Augustin Lecler

Endovascular Treatment of Intracranial Unruptured Aneurysms: A Systematic Review of the Literature on Safety with Emphasis on Subgroup Analyses

PURPOSE To report subgroup analyses of an updated systematic review on endovascular treatment of intracranial unruptured aneurysms (UAs); to compare types of embolic agents, adjunct techniques, and newer devices; and to identify potential risk factors for poor outcomes. MATERIALS AND METHODS Meta-Analysis of Observational Studies in Epidemiology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to prepare this article, and the literature was searched with PubMed and with EMBASE and Cochrane databases. Six eligibility criteria (procedural complications rates; at least 10 patients; saccular, nondissecting UAs; original study published in English or French between January 2003 and July 2011; methodological quality score > 6 [modified Strengthening and Reporting of Observational Studies in Epidemiology criteria]; a study published in a peer-reviewed journal) were used. End points included procedural mortality and unfavorable outcomes (death or modified Rankin Scale, Glasgow Outcome Scale, or World Federation of Neurosurgeons Scale at 1 month scores, all > 2). A fixed-effects model (Mantel-Haenszel) was used for pooled estimates of mortality and unfavorable outcomes; a random-effects model (DerSimonian-Laird) was used in case of heterogeneity. RESULTS Ninety-seven studies with 7172 patients (26 studies published July 2008 through July 2011) were included. Sixty-nine (1.8%) of 7034 patients died (fixed-effect weighted average; 99% confidence interval [CI]: 1.4%, 2.4%; Q value, 55.0; I(2) = 0%). Unfavorable outcomes, including death, occurred in 4.7% (242 of 6941) of patients (99% CI: 3.8, 5.7; Q value, 128.3; I(2) = 26.8%). Patients treated after 2004 had better outcomes (unfavorable outcome, 3.1; 99% CI: 2.4, 4.0) than patients treated during 2001-2003 (unfavorable outcome, 4.7%; 99% CI: 3.6%, 6.1%; P = .01) or in 2000 and before (unfavorable outcome, 5.6%; 99% CI: 4.7%, 6.6%; P < .001). Significantly higher risk was associated with liquid embolic agents (8.1%; 99% CI: 4.7%, 13.7%) versus simple coil placement (4.9%; 99% CI: 3.8%, 6.3%; P = .002). Unfavorable outcomes occurred in 11.5% (99% CI: 4.9%, 24.6%) of patients treated with flow diversion. CONCLUSION Procedure-related poor outcomes occurred (4.7% of patients), risks decreased, and liquid embolic agents and flow diversion were associated with higher risks.

Quality Indicators for Colonoscopy Procedures: A Prospective Multicentre Method for Endoscopy Units

Background and Aims Healthcare professionals are required to conduct quality control of endoscopy procedures, and yet there is no standardised method for assessing quality. The topic of the present study was to validate the applicability of the procedure in daily practice, giving physicians the ability to define areas for continuous quality improvement. Methods In ten endoscopy units in France, 200 patients per centre undergoing colonoscopy were enrolled in the study. An evaluation was carried out based on a prospectively developed checklist of 10 quality-control indicators including five dependent upon and five independent of the colonoscopy procedure. Results Of the 2000 procedures, 30% were done at general hospitals, 20% at university hospitals, and 50% in private practices. The colonoscopies were carried out for a valid indication for 95.9% (range 92.5–100). Colon preparation was insufficient in 3.7% (range 1–10.5). Colonoscopies were successful in 95.3% (range 81–99). Adenoma detection rate was 0.31 (range 0.17–0.45) in successful colonoscopies. Conclusion This tool for evaluating the quality of colonoscopy procedures in healthcare units is based on standard endoscopy and patient criteria. It is an easy and feasible procedure giving the ability to detect suboptimal practice and differences between endoscopy-units. It will enable individual units to assess the quality of their colonoscopy techniques.

Intracranial Aneurysms: Recurrences More than 10 Years after Endovascular Treatment—A Prospective Cohort Study, Systematic Review, and Meta-Analysis

PURPOSE To assess the efficacy of endovascular treatment (EVT) of intracranial aneurysms for recurrence, bleeding, and de novo aneurysm formation at long-term follow-up (> 10 years after treatment) with magnetic resonance (MR) angiography and to identify risk factors for recurrence through a prospective study and a systematic review of the literature. MATERIALS AND METHODS Clinical examinations and 3-T MR angiography were performed prospectively 10 years after EVT of intracranial aneurysms in a single institution. Ethics committee approval and informed consent were obtained. PubMed, EMBASE, and Cochrane databases were searched to identify studies in which authors reported bleeding and/or aneurysm recurrence rates in patients who received follow-up more than 10 years after EVT. Univariate and multivariate subgroup analyses were performed to identify risk factors (midterm MR angiographic results, aneurysm characteristics, retreatment within 5 years). RESULTS In the prospective study, sac recanalization occurred between midterm and long-term MR angiography in 16 of 129 (12.4%) aneurysms. Grade 2 classification on the Raymond scale at midterm MR angiography (relative risk [RR], 4.16; 99% confidence interval [CI]: 2.12, 8.14) and retreatment within 5 years (RR, 4.67; 99% CI: 1.55, 14.03) were risk factors for late recurrence. In the systematic review (15 cohorts, 2773 patients, 2902 aneurysms), bleeding, aneurysm recurrence, and de novo lesion formation rates were, respectively, 0.7% (99% CI: 0.2%, 2.7%; I(2), 0%; one of 694 patients), 11.4% (99% CI: 7.0%, 18.0%; I(2), 21.6%), and 4.1% (99% CI: 1.7, 9.4%; I(2), 54.1%). Raymond grade 2 initial result (RR, 7.08; 99% CI: 1.24, 40.37; I(2), 82.6%) and aneurysm size greater than 10 mm (RR, 4.37; 99% CI: 1.83, 10.44; I(2), 0%) were risk factors for late recurrence. CONCLUSION EVT of intracranial aneurysm is effective for prevention of long-term bleeding, but recurrences occur in a clinically relevant percentage of patients, a finding that may justify follow-up of selected patients for 10 years or more, such as patients with aneurysms larger than 10 mm or classified as Raymond grade 2 at midterm MR angiography.

Blood-Brain Barrier Leakage in Early Alzheimer Disease

From Yoshiharu Ohno, MD, PhD,*† Masao Yui, MS,‡ Hisanobu Koyama, MD, PhD,§ Takeshi Yoshikawa, MD, PhD,*† Shinichiro Seki, MD, PhD,§ Yoshiko Ueno, MD, PhD,§ Mitsue Miyazaki, PhD,|| and Kazuro Sugimura, MD§ Division of Functional and Diagnostic Imaging Research* and Division of Radiology,§ Department of Radiology, and Advanced Biomedical Imaging Research Center,† Kobe University Graduate School of Medicine, Kobe, Hyogo 650-0017, Japan e-mail: yosirad@kobe-u.ac.jp Toshiba Medical Systems, Otawara, Tochigi, Japan‡ Toshiba Medical Research Institute, Vernon Hills, Ill||

Relationship between Watershed Infarcts and Recent Intra Plaque Haemorrhage in Carotid Atherosclerotic Plaque

Objective Watershed infarcts (WSI) are thought to result from hemodynamic mechanism, but studies have suggested that microemboli from unstable carotid plaques may distribute preferentially in watershed areas, i.e., between two cerebral arterial territories. Intraplaque haemorrhage (IPH) is an emerging marker of plaque instability and microembolic activity. We assessed the association between WSI and IPH in patients with recently symptomatic moderate carotid stenosis. Methods and Results We selected 65 patients with symptomatic moderate (median NASCET degree of stenosis = 31%) carotid stenosis and brain infarct on Diffusion-Weighted Imaging (DWI) on Magnetic Resonance Imaging (MRI) from a multicentre prospective study. Fourteen (22%) had WSI (cortical, n = 8; internal, n = 4; cortical and internal, n = 2). Patients with WSI were more likely to have IPH than those without WSI although the difference was not significant (50% vs. 31%, OR = 2.19; 95% CI, 0.66–7.29; P = 0.20). After adjustment for degree of stenosis, age and gender, the results remained unchanged. Conclusion About one in fifth of brain infarcts occurring in patients with moderate carotid stenosis were distributed in watershed areas. Albeit not significant, an association between IPH - more generally plaque component - and WSI, still remains possible.

Magnetic resonance post-contrast vascular hyperintensities at 3 T: a new highly sensitive sign of vascular occlusion in acute ischaemic stroke

BackgroundMagnetic resonance imaging (MRI) is the diagnostic cornerstone for precisely identifying acute ischaemic strokes and locating vascular occlusions, especially since mechanical thrombectomy has become a reference treatment. We observed that a post-contrast three-dimensional turbo-spin-echo T1-weighted sequence showed striking post-contrast vascular hyperintensities (PCVH) in ischaemic territories. We aimed to evaluate the prevalence and the meaning of this finding.MethodsThis retrospective single centre study included 130 consecutive patients admitted for acute ischaemic stroke with a 3-T MRI performed in the first 12 h of symptom onset from September 2014 through September 2016. Two neuroradiologists blinded to clinical data analysed the first MRI assessments. The association between PCVH and clinical, radiological and follow-up findings was assessed, as well as inter- and intra-observer agreements.ResultsOf 130 patients, 105 (81%) had PCVH in the ischaemic territory. PCVH were associated with the presence of thrombus on susceptibility weighted imaging (p < 0.0001) and vascular occlusions on MR angiography (p < 0.0001). All patients with a visible thrombus had PCVH closely surrounding the clot. PCVH were associated with higher initial (p < 0.01) and follow-up (p < 0.01) National Institutes of Health Stroke Scale score, and higher mRS score (p < 0.05). Thrombectomy was the reference treatment for all patients with arterial occlusions. Inter- and intra-observer agreements for the detection of PCVH were excellent (κ = 0.95 and κ = 0.91, respectively).ConclusionsPCVH during acute strokes are a striking sensitive and reproducible tool for diagnosing and locating vascular occlusions. It may help triage patients who can benefit from thrombectomy.Key points• Post-contrast vascular hyperintensities (PCVH) are a sensitive MR finding in acute stroke• PCVH are strongly associated with the presence and location of arterial occlusions• Inter- and intra-observer agreements for the detection of PCVH are excellent• PCVH are visible even in the case of significant motion artefacts• PCVH may help triage patients who can benefit from mechanical thrombectomy

Atypical intracranial artifacts caused by dreadlocks during brain Magnetic Resonance Imaging: Keep calm and recognize them

Artifacts in magnetic resonance imaging (MRI) are widely known and discussed [1,2]. They are divided into three groups: image reconstruction-related artefacts, systemrelated artifacts, and physiology-related source artifacts. The most frequent artifacts encountered during clinical practice are motion artifacts, aliasing artifacts, chemical shift artifacts, and magnetic susceptibility artifacts [3—5]. Among patients with dreadlocked hairstyles, we encountered an unusual and undescribed artifact with 3D spin echo (SE) T1 and 3D fluid-attenuated inversion recovery (FLAIR) weighted imaging (WI) intracranial hyperintense lesions. We tried to identify and describe this artifact.

Anévrismes intracrâniens non rompus : revue systématique et analyse en sous-groupes de la morbimortalité du traitement endovasculaire

Objectifs.— Rapporter notre expérience dans le traitement des anévrismes intracrâniens de forme complexe localisés sur la bifurcation sylvienne par « Y » stenting. Patients et méthodes.— Les résultats cliniques et angiographiques de 47 procédures chez 46 patients traités par « Y » stenting ont été analysés rétrospectivement. Résultats.— On note que 49 anévrismes de forme complexe localisés sur la bifurcation de l’artère sylvienne ont été traités chez 46 patients (16 hommes et 30 femmes, âgés de 28 à 71, moyenne : 52 ans) au cours de 47 procédures. Sur 47 procédures, 91,5 % (43/47) ont été réalisées avec « Y » stenting, 8,5 % (4/47) ont échoué. Les complications neurologiques transitoires ou réversibles furent de 12,8 % (6/47), versus 10,6 % (5/47) pour les permanentes. Il n’y a pas eu de mortalité. Une occlusion complète a été obtenue dans 51,0 % (25/49) des anévrismes, partielle dans 49,0 % (24/49). Un total de 55,1 % (27/49) des anévrismes ont été jusqu’à présent suivis par angiographie (moyenne : 9,2 mois) qui a mis en évidence une recanalisation dans 7,4 % (2/27) et une amélioration dans 40,7 % (11/27). Le score mRS à la sortie de l’hôpital et au contrôle était 0 pour 87,0 % (40/46) des patients, deux pour 2,2 % (1/46), trois pour 4,3 % (2/46) quatre pour 6,5 % (3/46). Conclusion.— Le traitement des anévrismes localisés sur la bifurcation de l’artère sylvienne par « Y » stenting est réalisable et efficace. L’amélioration des stents et une meilleure sélection des patients pourraient réduire la morbidité permanente en future.