Francis Turjman

Thrombolysis With Intravenous rtPA in a Series of 100 Cases of Acute Carotid Territory Stroke Determination of Etiological, Topographic, and Radiological Outcome Factors

BACKGROUND AND PURPOSE Although new, large, double-blind, randomized studies are needed to establish the efficiency of intravenous thrombolysis, open trials of sufficient size may also provide novel data concerning specific outcomes after thrombolysis. METHODS An open study of intravenous rtPA in 100 patients with internal carotid artery (ICA) territory strokes between 20 and 81 years of age, with a baseline Scandinavian Stroke Scale (SSS) score of <48 at entry was conducted. Inclusion time was within 7 hours after stroke onset. rtPA (0.8 mg/kg) was infused for 90 minutes, with an initial 10% bolus. Heparin was given according to 3 consecutive protocols. The SSS evaluation was done on days 0, 1, 7, 30, and 90. CT scan was performed before treatment, on days 1 and 7. Etiological investigations included echocardiography and carotid Doppler sonography and/or angiography. Outcome at 1 year was documented by SSS score, the modified Rankin Scale (mRS) score, and a 10-point invalidity scale. Multivariate logistic regression was used to identify predictors of poor versus good outcome. RESULTS At day 90, 45 patients (45%) had a good result, defined as complete regression or slight neurological sequelae (mRS score of 0-1), 18 patients had a moderate outcome (mRS 2-3), and 31 patients had serious neurological sequelae (mRS 4-5). Six patients died, 2 with intracerebral hematoma after immediate heparin. Five of 11 patients (45.5%) treated between 6 and 7 hours had a good result. The overall intracerebral hematoma rate was 7%. Higher values of fibrin degradation products at 2 hours were observed in the subgroup with intracerebral hematomas. Significant predictors of poor outcome on multivariate logistic regression analysis were baseline SSS score of <15 (odds ratio [OR], 3.38; 95% confidence interval [CI], 1.07 to 10. 74; P=0.04), indistinction between white and gray matter on CT scan (OR, 6.59; 95% CI, 2.19 to 19.79; P=0.0008), and proximal internal carotid thrombosis (OR, 3.29; 95% CI, 0.99 to 10.95; P=0.05). CONCLUSIONS Our study confirms the safety of intravenous rtPA at a dose of 0.8 mg/kg and suggests efficacy for this drug even within 7 hours. Outcome and hematoma rates were at least as favorable as for trials of therapy with a 3-hour time window. Subgroups with a poor prognosis include low baseline neurological score, baseline CT changes, and proximal ICA thrombosis. However, approximately 30% of patients with each of these characteristics show a good outcome, so their inclusion in future routine rtPA protocols is still justified.

Intravenous tPA in acute ischemic stroke related to internal carotid artery dissection

Article abstract The authors describe the outcomes in 11 patients who had acute ischemic stroke related to internal carotid artery (ICA) dissection and were treated with IV tissue plasminogen activator (tPA). One symptomatic intracerebral hemorrhage occurred 36 hours after tPA was given. The mean day 90 modified Rankin Scale (m-RS) score was 2.4 (±1.6). No death was observed at 3 months. Four patients of 11 (36.4%) made an excellent recovery (day 90 m-RS score: 0 to 1). This study demonstrates the feasibility of IV thrombolysis with tPA (0.8 mg/kg) in ischemic stroke related to ICA dissection within the first 7 hours.

Surpass Flow Diverter in the Treatment of Intracranial Aneurysms: A Prospective Multicenter Study

BACKGROUND AND PURPOSE: Incomplete occlusion and recanalization of large and wide-neck brain aneurysms treated by endovascular therapy remains a challenge. We present preliminary clinical and angiographic results of an experimentally optimized Surpass flow diverter for treatment of intracranial aneurysms in a prospective, multicenter, nonrandomized, single-arm study. MATERIALS AND METHODS: At 24 centers, 165 patients with 190 intracranial aneurysms of the anterior and posterior circulations were enrolled. The primary efficacy end point was the percentage of intracranial aneurysms with 100% occlusion on 6-month DSA. The primary safety end point was neurologic death and any stroke through a minimum follow-up of 6 months. RESULTS: Successful flow-diverter delivery was achieved in 161 patients with 186 aneurysms (98%); the mean number of devices used per aneurysm was 1.05. Clinical follow-up (median, 6 months) of 150 patients (93.2%), showed that the primary safety end point occurred in 18 subjects. Permanent neurologic morbidity and mortality were 6% and 2.7%, respectively. Morbidity occurred in 4% and 7.4% of patients treated for aneurysms of the anterior and posterior circulation, respectively. Neurologic death during follow-up was observed in 1.6% and 7.4% of patients with treated intracranial aneurysms of the anterior and posterior circulation, respectively. Ischemic stroke at ≤30 days, SAH at ≤7 days, and intraparenchymal hemorrhage at ≤7 days were encountered in 3.7%, 2.5%, and 2.5% of subjects, respectively. No disabling ischemic strokes at >30 days or SAH at >7 days occurred. New or worsening cranial nerve deficit was observed in 2.7%. Follow-up angiography available in 158 (86.8%) intracranial aneurysms showed 100% occlusion in 75%. CONCLUSIONS: Clinical outcomes of the Surpass flow diverter in the treatment of intracranial aneurysms show a safety profile that is comparable with that of stent-assisted coil embolization. Angiographic results showed a high rate of intracranial aneurysm occlusion.

Open Trial of Intravenous Tissue Plasminogen Activator in Acute Carotid Territory Stroke Correlations of Outcome With Clinical and Radiological Data

BACKGROUND AND PURPOSE Pilot studies using early thrombolytic therapy in stroke have suggested that recombinant tissue plasminogen activator (rTPA) might be effective. While large, double-blind, randomized studies are needed, open trials could generate hypotheses concerning (1) the clinical correlations of outcome, (2) the significance of CT scan data during the first week, and (3) the use of adjunctive therapies. METHODS We performed an open trial of intravenous rTPA on patients referred to our emergency service with all types of ischemic stroke in the carotid territory. All patients between 20 and 81 years hospitalized during 1994 with completed stroke in the internal carotid artery territory and a baseline Scandinavian Stroke Scale score lower than 48, even with severe disturbances of consciousness, were included. The inclusion time was within 7 hours after stroke onset. A 0.8-mg/kg dose of rTPA was infused for 90 minutes. Intravenous heparin was given either immediately at efficient dosage or after 24 hours. Mannitol was used in patients with severe presentation. The Scandinavian Stroke Scale evaluation was done at baseline, 3 hours, and 1, 7, 30, and 90 days. The CT scan was performed before the treatment and at days 1 (24 +/- 6 hours) and 7. RESULTS Forty-three consecutive patients met the criteria of the protocol. The mean age at inclusion was 65 +/- 10.4 years, and the mean interval to treatment was 232 +/- 79 minutes. At day 90, 25 patients (58.1%) exhibited a complete regression of symptoms, and 3 had moderate neurological sequelae. Thirteen patients had severe neurological sequelae, 11 with infarcts and 2 with secondary parenchymal hematomas. Two patients died (4.6%), 1 with hematoma. The overall hematoma rate was 6.9%. Excellent outcome at day 90 was significantly correlated with major neurological improvement at day 1. Intravenous immediate heparin versus delayed heparin after 24 hours improved the ischemic outcome but not the overall outcome. Reinfarction syndromes after major neurological improvement, likely to be rethrombosis syndromes, were observed in 3 patients (6.9%). For the day 1 CT scan, poor outcome was associated with the presence of structured and homogeneous hypodensities likely to represent classic infarcts, as confirmed by day 7 CT scan. Conversely, total recovery was significantly associated with the absence of any image or with unstructured hypodensities, a particular type of image characterized by its heterogeneous darkness and often polylobar shape. This type of image disappeared at day 7 in 17.6% of the cases and is likely to represent reperfusion images and/or incomplete ischemic damage. CONCLUSIONS The results obtained in this open, small study suggest safety and effectiveness of rTPA thrombolysis at the dose of 0.8 mg/kg within 7 hours in acute strokes of the carotid territory, including highly serious baseline neurological presentations, until age 81 years and under special therapeutic conditions. Complete recovery is significantly associated with major neurological improvement during the first 24 hours and the presence of a particular type of image at day 1 CT scan characterized by an unstructured hypodensity, often polylobar and heterogeneous, which is likely to correspond to reperfusion images.

WEB intrasaccular flow disruptor-prospective, multicenter experience in 83 patients with 85 aneurysms.

BACKGROUND AND PURPOSE: The safety and efficacy of WEB flow disruption have been analyzed in small, retrospective series. The object of this study was to evaluate the safety and efficacy of WEB flow disruption in a large, multicenter, prospectively collected population. MATERIALS AND METHODS: Data from all patients treated with the WEB-DL device between June 2011 and October 2013 in 11 French neurointerventional centers were prospectively collected and retrospectively analyzed. Complications occurring during and after treatment were analyzed as well as morbidity and mortality at 1 month. Aneurysm occlusion status at the last follow-up was analyzed. RESULTS: Eighty-three patients with 85 aneurysms were included in this series. Technical success was achieved in 77 patients with 79 aneurysms (92.9%). Periprocedural complications were observed in 9 patients (10.8%), leading to permanent neurologic deficits in 3 (3.9%). Morbidity and mortality at 1 month were 1.3% and 0.0%, respectively. Angiographic follow-up was performed for 65/79 aneurysms (82.3%) 3–24 months after treatment (mean, 5.3 months). Complete aneurysm occlusion was observed in 37/65 aneurysms (56.9%); neck remnant, in 23/65 (35.4%); and aneurysm remnant, in 5/65 (7.7%). CONCLUSIONS: In this large prospective series of patients, WEB flow disruption was a safe and efficient technique.

Treatment of experimental carotid aneurysms by endoprosthesis implantation: preliminary report.

Four experimental aneurysms were treated by implantation of an endoprosthetic stent. The aneurysms were surgically created by grafting a venous pouch on the carotid artery of mongrel dogs. Aneurysm patency was assessed angiographically. Under systemic heparinization and via a transfemoral approach, the stent measuring 20 mm in length and 5 mm in diameter, was implanted in the lumen of the parent artery at the level of the aneurysmal neck. Good angiographic results were obtained immediately following implantation, showing exclusion of the aneurysm from the circulation. Patency of the parent vessel was preserved in all the experimental aneurysms treated. In one case an angiogram performed 30 days later showed the same findings with excellent tolerance of the device. The technique of endovascular treatment of experimental aneurysms by stent implantation appears feasible and safe in vivo. Further investigations are still necessary before clinical applications.

Multiresolution reconstruction in fan-beam tomography

In this paper, a new multiresolution reconstruction approach for fan-beam tomography is established. The theoretical development assumes radial wavelets. An approximate reconstruction formula based on a near-radial quincunx multiresolution scheme is proposed. This multiresolution algorithm allows to compute both the quincunx approximation and detail coefficients of an image from its fan-beam projections. Simulations on mathematical phantoms show that wavelet decomposition is acceptable for small beam angles but deteriorates at high angles. The main applications of the method are denoising and wavelet-based image analysis.

Multidisciplinary treatment of cerebral arteriovenous malformations

A series of 67 patients treated for cerebral AVM with a multidisciplinary approach is reported. The malformations were classified after the Spetzler Grading Scale, with 67% low-grade and 33% high-grade AVMs. Three modes of treatment were used: surgical resection, endovascular embolization, and radiosurgery (linear accelerator technique). The actual treatment was: surgical resection alone (25% of cases), embolization plus resection (25% of cases), embolization alone (21%) and radiosurgery (30%) either alone (12%), or after incomplete embolization (15%) or after incomplete resection (3%). The clinical outcome was evaluated in terms of deterioration due to treatment. The treatment was responsible for a deterioration in 28% of all patients, either minor deterioration (19%) neurological deficit (4%), or death (4%). All complications of surgical resection (17% of all operated cases) and of radiosurgery (10% of irradiated cases) remained minor. None was haemodynamic-related. After endovascular embolization, a deterioration occurred in 25% of all embolized cases (minor 13%, neurological deficit 5% and death 8%). These complications occurring after embolization were haemodynamic related: ischaemia and haemorrhage (50% for each mechanism). Haemorrhage occurred either during or some days after the embolization procedure. The angiographic eradication rate was: 80% overall, 91% after resection (with or without previous embolization), 87% after radiosurgery (alone or after other techniques), and 10% after embolization alone. The discussion reviews in the literature the general evolution of the management of cerebral AVMs, with successive application of first surgical resection, the embolization and lastly radiosurgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Brain Stem Diffusion-Weighted Imaging Lesion Score: A Potential Marker of Outcome in Acute Basilar Artery Occlusion

BACKGROUND AND PURPOSE: The benefit of recanalization in basilar artery occlusion (BAO) has been established. The baseline extent of brain stem damage may also influence the outcome. We investigated whether a baseline diffusion-weighted imaging (DWI) score may provide additional prognostic value in BAO. MATERIALS AND METHODS: We analyzed baseline clinical and DWI parameters in consecutive patients treated with endovascular procedures for acute BAO. Brain stem DWI lesions were assessed by using a semiquantitative score based on arterial territory segmentation. Outcome at 3 months was dichotomized according to the modified Rankin Scale (mRS) as favorable (mRS, 0–2) or unfavorable (mRS, 3–6). Spearman rank correlation tests assessed the correlation between DWI and clinical variables. Univariate and multivariate logistic regression analyses were used to identify clinical and MR imaging predictors of outcome. RESULTS: Twenty-nine patients were included. The brain stem DWI score (median, 3; range, 0–14) was correlated with the baseline National Institutes of Health Stroke Scale (NIHSS) score and the presence and length of coma (r = 0.67, 0.49, and 0.53, respectively; P < .01). Recanalization was achieved in 76%. A higher baseline NIHSS score (P = .02) and brain stem DWI score (P = .03), a lower Glasgow Coma Scale score (P = .04), and the presence of coma (P = .05) were associated with poor outcome in univariate analysis. Multivariate analysis showed that the brain stem DWI score was the only independent baseline predictor for clinical outcome (P = .026). CONCLUSIONS: Baseline brain stem DWI lesion score is an independent marker of outcome in BAO.

Recovery of third nerve palsy after endovascular treatment of posterior communicating artery aneurysms

BACKGROUND High recovery rates after endovascular treatment of TNP-inducing PcomA aneurysms have been reported. However, only few and often small series were reported. The results of the 2 available comparative studies are controversial. Choosing clipping or coiling as treatment modality nowadays is still a matter of debate. We report the ophthalmologic outcome of 20 consecutive patients treated by coiling of TNP-inducing PcomA aneurysms. METHODS The third nerve function before and after endovascular treatment was assessed and studied retrospectively. Predictive recovery factors known from literature including treatment timing, the degree of preoperative nerve deficit, the association with SAH, coil type, cardiovascular risk factors, and age were analyzed. A review of the literature was performed. RESULTS Eight patients presented initially with complete nerve palsy (40%) and 12 with partial palsy (60%). Eleven patients had SAH. The mean aneurysm size was 7.14 mm; there were no partially thrombosed aneurysms. Of the 20 patients, 19 (95%) recovered. Recovery was complete in 7 patients (35%), partial in 12 patients (60%), and 1 patient remained unchanged (5%). The mean duration of follow-up was 24.7 months. One patient with complete TNP recovered completely after 5 months of coiling. One case of late complete nerve recovery was observed at 20 months. No cases of reoccurrences or worsening of the partial TNP were observed, including patients who developed recanalization of the aneurysmal sac. Clinical presentation with SAH and early management were statistically significant factors that positively influenced nerve recovery (P = .006549 and P = .015718, respectively). Initial partial TNP seems to influence recovery but did not reach significance (P = .079899). CONCLUSION Coiling of PcomA aneurysms is associated with high rates of third nerve function recovery. Complete recovery can be expected even after long periods and in cases of initial complete nerve palsy. The early treatment and the association with SAH seem to promote the nerve recovery.