/10.1159/000512203DOI Listing
December 2020

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

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

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

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

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

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

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

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

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

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

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

Time from I.V. Thrombolysis to Thrombectomy and Outcome in Acute Ischemic Stroke.

Ann Neurol 2021 03 15;89(3):511-519. Epub 2020 Dec 15.

Department of Diagnostic and Therapeutic Neuroradiology, CHRU-Nancy, Université de Lorraine, Nancy, France.

Objective: Whether the time from intravenous thrombolysis (IVT) to endovascular treatment (EVT) in patients with acute ischemic stroke has an effect on the functional outcome is unknown.

Methods: The Endovascular Treatment in Ischemic Stroke (ETIS) registry is an ongoing, prospective, multicenter, observational study that perform EVT in France. Data were analyzed from patients treated by IVT and EVT between October 2013 and December 2018 in 6 comprehensive stroke centers. In the primary analysis, we assessed the association of time from IVT administration to start of EVT with functional outcome (measured with the modified Rankin Scale [mRS]), by means of ordinal logistic regression. Secondary end points included angiographic and safety outcomes.

Results: We analyzed 1,986 patients with acute ischemic stroke due to anterior circulation large vessel occlusion who underwent IVT and EVT. An increased IVT to start of EVT time was associated with a worse functional outcome at 90 days (mRS = 0-2, adjusted odds ratio [OR] per 30 minutes increase in time = 0.91, 95% confidence interval [CI] = 0.86-0.96; mRS = 0-1, adjusted OR per 30 minutes increase in time = 0.89, 95% CI = 0.84-0.94), a lower chance of modified Thrombolysis in Cerebral Infarction (mTICI) grade 2b to 3 reperfusion (adjusted OR per 30 minutes increase in time = 0.93, 95% CI = 0.87-0.98), and an increased probability of symptomatic intracerebral hemorrhage (adjusted OR per 30 minutes increase in time = 1.09, 95% CI = 0.99-1.18).

Interpretation: These findings provide a basis for further studies to determine if the functional outcome of patients with stroke can be greatly improved by optimizing IVT to EVT times. ANN NEUROL 2021;89:511-519.
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http://dx.doi.org/10.1002/ana.25978DOI Listing
March 2021

Changes in Neuroendovascular Procedural Volume During the COVID-19 Pandemic: An International Multicenter Study.

J Neuroimaging 2021 01 23;31(1):171-179. Epub 2020 Nov 23.

Department of Neurology, University of Texas Rio Grande Valley - Valley Baptist Medical Center, Harlingen, TX.

Background And Purpose: The effect of coronavirus disease 2019 (COVID-19) pandemic on performance of neuroendovascular procedures has not been quantified.

Methods: We performed an audit of performance of neuroendovascular procedures at 18 institutions (seven countries) for two periods; January-April 2019 and 2020, to identify changes in various core procedures. We divided the region where the hospital was located based on the median value of total number of COVID-19 cases per 100,00 population-into high and low prevalent regions.

Results: Between 2019 and 2020, there was a reduction in number of cerebral angiograms (30.9% reduction), mechanical thrombectomy (8% reduction), carotid artery stent placement for symptomatic (22.7% reduction) and asymptomatic (43.4% reduction) stenoses, intracranial angioplasty and/or stent placement (45% reduction), and endovascular treatment of unruptured intracranial aneurysms (44.6% reduction) and ruptured (22.9% reduction) and unruptured brain arteriovenous malformations (66.4% reduction). There was an increase in the treatment of ruptured intracranial aneurysms (10% increase) and other neuroendovascular procedures (34.9% increase). There was no relationship between procedural volume change and intuitional location in high or low COVID-19 prevalent regions. The procedural volume reduction was mainly observed in March-April 2020.

Conclusions: We provided an international multicenter view of changes in neuroendovascular practices to better understand the gaps in provision of care and identify individual procedures, which are susceptible to change.
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http://dx.doi.org/10.1111/jon.12803DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7753603PMC
January 2021

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

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

Interventional Neuroradiology Department, Fondation Rothschild, Paris, France.

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

Safety and Outcome of Carotid Dissection Stenting During the Treatment of Tandem Occlusions: A Pooled Analysis of TITAN and ETIS.

Stroke 2020 12 10;51(12):3713-3718. Epub 2020 Nov 10.

Université de Lorraine, CHRU-Nancy, Department of Diagnostic and Therapeutic Neuroradiology, F-54000 Nancy, France (B.G.).

Background And Purpose: The efficacy of endovascular therapy in patients with acute ischemic stroke due to tandem occlusion is comparable to that for isolated intracranial occlusion in the anterior circulation. However, the optimal management of acute cervical internal carotid artery lesions is unknown, especially in the setting of carotid dissection, but emergency carotid artery stenting (CAS) is frequently considered. We investigated the safety and efficacy of emergency CAS for carotid dissection in patients with acute stroke with tandem occlusion in current clinical practice.

Methods: We retrospectively analyzed a prospectively maintained database composed of 2 merged multicenter international observational real-world registries (Endovascular Treatment in Ischemic Stroke and Thrombectomy in Tandem Lesion). Data from endovascular therapy performed in the treatment of tandem occlusions related to acute cervical carotid dissection between January 2012 and January 2019 at 24 comprehensive stroke centers were analyzed.

Results: The study assessed 136 patients with tandem occlusion due to dissection, including 65 (47.8%) treated with emergency CAS and 71 (52.2%) without. The overall rates of favorable outcome (90-day modified Rankin Scale score, 0-2) and successful reperfusion (modified Thrombolysis in Cerebral Infarction, 2b-3) were 58.0% (n=76 [95% CI, 49.6%-66.5%]) and 77.9% (n=106 [95% CI, 71.0%-85.0%]), respectively. In subgroup analyses, the rate of successful reperfusion (89.2% versus 67.6%; adjusted odds ratio, 2.24 [95% CI, 1.33-3.77]) was higher after CAS, whereas the 90-day favorable outcome (54.3% versus 61.4%; adjusted odds ratio, 0.84 [95% CI, 0.58-1.22]), symptomatic intracerebral hemorrhage (sICH; 10.8% versus 5.6%; adjusted odds ratio, 1.59 [95% CI, 0.79-3.17]), and 90-day mortality (8.0% versus 5.8%; adjusted odds ratio, 1.00 [95% CI, 0.48-2.09]) did not differ. In sensitivity analyses of patients with successful intracranial reperfusion, CAS was not associated with an improved clinical outcome.

Conclusions: Emergency stenting of the dissected cervical carotid artery during endovascular therapy for tandem occlusions seems safe, whatever the quality of the intracranial reperfusion.
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http://dx.doi.org/10.1161/STROKEAHA.120.030038DOI Listing
December 2020

Neuron-Specific Enolase Levels in Adults Under Venoarterial Extracorporeal Membrane Oxygenation.

Crit Care Explor 2020 Oct 15;2(10):e0239. Epub 2020 Oct 15.

Université de Paris, INSERM UMR1148, Team 6, Paris, France.

Objectives: We aimed to determine if elevations in serum neuron-specific enolase are associated with brain injury and outcomes in adults who require venoarterial extracorporeal membrane oxygenation.

Design: Prospective observational study.

Setting: Two ICUs of a university hospital, Paris, France.

Patients: Consecutive adult patients treated with venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock or in-hospital refractory cardiac arrest.

Interventions: None.

Measurements And Main Results: Serum sampled 1, 3, and 7 days after venoarterial extracorporeal membrane oxygenation cannulation was stored at -80°C and neuron-specific enolase concentrations were measured in batches at the end of the study. The association between neuron-specific enolase concentrations and outcomes (28-d mortality and poor outcome, defined by a score of 4-6 on the modified Rankin scale at 90 d) were explored by multivariable logistic regression, with neuron-specific enolase concentrations dichotomized according to median values. One-hundred three patients were included, of whom 26 (25%) received preextracorporeal membrane oxygenation cardiopulmonary resuscitation. Median (interquartile range) day-1, day-3, and day-7 neuron-specific enolase serum concentrations were 37 μg/L (26-51 μg/L), 25 μg/L (19-37) μg/L, and 22 μg/L (17-31 μg/L). After adjustment for Simplified Acute Physiology Score II, preextracorporeal membrane oxygenation cardiopulmonary resuscitation, and Sepsis Organ Failure Assessment score at time of cannulation, a day-3 neuron-specific enolase greater than 25 μg/L remained independently associated with 28-day mortality (adjusted odds ratio, 4.98; 95% CI, 1.86-13.32) and poor outcome at 90 days (adjusted odds ratio, 4.63; 95% CI, 1.81-11.84). A day-3 neuron-specific enolase threshold greater than 80 μg/L had a 100% specificity for prediction of both mortality (95% CI, 92-100%) and poor functional outcome (95% CI, 89-100%). In a subset of patients who underwent brain CT, neuron-specific enolase concentrations were significantly higher in patients diagnosed with stroke, as compared with those without stroke.

Conclusions: In adult patients under venoarterial extracorporeal membrane oxygenation, day-3 serum neuron-specific enolase concentrations are independently associated with short-term mortality and poor functional outcomes. These findings deserve validation in a multicenter setting.
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http://dx.doi.org/10.1097/CCE.0000000000000239DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7566864PMC
October 2020

The role of infarct location in patients with DWI-ASPECTS 0-5 acute stroke treated with thrombectomy.

Neurology 2020 12 22;95(24):e3344-e3354. Epub 2020 Oct 22.

From the Department of Neuroradiology (P.P.), Division of Interventional Neuroradiology, and Department of Neurosurgery (P.P., M.C.), San Raffaele University Hospital, Milan, Italy; Department of Interventional Neuroradiology (M.M., M.P., R. Blanc), Rothschild Foundation, Paris; IADI, INSERM U1254 (B.C., G.H., R.A., B.G.), and Department of Diagnostic and Therapeutic Neuroradiology (R.A., B.G.), Department of Neurology, Stroke Unit (S.R.), and INSERM U1116 (S.R.), CHRU-Nancy, Université de Lorraine, Nancy; Departments of Diagnostic and Interventional Neuroradiology (A.C.) and Neurology (B.L.), Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes; Departments of Interventional Neuroradiology (C.D.) and Neurology (C.A.), CHRU Gui de Chauliac, Montpellier; Department of Diagnostic and Interventional Neuroradiology (G.M.) and Department of Neurology, Stroke Center (I.S.), University Hospital of Bordeaux; and Department of Neuroradiology (R. Bourcier), University Hospital of Nantes, France.

Objective: To determine whether hemisphere involvement and infarct location on the Alberta Stroke Program CT Score (ASPECTS) template should serve as predictors of 90-day clinical outcome in patients with acute ischemic stroke with pretreatment diffusion-weighted imaging (DWI)-ASPECTS 0-5 treated with mechanical thrombectomy (MT).

Methods: We analyzed data of all consecutive patients included in the Endovascular Treatment in Ischemic Stroke registry between January 1, 2012, and August 31, 2018, who presented with a pretreatment DWI-ASPECTS 0-5 and underwent MT. Multivariable analyses were performed in order to identify the role of infarct location and hemisphere involvement on good outcome defined by a modified Rankin Scale (mRS) score 0-2 at 90 days and on the whole distribution of mRS (shift analysis).

Results: A total of 344 patients with a DWI-ASPECTS 0-5 (median 4, IQR 3-5) were included. Neither infarct location nor hemisphere involvement was found to be an independent predictor of good outcome. Involvement of the M6 region in right-sided strokes (adjusted odds ratio [aOR] 2.6, 99% confidence interval [CI] 1.14-5.8; = 0.003) and the internal capsule in left-sided strokes (aOR 2.6, 99% CI 0.8-7.9; < 0.020) independently predicted increased disability on the mRS distribution in the affected subpopulations.

Conclusion: Our study suggests that neither hemisphere nor infarct location should be considered as an exclusion criterion for MT in patients with stroke with pretreatment DWI-ASPECTS 0-5. The involvement of specific regions of interest was associated with increased disability. These may provide valuable information regarding stroke management options and neurologic recovery for use of caregivers in the postacute phase.
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http://dx.doi.org/10.1212/WNL.0000000000011096DOI Listing
December 2020

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

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

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

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

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

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

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

[Recanalization after cerebral ischemia].

Authors:
Mikaël Mazighi

Rev Prat 2020 Jun;70(6):626-628

Département de neurologie, département médico-universitaire (DMU) neurosciences, Assistance publique-Hôpitaux de Paris (AP-HP) Nord, Paris, France ; service de neuroradiologie interventionnelle, fondation Adolphe-de- Rothschild, Paris, France ; unité Inserm U1148 ; Laboratory of vascular translational science, Paris, France ; fédération hospitalo-universitaire (FHU) NeuroVasc ; université de Paris, France.

Recanalization after cerebral ischemia. Acute ischemic stroke (AIS) management is based on stroke unit admission and arterial recanalization. Recanalization therapies include the endovascular approach (also called mechanical thrombectomy) and intravenous (IV) alteplase (i.e. thrombolysis). In the setting of AIS consecutive to large vessel occlusion of the anterior circulation (i.e. internal carotid and/or middle cerebral arteries), IV alteplase is associated to endovascular approach. IV alteplase alone being devoted to AIS without large vessel occlusion. The therapeutic window is of 4h30 for IV alteplase administration and 6 hours for endovascular approach. Using MRI and perfusion brain imaging, the therapeutic window may be individualized and extended up to 24 hours. Although this extended time window is an opportunity to treat more patients, the rapidity of recanalization remains critical, as it is a major predictor of clinical outcome, emphasizing the need to reduce, as much as possible, treatment delays.
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June 2020

Anaesthesia and haemodynamic management of acute ischaemic stroke patients before, during and after endovascular therapy.

Anaesth Crit Care Pain Med 2020 12 8;39(6):859-870. Epub 2020 Oct 8.

Department of Anaesthesiology and Critical Care, Lariboisière Hospital, DMU Parabol, AP-HP Nord & University of Paris, Paris, France; UMR-S 942 MASCOT, Inserm, France. Electronic address:

Endovascular therapy (EVT) is now standard of care for eligible patients with acute ischaemic stroke caused by large vessel occlusion in the anterior circulation. EVT can be performed with general anaesthesia (GA) or with monitored anaesthesia care, involving local anaesthesia with or without conscious sedation (LA/CS). Controversies remain regarding the optimal choice of anaesthetic strategy and observational studies suggested poorer functional outcome and higher mortality in patients treated under GA, essentially because of its haemodynamic consequences and the delay to put patients under GA. However, these studies are limited by selection bias, the most severe patients being more likely to receive GA and recent randomised trials and meta-analysis showed that protocol-based GA compared with LA/CS is significantly associated with less disability at 3 months. Unlike for intravenous thrombolysis, few data exist to guide management of blood pressure (BP) before and during EVT, but arterial hypotension should be avoided as long as the occlusion persists. BP targets following EVT should probably be adapted to the degree of recanalisation and the extent of ischaemia. Lower BP levels may be warranted to prevent reperfusion injuries even if prospective haemodynamic management evaluations after EVT are lacking.
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http://dx.doi.org/10.1016/j.accpm.2020.05.020DOI Listing
December 2020

Admission Blood Pressure and Outcome of Endovascular Therapy: Secondary Analysis of ASTER Trial.

J Stroke Cerebrovasc Dis 2020 Dec 3;29(12):105347. Epub 2020 Oct 3.

Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Université de Lorraine, INSERM U1254, Nancy, France. Electronic address:

Background: Elevated blood pressure (BP) is common among patients presenting with acute ischemic stroke due to large vessel occlusions. The literature is inconsistent regarding the association between admission BP and outcome of mechanical thrombectomy (MT). Moreover, it is unclear whether the first line thrombectomy strategy (stent retriever [SR] versus contact aspiration [CA]) modifies the relationship between BP and outcome.

Methods: This is a post hoc analysis of the ASTER (Contact Aspiration Versus Stent Retriever for Successful Revascularization) randomized trial. BP was measured prior to randomization in all included patients. Co-primary outcomes included 90-day functional independence (modified Rankin Scale [mRS] 0-2) and successful revascularization (modified Treatment in Cerebral Ischemia [mTICI] 2b-3). Secondary outcomes included symptomatic intracerebral hemorrhage (sICH) and parenchymal hemorrhage (PH) within 24 hours.

Results: A total of 381 patients were included in the present study. Mean (SD) systolic BP (SBP) and diastolic BP (DBP) were 148 (26) mm Hg and 81 (16) mm Hg, respectively. There was no association between SBP or DBP and successful revascularization or 90-day functional independence. Similarly, there was no association between admission SBP or DBP with sICH or PH. Subgroup analysis based on the first-line thrombectomy strategy revealed similar results with no heterogeneity across groups.

Conclusion: Admission BP was not associated with functional, angiographic or safety outcomes. Results were similar in both CA and CA groups.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.105347DOI Listing
December 2020

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Local Anesthesia Without Sedation During Thrombectomy for Anterior Circulation Stroke Is Associated With Worse Outcome.

Stroke 2020 10 8;51(10):2951-2959. Epub 2020 Sep 8.

Université de Lorraine, CHRU-Nancy, Department of Diagnostic and Therapeutic Neuroradiology, F-54000 Nancy, France (R.A., F.Z., B.G.).

Background And Purpose: The best anesthetic management for mechanical thrombectomy of large vessel occlusion strokes is still uncertain and could impact the quality of reperfusion and clinical outcome. We aimed to compare the efficacy and safety outcomes between local anesthesia (LA) and conscious sedation in a large cohort of acute ischemic stroke patients with anterior circulation large vessel occlusion strokes treated with mechanical thrombectomy in current, everyday clinical practice.

Methods: Patients undergoing mechanical thrombectomy for anterior large vessel occlusion strokes at 4 comprehensive stroke centers in France between January 1, 2018, and December 31, 2018, were pooled from the ongoing prospective multicenter observational Endovascular Treatment in Ischemic Stroke Registry in France. Intention-to-treat and per-protocol analyses were used.

Results: Among the included 1034 patients, 762 were included in the conscious sedation group and 272 were included in the LA group. In the propensity score matched cohort, the rate of favorable outcome (90-day modified Rankin Scale score 0-2) was significantly lower in the LA group than in the conscious sedation group (40.0% versus 52.0%, matched relative risk=0.76 [95% CI, 0.60-0.97]), as well as the rate of successful reperfusion (modified Thrombolysis in Cerebral Infarction grade 2b-3; 76.6% versus 87.1%; matched relative risk=0.88 [95% CI, 0.79-0.98]). There was no difference in procedure time between the 2 groups. In the inverse probability of treatment weighting-propensity score-adjusted cohort, similar significant differences were found for favorable outcomes and successful reperfusion. In inverse probability of treatment weighting-propensity score-adjusted cohort, a higher rate of 90-day mortality and a lower parenchymal hematoma were observed after LA. The sensitivity analysis restricted to our per-protocol sample provided similar results in the matched- and inverse probability of treatment weighting-propensity cohorts.

Conclusions: In the Endovascular Treatment in Ischemic Stroke registry mainly included patients in early time window (<6 hours), LA was associated with lower odds of favorable outcome, successful reperfusion, and higher odds of mortality compared with conscious sedation for mechanical thrombectomy of large vessel occlusion.
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http://dx.doi.org/10.1161/STROKEAHA.120.029194DOI Listing
October 2020