Aurélien Nouet

Atorvastatin decreases computed tomography and S100-assessed brain ischemia after subarachnoid aneurysmal hemorrhage: a comparative study.

Objective: Statins, which improve the bioavailability of endogenous nitric oxide and upregulate endothelial nitric oxide synthase, have been used to prevent cerebral vasospasm after aneurysmal subarachnoid hemorrhage. The objective of this study was to determine whether statin therapy diminished vasospasm-induced ischemia as assessed using daily measurements of serum S100B, a biomarker for cerebral ischemia, and computed tomography measurement of ischemic lesion volume. Design: Single-center study of cases and historical controls. Setting: Neurointensive care unit in a university hospital. Patients: Consecutive patients with aneurysmal subarachnoid hemorrhage treated with clipping or coiling within 96 hrs of symptom onset (n = 278) were included from April 2004 to October 2007. Intervention: Oral atorvastatin, 40 mg/day for 21 days, was used routinely starting on December 1, 2005, in 142 patients, who were compared with the 136 patients managed earlier. Measurements and Main Results: Ischemic lesion size was measured using computed tomography on the last available scan and serum S100B was assayed daily for 15 days after admission. Angiographic narrowing was semiquantitatively assessed in patients with vasospasm. In the overall population, cerebral vasospasm was significantly less common in the statin-treated group. Severity of vasospasm, as assessed on the most severe angiogram, was lowered with statin. Statins significantly reduced volume of ischemia in patients with vasospasm and an uncomplicated coiling procedure. S100B levels were significantly lower in statin-treated patients, and the decrease was greatest among high-grade patients (World Federation of Neurological Surgeons 3–5). No differences were found between statin-treated and untreated groups regarding rescue therapy intensity or 1-yr clinical outcomes. Conclusions: Atorvastatin reduces the incidence, the severity and the ischemic consequences of vasospasm as assessed on computed tomography. In high-grade World Federation of Neurological Surgeons patients, atorvastatin decreases serum levels of S100B, a biomarker of brain ischemia. Despite these positive effects on biomarkers, no improvement of outcome was seen in the overall population, although there was a tendency for a better clinical outcome in high-grade patients.

An Admission Bioclinical Score to Predict 1-Year Outcomes in Patients Undergoing Aneurysm Coiling

Background and Purpose— A number of scores were developed to predict outcomes after clipping for subarachnoid hemorrhages, yet there is no score for patients undergoing endovascular treatment. Our goal was to develop, compare, and validate a predictive score for 1-year outcomes in patients with coiled subarachnoid hemorrhage. Methods— We studied 526 patients for 1 year after intensive care unit discharge. We developed an admission bioclinical score (ABC score), which integrated biomarkers such as troponin I and S100&bgr;, with the Glasgow Coma Scale. Using the receiver operating characteristic curve (95% CI), the ABC score was compared with the Glasgow Coma Scale, World Federation of Neurosurgical Societies score, and Fisher score in the derivation cohort and further validated in an independent cohort. Results— In the derivation cohort (from 2003–2007, n=368), multivariate logistic regression analysis showed that only Glasgow Coma Scale (P<0.001), high S100&bgr; (P<0.001), and high troponin (P<0.02) were independently associated with 1-year mortality. Troponin, S100&bgr;, and Glasgow Coma Scale were thus integrated to derive the ABC score. In the derivation cohort, the ABC score reached an receiver operating characteristic curve of 0.82 (0.77–0.88, P<0.001) and was significantly greater than the receiver operating characteristic curves of the Glasgow Coma Scale, World Federation of Neurosurgical Societies, and Fisher scores for predicting 1-year mortality. In the validation cohort (from 2008–2009, n=158), the ABC scores receiver operating characteristic curve of 0.76 (0.67–0.86, P<0.001) remained superior to the 3 other scores for predicting 1-year mortality. Conclusions— The ABC score improves 1-year outcome prediction at admission for patients with coiled subarachnoid hemorrhage. Our study provides large cohort-based evidence supporting integration of individual biomarkers and clinical characteristics to predict outcomes. Clinical Trial Registration— URL: www.clinicaltrials.gov. Unique identifier: NCT01357057.

Flow Diverter Stents for the Treatment of Anterior Cerebral Artery Aneurysms: Safety and Effectiveness

Background and PurposeFlow diverter stents (FDSs) are increasingly used for the treatment of intracranial aneurysms. Initially developed for the management of giant and large aneurysms, their indications have progressively expanded. The purpose of our study was to evaluate the safety and effectiveness of FDSs for the treatment of anterior cerebral artery (ACA) aneurysms.Materials and MethodsAmong the 94 consecutive patients treated for 100 intracranial aneurysms by means of FDSs in our institution from October 2010 to January 2015, eight aneurysms (8 %) in seven patients were located on the ACA. Three aneurysms were located on the A1 segment, three aneurysms on the anterior communicating artery (ACom) and two on the A2–A3 junction. In three cases, FDS was used for angiographic recurrence after coiling. Five patients were treated with a Pipeline embolization device, one with a NeuroEndograft and the last one with a Silk FDS.ResultsTreatment was feasible in all cases. No technical difficulty was reported. No acute or delayed clinical complication was recorded. Modified Rankin Scale was 0 for six patients and one for one patient. Mean angiographic follow-up was 9.7 ± 3.9 months (range 6–15).Total exclusion was observed in five aneurysms (71.4 %) and neck remnant in two (28.6 %) cases. One patient refused the control DSA.ConclusionOur series shows the safety and effectiveness of FDSs for the treatment of ACA aneurysms.

Spontaneous closure of intracranial dural arteriovenous fistulas: A report of 3 cases

Spontaneous closures of dural arteriovenous fistulas (dAVFs) are rare. We present spontaneous occlusion of dAVFs in 3 cases (one type IIa dAVF, one type IIb and one type III). Patients were 3 males with a mean age of 55 years (range 45-61). For two patients, the dAVF was revealed by hemorrhage. No head trauma was recorded at the interrogatory. Mean delay for spontaneous closure was 4 months (3-5 months). Review of the literature about this rare occurrence is presented and the factors that may lead to spontaneous occlusion of dAVFs are discussed.

Elderly Age as a Prognostic Marker of 1-year Poor Outcome for Subarachnoid Hemorrhage Patients through Its Interaction with Admission Hydrocephalus

Background:An increasing number of elderly patients are treated for aneurysmal subarachnoid hemorrhage. Given that elderly age is associated with both poor outcome and an increased risk of hydrocephalus, we sought to investigate the interaction between age and hydrocephalus in outcome prediction. Methods:We enrolled 933 consecutive patients treated for subarachnoid hemorrhage between 2002 and 2010 and followed them for 1 yr after intensive care unit discharge. We first performed stepwise analyses to determine the relationship among neurologic events, elderly age (60 or more yr old), and 1-yr poor outcome (defined as Rankin 4–6). Within the most parsimonious model, we then tested for interaction between admission hydrocephalus and elderly age. Finally, we tested the association between age as a stratified variable and 1-yr poor outcome for each subgroup of patients with neurologic events. Results:24.1% (n = 225) of subarachnoid hemorrhage patients were 60 yr old or more and 19.3% (n = 180) had 1-yr poor outcomes. In the most parsimonious model (area under the receiver operating characteristic curve, 0.84; 95% CI: 0.82 to 0.88; P < 0.001), elderly age and admission hydrocephalus were two independent predictors for 1-yr outcome (P < 0.001 and P = 0.004, respectively). Including the significant interaction between age and hydrocephalus (P = 0.04) improved the model’s outcome prediction (P = 0.03), but elderly age was no longer a significant predictor. Finally, stratified age was associated with 1-yr poor outcome for hydrocephalus patients (P = 0.007), but not for patients without hydrocephalus (P = 0.87). Conclusion:In this observational study, elderly age and admission hydrocephalus predicted poor outcome, but elderly age without hydrocephalus did not. An external validation, however, will be needed to generalize this finding.

Is a high initial World Federation of Neurosurgery (WFNS) grade really associated with a poor clinical outcome in elderly patients with ruptured intracranial aneurysms treated with coiling

Background Coiling of ruptured intracranial aneurysms in elderly patients remains debatable in terms of technical feasibility and clinical outcome. Aims In this observational cohort study we aimed to assess the technical feasibility, complication profile and clinical outcomes of elderly patients with subarachnoid hemorrhage (SAH) treated with endovascular therapy. Methods The study included 59 consecutive patients (47 women) aged ≥70 years (mean age 76 years, range 71–84) admitted to our institution with SAH from January 2002 to July 2011. The patients were treated for 66 aneurysms (regular coiling: n=62 (94%), balloon-assisted technique: n=2 (3%), stent and coil technique: n=2 (3%)). World Federation of Neurosurgery (WFNS) grade at admission was 1 in 13 patients, 2 in 23 patients, 3 in 8 patients, 4 in 11 patients and 5 in 4 patients. We analysed data by univariate and multivariate statistical analyses with an emphasis on the initial clinical situation, complications and clinical outcome. Results The technical success rate was 98% with a procedure-related deficit rate of 10% and procedure-related death rate of 5%. The Glasgow Outcome Scale score at 6 months was 1 in 15 patients (25.4%), 2 in 8 patients (13.6%), 3 in 14 patients (23.7%), 4 in 11 patients (18.6%) and 5 in 11 patients (18.6%). Patients admitted with a high initial WFNS grade did not differ statistically in terms of clinical outcome. The final clinical outcome was not significantly correlated with age, initial Fisher score or procedure-related complications. Conclusions Endovascular treatment of elderly patients with ruptured cerebral aneurysms is feasible, safe and beneficial regardless of the presenting WFNS score.

Admission risk factors for cerebral vasospasm in ruptured brain arteriovenous malformations: An observational study

IntroductionCerebral vasospasm is a well-documented complication of aneurismal subarachnoid hemorrhage but has not been extensively studied in brain arteriovenous malformations (BAVMs). Here, our purpose was to identify risk factors for cerebral vasospasm after BAVM rupture in patients requiring intensive care unit (ICU) admission.MethodsPatients admitted to our ICU from January 2003 to May 2010 for BAVM rupture were included in this observational study. Clinical, laboratory and radiological features from admission to ICU discharge were recorded. The primary endpoint was cerebral vasospasm by transcranial Doppler (TCD-VS) or cerebral infarction (CI) associated with vasospasm. Secondary endpoints included the Glasgow Outcome Scale (GOS) at ICU discharge.ResultsOf 2,734 patients admitted to our ICU during the study period, 72 (2.6%) with ruptured BAVM were included. TCD-VS occurred in 12 (17%) and CI in 6 (8%) patients. All patients with CI had a previous diagnosis of TCD-VS. A Glasgow Coma Scale score <8 was a risk factor for both TCD-VS (relative risk (RR), 4.7; 95% confidence interval (95% CI), 1.6 to 26) and CI (RR, 7.8; 95% CI, 0.1 to 63). Independent risk factors for TCD-VS by multivariate analysis were lower Glasgow Coma Scale score (odds ratio (OR) per unit decrease, 1.38; 95% CI, 1.13 to 1.80), female gender (OR, 4.86; 95% CI, 1.09 to 25.85), and younger age (OR per decade decrease, 1.39; 95% CI, 1.05 to 1.82). The risk of a poor outcome (GOS <4) at ICU discharge was non-significantly increased in the patients with TCD-VS (RR, 4.9; 95% CI, 0.7 to 35; P = 0.09). All six patients with CI had poor outcomes.ConclusionsThis is the first cohort study describing the incidence and risk factors for cerebral vasospasm after BAVM rupture. Larger studies are needed to investigate the significance of TCD-vasospasm and CI in these patients.

Occlusion of M1 segment after superficial temporal artery-middle cerebral artery bypass in a giant M1 aneurysm with Onyx-34 injected via a double-lumen balloon under balloon inflation

A 29-year-old patient attended our institution for recurrent strokes related to a giant partially thrombosed M1 aneurysm. Superficial temporal artery-middle cerebral artery (STA-MCA) bypass and subsequent occlusion of both the aneurysm and the dysplastic M1 segment were planned. However, owing to the shortness of the non-dysplastic segment of M1 and the risk of occlusion of the lenticulostriate arteries, the use of a double-lumen balloon was considered for coiling and subsequent injection of Onyx. STA-MCA bypass was performed using a regular technique. Endovascular occlusion of both the aneurysm and the parent artery was subsequently performed by means of coils and Onyx-34 that was injected via the Ascent balloon under balloon inflation. No complications were recorded and no stroke was observed on control MRI. The injection of Onyx-34 through a double-lumen balloon under balloon inflation is a quick and safe technique for precise occlusion of a parent artery.

O-029 safety and effectiveness of middle cerebral artery aneurysms treatment (endovascular and surgical): retrospective analysis of a single center series with 362 consecutive patients

Introduction Middle cerebral artery (MCA) aneurysms are eligible for both treatment options (microsurgery and embolization). The purposes of our study were 1) to evaluate the morbi-mortality rate related to endovascular and microsurgical treatments of ruptured and unruptured MCA aneurysms and 2) to study the effectiveness of endovascular and surgical treatments for these aneurysms in terms of recanalization/recurrence and bleeding at short and long terms angiographic and clinical follow-ups. Material and methods Our study is a mono-centric retrospective observational study, reporting clinical and angiographic follow-up of consecutive patients treated for MCA aneurysms (ruptured and unruptured). From 2002 to 2012, 362 consecutive patients were admitted at our institution for the treatment of 390 MCA aneurysms (255 ruptured and 135 unruptured). Among the procedures, 127 aneurysms were treated by endovascular means (32.5%) and 263 (67.5%) by microsurgery. Procedure-related death and complications (major/minor) were systematically assessed. The per-procedural rupture rate was also evaluated. The quality of the aneurysms exclusion was evaluated according to the Roy-Raymond scale in post-procedure and at long term angiographic follow-up (mean delay = 36 months). Results Procedure related death rate was 1.9%. This rate was slightly higher in the group of ruptured aneurysms treated by endovascular (EV) means (3.2% vs 1.2% in the group S [Surgery]), but this difference was not significant (p = 0.23). The procedure-related major complication rate was slightly higher in the group S (5.6% vs 2.4% for the group EV; p = 0.19, non-significant). Minor complications were slightly more frequent in the group S (5.6% vs 4.8% for the group EV), but this difference was also not statistically significant (p = 1). Per-procedure rupture rate was 14.4%; per-procedure ruptures were more frequently observed for ruptured aneurysms treated by microsurgery. During the hospital stay, 69% of the patients with ruptured aneurysms had a favorable outcome (mRS ≤ 3); this rate increased to 72.9% at 6 months and 72.3% at 12 months follow-up. In post-procedure, Roy-Raymond grade A or B occlusion rate was 94.8% for the overall population; this rate was similar for the group S and the group EV (95.6% for the group S vs 92.2% for the group EV; NS). However, long-term angiographic follow-up showed a higher Roy-Raymond grade A or B for the group S (94.2% for the group S vs 78% for the group EV [p Conclusion Both microsurgical and endovascular techniques are safe for the treatment of MCA aneurysms, with an acceptable complication rate (overall morbi-mortality rate: 5.6%). The two techniques allow for a satisfactory exclusion of aneurysm. However, long-term angiographic follow-up showed more stable results for the surgical treatment, but without bleeding/rebleeding event observed during the long-term clinical follow-up for both techniques. Disclosures N. Sourour: 2; C; eV3/Covidien. S. Hallout: None. F. Di Maria: None. A. Nouet: None. J. Gabrieli: None. P. Cornu: None. J. Chiras: None. F. Clarencon: None.