F. Turjman

Stent-Retriever Thrombectomy for Acute Anterior Ischemic Stroke with Tandem Occlusion: A Systematic Review and Meta-Analysis.

AbstractObjectivesTo assess the efficacy and safety profile of stent-retriever thrombectomy (SRT) in acute anterior ischemic stroke patients with tandem occlusion.Materials and methodsUsing the MEDLINE database, we conducted a systematic review and meta-analysis of all studies that included patients with acute ischemic stroke attributable to tandem occlusion who received treatment with SRT between November 2010 and May 2015.ResultsThe literature search identified 11 previous studies involving a total of 237 subjects out of whom 193 (81.4xa0%) were treated with acute stent placement for the extracranial internal carotid artery occlusion. Mean initial NIHSS score was 17, and median time from onset to recanalization was 283.5xa0min. Mean intravenous thrombolysis rate was 63.8xa0%. In the meta-analysis, the recanalization rate reached 81xa0% (95xa0% CI, 73–89). Meta-analysis of clinical outcomes showed a pooled estimate of 44xa0% (95xa0% CI, 33–55; 10 studies) for favourable outcome, 13xa0% (95xa0% CI, 8–20; 10 studies) for mortality, and 7xa0% (95xa0% CI, 2–13; eight studies) for symptomatic intracranial haemorrhage.ConclusionSRT with emergency carotid stenting is associated with acceptable safety and efficacy in acute anterior stroke patients with tandem occlusion compared to natural history. However, the best modality to treat proximal stenosis is based on an individual case basis.Key Points• Stent retriever thrombectomy of tandem occlusion is efficient and safe.n • Emergent carotid stenting during thrombectomy increase symptomatic intracranial haemorrhage without impact mortality.• Thrombectomy of tandem anterior circulation occlusion may be the first therapeutic option

Dural arteriovenous fistula of the anterior fossa treated with the Onyx liquid embolic system and the Sonic microcatheter

We report an association of new technologies (the Onyx liquid embolic system and the Sonic microcatheter) for transarterial embolization through the anterior branch of the middle meningeal artery of a dural arteriovenous fistula (DAVF) of the anterior fossa. The place of endovascular treatment in anterior fossa DAVFs is reviewed, and its clinical implications discussed in light of the case of a patient whose management was modified by this association of new technologies.

One-Year Angiographic Follow-Up after WEB-SL Endovascular Treatment of Wide-Neck Bifurcation Intracranial Aneurysms.

BACKGROUND AND PURPOSE: Endovascular coiling of wide-neck intracranial aneurysms is associated with low rates of initial angiographic occlusion and high rates of recurrence. The WEB intrasaccular device has been developed specifically for this indication. To date, there has been no report of the long-term follow-up of a series of patients with aneurysms treated with this type of device, to our knowledge. Our aim was to evaluate a 1-year follow-up of angiographic results in a prospective single-center series of patients treated with the WEB-Single-Layer (SL) device. MATERIALS AND METHODS: All patients treated with the WEB-SL device in our center between August 2013 and May 2014 were prospectively included. One-year angiographic outcomes were assessed. Results at follow-up were graded as complete occlusion, neck remnant, or residual aneurysm. RESULTS: Eight patients with 8 unruptured wide-neck aneurysms were enrolled in this study. Average dome width was 7.5 mm (range, 5.4–10.7 mm), and average neck size was 4.9 mm (range, 2.6–6.5 mm). One-year angiographic follow-up obtained in all aneurysms included 1 complete aneurysm occlusion (12.5%), 6 neck remnants (75%), and 1 aneurysm remnant (12.5%). Of 8 aneurysms, worsening of aneurysm occlusion was observed in 2 (25%) by compression of the WEB device. There was no angiographic recurrence of initially totally occluded aneurysms. No bleeding was observed during the follow-up period. CONCLUSIONS: Endovascular therapy of intracranial aneurysms with the WEB-SL device allows treatment of wide-neck aneurysms with a high rate of neck remnant at 1 year, at least partially explained by WEB compression. Initial size selection and technologic improvements could be an option for optimization of aneurysm occlusion in WEB-SL treatment.

Temporary Solitaire Stent–Assisted Coiling: A Technique for the Treatment of Acutely Ruptured Wide-Neck Intracranial Aneurysms

BACKGROUND AND PURPOSE: Wide-neck intracranial aneurysms in patients with acute SAH are often challenging lesions to treat by neurosurgical and endovascular approaches. The aim of this study was to investigate the feasibility, safety, and efficacy of the use of temporary Solitaire AB stent–assisted technique with coiling for the treatment of acutely ruptured wide-neck aneurysms without perioperative antiplatelet therapy. MATERIALS AND METHODS: A retrospective review of our endovascular data base identified all patients treated in the acute phase with a temporary stent–assisted technique by use of a fully resheathable Solitaire AB stent and coiling. One-year clinical and angiographic outcomes were evaluated. RESULTS: Eight patients (5 women and 3 men; mean age, 57.5 years) with 8 ruptured wide-neck aneurysms were treated. There were 3 complications without clinical impact. Postoperative complete occlusion was achieved in 5 aneurysms, and 3 had a neck remnant. Three patients had an mRS score of 0, and 1 an mRS score of 3. Among the 4 patients admitted with a World Federation of Neurological Societies grade of V, 1 died, 1 improved to an mRS score of 1, and the other 2 achieved mRS scores of 4 and 5. Five had a stable occlusion, and 2 of the 3 incompletely occluded aneurysms underwent recanalization. CONCLUSIONS: In this small series, temporary placement of the Solitaire AB stent during coiling was a feasible and effective treatment for acutely ruptured wide-neck aneurysms. This technique, avoiding the need for perioperative antiplatelet therapy, could be a valuable option for the treatment of such lesions when the balloon remodeling technique is either not an option or unsuccessful.

Thrombectomy after intravenous thrombolysis is the new standard of care in acute stroke with large vessel occlusion.

Since the demonstration of the efficacy of intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rt-PA) 20 years ago with the publication of NINDS, no medical or interventional treatment had shown further clinical benefit in acute cerebral infarction. Although three randomized trials (IMS 3 SYNTHESIS, MR RESCUE) using first-generation devices (MERCI system) failed to show benefit of intra-arterial revascularization,1–3 the therapeutic management of acute ischemic stroke has been revolutionized by the recent results of six randomized controlled trials (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT, THRACE) comparing the usual medical management (including IV thrombolysis within 4.5u2009h of symptoms onset) with stent retriever thrombectomy in acute anterior ischemic stroke with proximal intracranial artery occlusion (distal internal carotid artery or proximal middle cerebral artery).4–9

Endovascular treatment in patients with acute ischemic stroke: Technical aspects and results

Ischemic stroke is the primary cause of acquired disability in the world and its treatment is still a challenge. Intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rt-PA) administered within 4½ hours of the onset of the symptoms is the only approved medical treatment in the acute phase of cerebral infarction. However, its efficacy is limited where there is proximal intracranial arterial occlusion, and there are many contraindications. The endovascular approach, combined or not with IV thrombolysis, allows high rates of recanalization to be achieved within a short period of time, with a low rate of procedural complications when thrombolysis is less effective (internal carotid artery, M1 segment of the middle cerebral artery). In these situations, endovascular techniques are playing an increasing role in the treatment of these patients even though there is still no indisputable scientific proof of their efficacy. The priority at present is to finish the French THRACE study, but it is already time to think about the next one.

More Transparency Is Needed in the Reporting of Clinical Research Studies

We read with great interest the systematic review published very recently by Asnafi et al[1][1] on the efficacy and safety of the Woven EndoBridge (WEB); (Sequent Medical, Aliso Viejo, California) aneurysm embolization system for the endovascular therapy of intracranial aneurysms. Their literature

In Reply to Antiplatelet Therapy Prior to Temporary Stent-Assisted Coiling

We would like to thank Drs Almekhlafi and Goyal for their comments[1][1] concerning our article, “Temporary Solitaire Stent-Assisted Coiling: A Technique for the Treatment of Acutely Ruptured Wide-Neck Intracranial Aneurysms.”[2][2]nnAlmekhlafi et al noticed that we performed the procedures