Nader-Antoine Sourour

S100B as an additional prognostic marker in subarachnoid aneurysmal hemorrhage.

Objectives:Studies of new neuroprotective approaches in patients with subarachnoid aneurysmal hemorrhage and better family information would benefit from the development of laboratory markers of brain ischemia. The goal of this study was to evaluate mean 15-day S100B for predicting outcomes after subarachnoid aneurysmal hemorrhage. Design:Single center prospective cohort with consecutive inclusions. Setting:Anesthesiology and Critical Care Neurosurgical Unit of a university hospital. Patients:One hundred nine patients admitted within 48 hrs after subarachnoid aneurysmal hemorrhage onset and treated by surgical clipping or coiling within 48 hrs following admission. Interventions:We recorded initial World Federation of Neurologic Surgeons and Fisher grades; comorbidities; initial severity; aneurysm location; presence of acute hydrocephalus; presence of intraventricular hemorrhage; initial seizures and neurogenic lung edema; initial troponin values; treatment of aneurysm; and occurrence of vasospasm. Measurements and Main Results:S100B was assayed daily over the first 15 days. Glasgow Outcome Scores were recorded at intensive care unit discharge and after 6 and 12 months. The main outcome criterion was the 12-month Glasgow Outcome Scale score dichotomized as poor (Glasgow Outcome Scale 1–3) or good (Glasgow Outcome Scale 4–5). Seventy percent of patients had good 12-month outcome. Poor outcome was associated with higher initial World Federation of Neurologic Surgeons and Fisher scores, neurogenic lung edema, high mean 15-day S100B but not initial, troponin initial value, intraventricular hemorrhage, angiographically documented vasospasm, all in an univariate manner. After multivariate analysis, only mean 15-day S100B value significantly predicted outcome (p < 0.0005). The best cutoff for the mean 15-day S100B value was 0.23 &mgr;g/L (specificity 0.90, 95% confidence interval [CI] 0.81–0.95; sensitivity 0.91, 95% CI 0.75–0.98; area under the curve 0.98, 95% CI 0.87−0.99). Conclusion:S100B elevation over the first 15 days after subarachnoid aneurysmal hemorrhage is associated with poor outcome after subarachnoid aneurysmal hemorrhage. This result supports the use of S100B as a surrogate marker for brain ischemia in patients with subarachnoid aneurysmal hemorrhage.

Medina® Embolization Device for the Treatment of Intracranial Aneurysms: Safety and Angiographic Effectiveness at 6 Months

BACKGROUND The Medina Embolization Device (MED) is a new concept device that combines the design of a detachable coil and the one of an intrasaccular flow disruption device. OBJECTIVE To evaluate the feasibility, safety, and 6‐ to 9‐mo effectiveness of this new device for the treatment of intracranial wide‐necked aneurysms. METHODS Twelve patients (10 females, mean age = 56 yr) with 13 wide‐necked intracranial aneurysms (3 ruptured; 10 unruptured) were treated by means of the MED from January 2015 to October 2015. In 15% of the cases, MEDs were used in a standalone fashion; in 85% of the cases, additional regular coils were used. Adjunctive compliant balloon was used in 4 of 13 cases (31%). Procedure‐related complications were systematically recorded; discharge and 6‐ to 9‐mo follow‐up modified Rankin Scale was assessed. Angiographic follow‐up was performed with a mean delay of 5.5 ± 1.7 mo. Occlusion rate was evaluated in postprocedure and at midterm follow‐up using the Roy-Raymond scale. RESULTS The deployment of the MED was feasible in all cases. No perforation was recorded. One case of thromboembolic complication was observed in a ruptured anterior communicating artery aneurysm, without any clinical consequence at follow‐up. Grade A occlusion rate was 61.5% in postprocedure and 83% at 6‐mo follow‐up. Two cases (17%) of recanalization were documented angiographically. CONCLUSION The MED is a new generation device combining the design of a detachable coil and an intrasaccular flow disruption device. According to our early experience, this device is safe and provides a satisfactory occlusion rate at angiographic follow‐up of 6 mo.

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.

Flow Diversion versus Standard Endovascular Techniques for the Treatment of Unruptured Carotid-Ophthalmic Aneurysms.

BACKGROUND AND PURPOSE: Over the past few years, flow diversion has been increasingly adopted for the treatment of intracranial aneurysms, especially in the paraclinoid and paraophthalmic carotid segment. We compared clinical and angiographic outcomes and complication rates in 2 groups of patients with unruptured carotid-ophthalmic aneurysms treated for 7 years by either standard coil-based techniques or flow diversion. MATERIALS AND METHODS: From February 2006 to December 2013, 162 unruptured carotid-ophthalmic aneurysms were treated endovascularly in 138 patients. Sixty-seven aneurysms were treated by coil-based techniques in 61 patients. Flow diverters were deployed in 95 unruptured aneurysms (77 patients), with additional coiling in 27 patients. Complication rates, clinical outcome, and immediate and long-term angiographic results were retrospectively analyzed. RESULTS: No procedure-related deaths occurred. Four procedure-related thromboembolic events (6.6%) leading to permanent morbidity in 1 case (1.6%) occurred in the coiling group. Neurologic complications were observed in 6 patients (7.8%) in the flow-diversion group, resulting in 3.9% permanent morbidity. No statistically significant difference was found between complication (P = .9) and morbidity rates (P = .6). In the coiling group (median follow-up, 31.5 ± 24.5 months), recanalization occurred at 1 year in 23/50 (54%) aneurysms and 27/55 aneurysms (50.9%) at the latest follow-up, leading to retreatment in 6 patients (9%). In the flow-diversion group (mean follow-up, 13.5 ± 10.8 months), 85.3% (35/41) of all aneurysms were occluded after 12 months, and 74.6% (50/67) on latest follow-up. The retreatment rate was 2.1%. Occlusion rates between the 2 groups differed significantly at 12 months (P < .001) and at the latest follow-up (P < .005). CONCLUSIONS: Our retrospective analysis shows better long-term occlusion of carotid-ophthalmic aneurysms after use of flow diverters compared with standard coil-based techniques, without significant differences in permanent morbidity.

Distant and delayed (>7 days) hemorrhage after treatment by flow-diverter stents in intracranial aneurysms: a rare but potentially serious complication.

In a recent meta-analysis, intraparenchymal hemorrhage secondary to treatment by a flow-diverter stent (FDS) was reported in 3% of the cases.[1][1] Most of these hemorrhages were periprocedural complications. More surprising cases of delayed ipsilateral hemorrhage have been reported lately in

O-036 Treatment of Intracranial Aneurysms with the LUNA AES: Midterm Clinical and Angiographic Follow-Up

Purpose The LUNA is a self-expanding ovoid device that serves as an intra saccular flow diverter as well as a scaffold for endothelization across the neck. The objective of this prospective clinical study (9 European centers) aiming to include a total of 63 patients was to evaluate the ability of the AES to occlude intracranial aneurysms while maintaining patency of the parent artery. Methods Immediate post-implantation occlusion grade, near-complete, or incomplete, and parent vessel compromise were evaluated. Patients underwent neurological testing with the NIHSS at baseline and time of discharge. Follow-up included clinical assessment at one, 3, 6, 9 and 12 months, and angiographic follow-up at 6 and 12 months. Results In 5 cases, the LUNA AES placement was carried out with balloon microcatheter assistance. In 2 cases, the LUNA AES placement was carried out with a stent (Table 1). Clinical and angiographic immediate results and at follow up are summarised in Table 2. Adverse events are summarised in Table 3. Conclusion Preliminary results demonstrate good safety profile. Angiographic follow up are promising. The clinical and angiographic follow-up will be extended to 36 months. Abstract O-036 Table 1 Abstract O-036 Table 2 Abstract O-036 Table 3 Disclosures M. Piotin: 2; C; Covidien, Stryker, Balt, MicroVention, Reverse Medical, Neuravi, Penumbra. A. Biondi: None. N. Sourour: 2; C; Covidien, Penumbra. R. Blanc: 2; C; Covidien, Stryker, Balt, MicroVention, Reverse Medical, Neuravi, Penumbra.

O-028 The LUNA aneurysm embolization system for treatment of intracranial aneurysms

Purpose The LUNA Aneurysm Embolization System (AES) is a self-expanding ovoid device that serves as an intra saccular flow diverter as well as a scaffold for endothelization across the neck. The objective of this prospective clinical study was to evaluate the ability of the AES to occlude intracranial aneurysms while maintaining patency of the parent artery. Materials and Methods 15 patients with intracranial aneurysms were enrolled (intention to treat) in the study so far. Immediate post-implantation occlusion grade (complete (complete obliteration of the aneurysm including the neck), near-complete (persistence of any portion of the original defect of the arterial wall), or incomplete (any opacification of the sac) compared to baseline), and parent vessel compromise were evaluated. Patients underwent neurological and neurocognitive testing with the Modified Rankin Scale and the National Institute of Health Stroke Scale (NIHSS) at baseline and time of discharge. Follow-up included clinical assessment at 1 month and 3 months, clinical and angiographic follow-up at 6 months. Results 15 patients (14 women, 1 man) with 14 unruptured and 1 ruptured saccular aneurysms (5 para-ophtalmic, 3 AcoA, 3 ICA-Pcom, 2 MCA, 1 ICA bifurcation, 1 A1; sizes from 5.0 to 6.7 mm) were enrolled to date in the study. In all but 1 aneurysm (1 failed procedure converted in coiling immediately after aneurysm dome perforation with the microcatheter of a recently ruptured aneurysm) 1 AES was deployed per aneurysm. In four cases, the AES embolization was carried out with balloon microcatheter assistance. In one case, the AES failed to detach and was exchanged for a second AES device that detached. In one case, AES placement led to aneurysm perforation that was controlled by temporary balloon occlusion and heparin reversion. In one case, thrombo-embolic complication was treated with i.a. injection of Abciximab. Immediate complete occlusion was obtained in one case, near complete occlusion was obtained in nine cases, no occlusion in four cases. Clinical follow-up was uneventful. To date, four patients with four aneurysms were followed with angiography at 6 months, showing complete occlusion in two cases, neck remnants in two cases. There was no parent artery stenosis or occlusion. Conclusion Preliminary results demonstrate good safety profile. The first short-term angiographic follow-up are promising. More and longer follow-up are pending. Competing interests None.

Erratum to: Double-lumen balloon for Onyx® embolization via extracranial arteries in transverse sigmoid dural arteriovenous fistulas: initial experience.

Transverse-sigmoid dural arteriovenous fistulas (TS DAVFs) can be challenging to treat by endovascular means. Indeed, a total cure of the fistula can only be achieved when complete occlusion of the fistulous point(s) is obtained by penetration of the embolic agent. However, in some cases, especially for transosseous branches from extracranial arteries like the occipital artery (OcA) or the superficial temporal artery (STA), such penetration is usually poor, leading to major proximal reflux and incomplete fistula obliteration. We present three cases of embolization in two patients with TS DAVF through the OcA and/or the STA with Onyx® using a double-lumen balloon (Microvention, Tustin, CA, USA). This technique allows the penetration of the embolic agent in the transosseous branches by forming a counter-pressure with the inflated balloon. This technique may be useful to achieve complete occlusion of TS DAVFs by endovascular means.

Early Rebleeding after Brain Arteriovenous Malformation Rupture, Clinical Impact and Predictive Factors: A Monocentric Retrospective Cohort Study

Background: Brain arteriovenous malformations (BAVMs) are a leading cause of intracranial hemorrhage in young adults. This study aimed to identify individual predictive factors of early rebleeding after BAVM rupture and determine its impact on prognosis. Methods: Early rebleeding was defined as a spontaneous intracranial hemorrhage within 30 days of BAVM rupture in patients with nonobliterated BAVMs. One hundred fifty one patients with 158 BAVM hemorrhagic events admitted to a tertiary care center during 14 years were included. Univariate followed by multivariate logistic regression was performed to assess the impact of early rebleeding on in-hospital mortality and modified Rankin Scale (mRS) score beyond 3 months and to identify independent predictors of early rebleeding. Results: Eight early rebleeding events were observed, 6 of which occurred during the first 7 days. Early rebleeding was independently and significantly associated with poor outcome (mRS ≥3 beyond 3 months, p = 0.004) but not with in-hospital mortality (p = 0.9). Distal flow-related aneurysms (p = 0.009) and altered consciousness with a Glasgow coma scale score of 3 (p = 0.01) were independently associated with early rebleeding. Conclusions: Early rebleeding is a severe complication that can occur after BAVM-related hemorrhage. Distal flow-related aneurysms and initial altered consciousness are associated with early rebleeding.

Comment on “Aneurysms Associated with Brain Arteriovenous Malformations”

We read with great interest the review article entitled “Aneurysms Associated with Brain Arteriovenous Malformations” by Rammos et al.[1][1] This article summarizes the different subtypes of intracranial aneurysms that may be associated with brain AVMs (bAVMs). We congratulate the authors for