Ronit Agid

ELAPSS score for prediction of risk of growth of unruptured intracranial aneurysms.

Objective: To develop a risk score that estimates 3-year and 5-year absolute risks for aneurysm growth. Methods: From 10 cohorts of patients with unruptured intracranial aneurysms and follow-up imaging, we pooled individual data on sex, population, age, hypertension, history of subarachnoid hemorrhage, and aneurysm location, size, aspect ratio, and shape but not on smoking during follow-up and family history of intracranial aneurysms in 1,507 patients with 1,909 unruptured intracranial aneurysms and used aneurysm growth as outcome. With aneurysm-based multivariable Cox regression analysis, we determined predictors for aneurysm growth, which were presented as a risk score to calculate 3-year and 5-year risks for aneurysm growth by risk factor status. Results: Aneurysm growth occurred in 257 patients (17%) and 267 aneurysms (14%) during 5,782 patient-years of follow-up. Predictors for aneurysm growth were earlier subarachnoid hemorrhage, location of the aneurysm, age >60 years, population, size of the aneurysm, and shape of the aneurysm (ELAPSS). The 3-year growth risk ranged from <5% to >42% and the 5-year growth risk from <9% to >60%, depending on the risk factor status. Conclusions: The ELAPSS score consists of 6 easily retrievable predictors and can help physicians in decision making on the need for and timing of follow-up imaging in patients with unruptured intracranial aneurysms.

Endovascular Management of Acute Stroke in the Elderly: A Systematic Review and Meta-Analysis

Background: Acute ischemic stroke occurs more frequently, presents with more severe symptoms, and has worse outcomes in elderly patients. The safety and efficacy of endovascular therapy for acute stroke in this age group has not been fully established. Purpose: We present the results of a systematic review and meta-analysis examining clinical, procedural, and radiologic outcomes of endovascular therapy for acute stroke in patients older than 80 years of age. Data Sources: We searched PubMed, MEDLINE, and EMBASE from 1992 to week 35 of 2017 for studies evaluating endovascular therapy for acute stroke in the elderly. Study Selection: Two independent reviewers selected studies and abstracted data. The primary end point was good functional outcome at 3 months defined as modified Rankin Scale score of ≤2. Data Analysis: Data were analyzed using random-effects meta-analysis. Data Synthesis: Seventeen studies reporting on 860 patients were included. The rate of good functional outcome at 3 months was 27% (95% CI, 21%–32%). Mortality at 3 months was 34% (95% CI, 23%–44%). Successful recanalization was achieved in 78% of patients (95% CI, 72%–85%). Procedure-related complications occurred in 11% (95% CI, 4%–17%). The incidence of intracranial hemorrhage was 24% (95% CI, 15%–32%), and for symptomatic intracranial hemorrhage, it was 8% (95% CI, 5%–10%). The mean time to groin was 251 minutes (95% CI, 224–278 minutes). Procedure time was 99 minutes (95% CI, 67–131 minutes). Limitations: I2 values were above 50% for all outcomes, indicating substantial heterogeneity. Conclusions: Good functional recovery in octogenarians treated with endovascular therapy for acute stroke can be achieved in a high proportion of patients despite the higher incidence of comorbidity in this cohort. Outcomes are inferior to those reported for younger patients; however, endovascular therapy can allow at least 1 in 4 patients older than 80 years of age to regain independent function at 3 months. More research is required to improve patient selection in the elderly, but age should not be a discriminator when deciding to offer endovascular therapy for patients with acute stroke.

Management of Residual Brain Arteriovenous Malformations After Stereotactic Radiosurgery

OBJECTIVEnTo assess outcome of residual brain arteriovenous malformation (BAVM) after stereotactic radiosurgery.nnnMETHODSnPatients with residual BAVM 3 years after radiosurgery were retrospectively included. Demographics, angioarchitectural characteristics, complications, bleeding, and cure rates of patients with intervention or conservative management (i.e., observation) were compared. We analyzed characteristics of patients treated conservatively who achieved cure or still had persistent BAVMs during follow-up.nnnRESULTSnThe study included 87 patients including 5 patients with subtotal obliteration with a mean follow-up time of 33.7 ± 36.6 months. Of patients, 27 (31.0%) received subsequent treatment (radiosurgery, nxa0= 23; microsurgery, nxa0= 3; embolization, nxa0= 1), and 60 (69%) were treated conservatively. After repeat SRS, 4 (14.8%) patients experienced symptomatic complications after the second treatment, and 7 (25.9%) experienced asymptomatic changes. Three (3.4%) patients, all of whom presented initially with a ruptured BAVM, experienced hemorrhage during follow-up. Subsequent treatment was effective with a complete cure of BAVM in 11 patients (40.7%). Complete resolution of the residual BAVM occurred in 15 (25%) patients treated conservatively.nnnCONCLUSIONSnComplete obliteration of a significant number of residual BAVMs may occur 3-5 years after the first irradiation, whereas increased radiation dose associated with repeat SRS may lead to an increased risk of complications. The fact that the interval risk of bleeding decreased after SRS (especially for ruptured BAVM) lends further strength to the argument for a conservative management approach for residual BAVM 3-5 years after the first irradiation.

Cerebrovascular Imaging: Which Test is Best?

Optimal diagnosis and characterization of cerebrovascular disease requires selection of the appropriate imaging exam for each clinical situation. In this review, we focus on intracranial arterial disease and discuss the techniques in current clinical use for imaging the blood vessel lumen and blood vessel wall, and for mapping cerebral hemodynamic impairment at the tissue level. We then discuss specific strategies for imaging intracranial aneurysms, arteriovenous malformations, dural arterial venous fistulas, and arterial steno-occlusive disease.

Interval angioarchitectural evolution of brain arteriovenous malformations following rupture

OBJECTIVEThe goal of this study was to describe changes in the angioarchitecture of brain arteriovenous malformations (bAVMs) between acute and delayed cerebral digital subtraction angiography (DSA) obtained after hemorrhage, and to examine bAVM characteristics predicting change.METHODSThis is a retrospective study of a prospective institutional bAVM database. The authors included all patients with ruptured bAVMs who had DSA in both acute and delayed phases, with no interval treatment of their bAVM, between January 2000 and April 2017. The authors evaluated the existence or absence of angioarchitectural changes. Demographic data, radiological characteristics of hemorrhages, and angioarchitectural features of the bAVMs of the two patients groups were analyzed. Univariate and multivariate logistic analyses were performed to identify predictors of angioarchitectural change.RESULTSA total of 42 patients were included in the series. Seventeen (40.5%) patients had angioarchitectural changes including bAVM only visible on the delayed DSA study (n = 8), spontaneous thrombosis of the AVM (n = 3), or alteration of the size or the opacification of the nidus (n = 6). The factors associated with angioarchitectural changes were a small nidus (3.8 ± 7.9 ml vs 6.1 ± 9.5 ml, p = 0.046), a superficial location (94.1% vs 5.9%, p = 0.016), and a single superficial draining vein (58.8% vs 24.0%, p = 0.029).CONCLUSIONSAngioarchitectural changes can be seen in 40% of ruptured bAVMs between the acute- and delayed-phase DSA. A small nidus, a superficial location, and a single superficial draining vein were statistically associated with the occurrence of angioarchitectural changes. These changes included either enlargement or spontaneous occlusion of the bAVM, as well as subsequent diagnosis of a bAVM following an initial negative DSA study.

Carotid Stenting for Treatment of Symptomatic Carotid Webs: A Single-Center Case Series

Background and Purpose: Carotid webs are an increasingly recognized cause of acute ischemic stroke, particularly in younger adults. The optimal medical and surgical strategies for managing these lesions have not been well established. We report a single-center case series of carotid stenting for treatment of symptomatic carotid webs. Materials and Methods: Consecutive patients undergoing stent placement for treatment of symptomatic carotid webs were included. Carotid webs were defined as a thin intraluminal filling defect along the posterior wall of the carotid bulb just beyond the carotid bifurcation on CTA. Data were collected on demographic characteristics, antiplatelet management, clinical presentation, imaging findings, treatment characteristics, complications, and stroke recurrence rates. Descriptive statistics are reported. Results: A total of 4 patients were treated. Their mean age was 44 years (range 30–50). Three patients were female and 1 was male. All patients were symptomatic presenting with ipsilateral transient ischemic attacks or stroke. Patients were placed on dual antiplatelet therapy with ticagrelor and aspirin prior to the procedure. There were no ischemic or hemorrhagic complications. Three patients had postoperative bradycardia, 1 of whom required atropine immediately following stenting. No patients had recurrent ischemic events. Conclusions: Stent placement for treatment of carotid webs can be performed safely. Further studies are needed to confirm our findings.

Endovascular treatment of intracranial vertebrobasilar artery dissecting aneurysms: Parent artery occlusion versus flow diverter.

PURPOSEnTo compare the safety and efficacy of endovascular parent artery occlusion (PAO) and flow diverter (FD) treatment in treating vertebrobasilar dissecting aneurysms (VBDAs).nnnMETHODSnA review of a prospective aneurysm database at our institution was performed to identify all consecutive patients with intracranial VBDAs managed with endovascular treatment, which were either PAO or FD. Clinical and imaging findings were compared between the two groups.nnnRESULTSnA total of 25 consecutive patients with 27 VBDAs were included. Seventeen VBDAs were treated by PAO, and 11 VBDAs were treated with FDs. Immediate total occlusion rate after initial treatment was higher in the PAO group than in the FD group (62.5% v.s. 9.1%, pu202f=u202f.018). Complete occlusion on follow-up at 18 months was more frequently observed in the PAO group (81.8%) compared to the FD group (55.6%), although the difference was not statistically significant (pu202f=u202f.433). Procedure related complication rate and mortality for the whole case series was 28% and 24% respectively, and were comparable in the two groups. Excellent outcome at discharge was achieved in 77.8% and 40% of patients treated with FD and PAO respectively, which was not statistically significant (pu202f=u202f.169). Excellent outcome at followed-up was comparable as well.nnnCONCLUSIONSnPAO and FD treatment are both feasible options for treatment of VBDAs. PAO provide higher immediate complete occlusion rate compared to FD. Despite low initial complete occlusion rates, FD group presented a comparable long-term outcome and similar perioperative events rate compared to the PAO group.

Flow-diverter Stents for Internal Carotid Artery Reconstruction Following Spontaneous Dissection: A Technical Report

Background and PurposeExtracranial internal carotid artery (ICA) dissection is an important cause of ischemic stroke in younger adults. The optimal medical and surgical strategies for managing these lesions have not been well established. We report axa0case series of extracranial ICA reconstruction using overlapping flow-diverter stents as axa0rescue therapy for the treatment of symptomatic ICA dissection in patients presenting with recurrent ischemic stroke and/or severe hemispheric hypoperfusion who failed medical management.Materials and MethodsConsecutive patients undergoing endovascular reconstruction of either occluded or severely narrowed ICA due to dissection and presenting with symptoms of recurrent cerebral ischemia or cerebral hypoperfusion were included. Data were collected on demographic characteristics, antiplatelet management, clinical presentation, imaging findings, treatment characteristics, complications and stroke recurrence rates.ResultsA total of 7xa0patients were included. The mean age was 47xa0years, 4 patients were male and 3 were female. All patients were symptomatic presenting with ipsilateral recurrent ischemia with or without cerebral hemodynamic compromise and necessitated reconstructive treatment. Patients were placed on dual antiplatelet therapy with aspirin and either ticagrelor or clopidogrel prior to the procedure. In cases where patients were not preloaded with dual antiplatelets intravenous abciximab was used as a bridging therapy. Post-stenting angioplasty was performed if deemed necessary. There were no symptomatic ischemic or hemorrhagic complications. No patients had recurrent ischemic events.ConclusionReconstruction of the ICA as axa0rescue strategy for extracranial carotid dissection using flow-diverter stents is feasible and was performed without adverse events in this small series.

Rationale and design for the detection and neurological impact of cerebrovascular events in non-cardiac surgery patients cohort evaluation (NeuroVISION) study: a prospective international cohort study

Objectives Covert stroke after non-cardiac surgery may have substantial impact on duration and quality of life. In non-surgical patients, covert stroke is more common than overt stroke and is associated with an increased risk of cognitive decline and dementia. Little is known about covert stroke after non-cardiac surgery. NeuroVISION is a multicentre, international, prospective cohort study that will characterise the association between perioperative acute covert stroke and postoperative cognitive function. Setting and participants We are recruiting study participants from 12 tertiary care hospitals in 10 countries on 5 continents. Participants We are enrolling patients ≥65 years of age, requiring hospital admission after non-cardiac surgery, who have an anticipated length of hospital stay of at least 2u2009days after elective non-cardiac surgery that occurs under general or neuraxial anaesthesia. Primary and secondary outcome measures Patients are recruited before elective non-cardiac surgery, and their cognitive function is measured using the Montreal Cognitive Assessment (MoCA) instrument. After surgery, a brain MRI study is performed between postoperative days 2 and 9 to determine the presence of acute brain infarction. One year after surgery, the MoCA is used to assess postoperative cognitive function. Physicians and patients are blinded to the MRI study results until after the last patient follow-up visit to reduce outcome ascertainment bias. We will undertake a multivariable logistic regression analysis in which the dependent variable is the change in cognitive function 1u2009year after surgery, and the independent variables are acute perioperative covert stroke as well as other clinical variables that are associated with cognitive dysfunction. Conclusions The NeuroVISION study will characterise the epidemiology of covert stroke and its clinical consequences. This will be the largest and the most comprehensive study of perioperative stroke after non-cardiac surgery. Trial registration number NCT01980511; Pre-results.

Treatment of an internal carotid artery aneurysm with a flow diverter through a double lumen balloon catheter

Background Double lumen balloon catheters (DLBCs) are currently used in the treatment of intracranial aneurysms, especially when involving balloon or stent-assisted coiling. The existing DLBCs allow the delivery of self-expandable stents but do not offer the possibility to deploy flow-diverters. Despite the increasing use and success of flow-diverters, there have been numerous reports of procedural complications such as early in-stent thrombosis or delayed distal embolization. It seems that these complications can be avoided by correct stent positioning and adequate wall apposition, achieved either by manoeuvres with the microguidewire and/or microcatheter or by performing balloon angioplasty following an exchange guidewire manoeuvre. Objective Report the use of a new DLBC able to deliver a flow-diverter. Methods A 41-year-old woman presented to our hospital with binocular horizontal diplopia for two weeks and reduced visual acuity. A left internal carotid artery aneurysm involving the cavernous and ophthalmic segments was found, with a maximum height of 19u2009mm and a broad 8u2009mm neck. It presented extra- and intra-dural components and the parent vessel was significantly narrowed. A decision was made to perform endovascular treatment of the aneurysm with placement of a flow diverter through a DLBC. Results Patency and adequate expansion of the flow diverter with evident intra-aneurysmal contrast stasis was observed in the final angiogram. No peri-procedural complications were observed. Conclusion This is a technical note demonstrating the feasibility of a new device to deploy a flow diverter, aiming to improve wall apposition and stent configuration without the need of additional devices or exchange manoeuvres.