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Delayed cerebral ischemia (DCI) is a severe subarachnoid hemorrhage (SAH) complication, closely related to cerebral vasospasm (CVS). CVS treatment frequently comprises intravenous milrinone, an inotropic and vasodilatory drug. Our objective is to describe milrinone's hemodynamic, respiratory and renal effects when administrated as treatment for CVS. Retrospective single-center observational study of patients receiving intravenous milrinone for CVS with systemic hemodynamics, oxygenation, renal disorders monitoring. We described these parameters' evolution before and after milrinone initiation (day – 1, baseline, day 1 and day 2), studied treatment cessation causes and assessed neurological outcome at 3–6 months. Ninety-one patients were included. Milrinone initiation led to cardiac output increase (4.5 L/min [3.4–5.2] at baseline vs 6.6 L/min [5.2–7.7] at day 2, p < 0.001), Mean Arterial Pressure decrease (101 mmHg [94–110] at baseline vs 95 mmHg [85–102] at day 2, p = 0.001) norepinephrine treatment requirement increase (32% of patients before milrinone start vs 58% at day 1, p = 0.002) and slight PaO2/FiO2 ratio deterioration (401 [333–406] at baseline vs 348 [307–357] at day 2, p = 0.016). Milrinone was interrupted in 8% of patients. 55% had a favorable outcome. Intravenous milrinone for CVS treatment seems associated with significant impact on systemic hemodynamics leading sometimes to treatment discontinuation. •Subarachnoid hemorrhage may lead to delayed cerebral ischemia, commonly due to cerebral vasospasm•Its treatment is unequivocal and frequently includes intravenous milrinone•Intravenous milrinone affects systemic hemodynamics and causes slight oxygenation deterioration in these patients•Milrinone was well tolerated with only 8% of patients needing cessation of treatment

Abstract BACKGROUND: Over the past decade, stenting of lateral sinus stenosis has been used to treat idiopathic intracranial hypertension. Two types of stenoses have been identified: extrinsic and intrinsic. OBJECTIVE: The aim of this study was to report the results of our use of this procedure to treat patients with extrinsic or intrinsic stenoses in idiopathic intracranial hypertension. METHODS: We retrospectively studied clinical, radiological, and manometric data from patients with idiopathic intracranial hypertension who were treated at our institution between January 2009 and January 2015 by stenting of the lateral sinus. RESULTS: Data were studied from 19 women and 2 men. Average body mass index was 29 kg/m2, and the median age at stenting was 33 years. Patients with extrinsic stenoses were younger than those with intrinsic stenoses. Transstenotic gradients measured with patients under general anesthesia were lower than those measured with patients under local anesthesia. In all cases, stenting was effective for papilledema and pulsatile tinnitus. Seventeen patients reporting headaches found that they disappeared completely after stenting. Two complications without long-term effects were reported. CONCLUSION: Irrespective of the type of stenosis, stenting of lateral sinus stenoses is an effective treatment for intracranial hypertension symptoms. At our institution, this treatment has replaced draining of cerebrospinal fluid when treatment with acetazolamide has proved to be ineffective.

Abstract BACKGROUND Whether delayed cerebral infarction (DCIn) after aneurysmal subarachnoid hemorrhage (aSAH) is driven by large artery vasospasm is still controversial. OBJECTIVE To study the association between DCIn and vasospasm by using quantitative assessment of vasospasm up to distal arteries with time and territorial-based correlation. METHODS Clinical and imaging data of 392 patients with aSAH treated at our center between 2012 and 2017 were reviewed. DCIn was defined as any cerebral infarction occurring within 3 to 21 d after ictus and not related to other specific cause. In patients with DCIn, vasospasm was assessed within 24 h around DCIn for each cerebral artery up to the end of the 2nd segments. DCIn and vasospasm analyses were blinded. RESULTS DCIn was found in 11% of patients (inter-rater k = 0.90, computed tomography (CT)-scan = 100%, follow-up MRI = 91%). Vasospasm was quantified in 258 artery territories including 66 with and 192 without DCIn (DSA = 93%, computed tomography angiography = 7%). Vasospasm was more severe in DCIn than in non-DCIn territories (60% [55-69] vs 20% [0-50], P < .001). Vasospasm was associated with DCIn in a “dose-dependent” manner (P for trend = .022). Every DCIn territory had a vasospasm ≥ 50%, including 39% only of distal artery segments. Only 9% of non-DCIn territories had vasospasm ≥ vasospasm in DCIn territories. CONCLUSION The necessary association between severe vasospasm and DCIn in our study brings additional arguments in favor of large artery vasospasm (especially of distal segments) as a major determinant of DCIn and a potential therapeutic target.

BackgroundMechanical thrombectomy (MT) for acute ischemic stroke can be performed under local anesthesia, with or without conscious sedation (CS), or under general anesthesia (GA). The hemodynamic consequence of anesthetic drugs may explain why GA may be associated with worse outcomes. We evaluated the association between hypotension duration during MT and the 90 day functional outcome under both anesthetic regimens.MethodsPatients were included in this retrospective study if they had an ischemic stroke treated by MT under GA or CS. The main exposure variable was the time below 90% of the reference value of arterial pressure measured before MT. The primary outcome was poor functional outcome defined as a 90 day modified Rankin Score ≥3.Results371 patients were included in the study. GA was performed in 42%. A linear association between the duration of arterial hypotension and outcome was observed. The odds ratio for poor functional outcome of 10 min under 90% of the baseline mean arterial pressure was 1.13 (95% CI 1.06 to 1.21) without adjustment and 1.11 (95% CI 1.02 to 1.21) after adjustment for confounding factors. The functional outcome was poorer for patients treated under GA compared with CS, but the association with the depth of hypotension remained similar under both conditions.ConclusionIn this study, we observed a linear association between the duration of hypotension during MT and the functional outcome at 90 days. An aggressive and personalized strategy for the treatment of hypotension should be considered. Further trials should be conducted to address this question.

Matching was performed on age, World Federation of Neurosurgical Societies (WFNS) grade, Fischer grade, need for external ventricular derivation (EVD) and severity assessed by Simplified Acute Physiology Score II (SAPS II). Regarding evolution of vessels diameters, we observed a slight increase in the median cerebral arteries diameters between D0 and D5–7 (0.03 mm (IQR [− 0.01; 0.06])) in the Levo group, while cerebral arteries showed signs of vasospasm with a decreasing diameter in the control group (− 0.47 mm (IQR [− 0.51; − 0.24]) (p = 0.002; Fig. 1). Definition of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage as an outcome event in clinical trials and observational studies: proposal of a multidisciplinary research group.

Purpose Endovascular treatment (EVT) has become a major option in management of infectious intracranial aneurysms (IIAs) complicating infective endocarditis. We report a retrospective, single-center series of consecutive patients with IIAs treated by EVT. Methods Patients were included from January 2009 to July 2020. IIAs were diagnosed on DSA. Each patient underwent a neurological assessment before and after EVT and was followed up by imaging within 15 days of EVT. Safety was assessed on the evolution of NIHSS score. A minor stroke was defined as a worsening of NIHSS < 4 points. Efficacy was defined as the absence of hemorrhagic event during cardiac surgery and the exclusion of the IIA on control imaging. Results Sixty-two IIAs (30 ruptured) were diagnosed in 31 patients. Fifty-six IIAs were diagnosed on the first DSA and 6 on the early control exploration. EVT was achieved in 55 IIAs by parent artery occlusion with glue in 52 distal IIAs and coils in 3 proximal IIAs. IIAs were located in 90.9% of cases on a fourth-division branch of a cerebral artery. The neurological examination remained unchanged in 29 patients (93.5%), and 2 patients suffered minor stroke. EVT was performed before cardiac surgery in 20/22 patients. All treated IIAs were excluded on follow-up imaging. No hemorrhage was observed during cardiac surgery or in the aftermath. Seven (11.3%) unruptured IIAs were not embolized. Conclusion EVT of IIAs by occlusion of the parent artery is effective in preventing rupture and carries no significant neurological risk.

Purpose Embolization of middle meningeal artery (MMA) has been proposed for postoperative recurrences and primary treatment of chronic subdural hematoma (CSDH). This endovascular intervention is safe only when MMA originates from the internal maxillary artery. The aim of this study was to report an unusual high frequency of MMA originating from the ophthalmic artery, which prohibits this treatment. Methods In this retrospective study, we reviewed the anatomical origin of the MMA in patients with CSDH who were referred to our center for endovascular treatment between January 2017 and May 2019 (42 patients with 58 CSDH). We compared the prevalence of this variant in a control group of 66 patients who underwent embolization for epistaxis during the same period. Results In CSDH group, MMA originated from the ophthalmic artery in 8 out of 58 internal carotid arteries (13.8%). In the control group, this variant was observed in only 1 case out of 131 internal carotid arteries (0.7%) (OR = 20; 95% CI 2.6 to 925.2, p  = 0.0003). Conclusion In this study, we report an extremely high prevalence of MMA originating from the ophthalmic artery in CSDH. In the hypothesis of prospective studies, a priori recognition of this variant will be necessary in order to exclude patients in whom endovascular treatment will not be feasible.

Background and purposeCervicocephalic artery dissection (CCAD) is a well-recognized cause of ischemic stroke. However, complex forms of CCAD, characterized by a wide intimal inlet without a visible intramural hematoma, pose diagnostic challenges and complicate endovascular access to the true lumen when recanalization is required. We aimed to analyze the clinical presentation, outcomes, and feasibility of endovascular treatment of complex CCAD and to propose a novel morphological classification.MethodsWe retrospectively analyzed consecutive patients treated for acute CCAD at Lariboisière Hospital between 2012 and 2023. Simple CCAD was mainly defined by the presence of a classic intramural hematoma, and complex CCADs by an intraluminal flap. We compared both types using univariate analysis and binary logistic regression for clinical presentation and outcomes.ResultsAmong the 496 CCADs, 71 (14%; 95% confidence interval (CI): 11 to 17%) were complex. Compared with simple CCAD, complex cases were associated with older age, male sex, anterior circulation, iatrogenic cause, intracranial CCAD, vessel occlusion, and ischemic stroke (P<0.01). Complex CCAD was an independent risk factor for ischemic presentation (odds ratio (OR)=3.0; 95% CI:1.4 to 6.5, P=0.006), early ischemic recurrence (OR=2.0; 95% CI: 1.0 to 3.9, P=0.049), unfavorable outcome (OR=2.0; 95% CI: 1.0 to 5.0, P=0.051) and no recanalization at 3 months (OR=5.2; 95% CI: 2.4 to 11.5, P<0.001). Stenting, possibly combined with angioplasty and intimal fenestration, yielded the highest recanalization rates.ConclusionComplex CCADs exhibit distinct morphology, clinical presentation, and outcomes compared with simple forms. Recognizing the different morphological subtypes may help optimize diagnosis and guide tailored endovascular strategies.

Dural sinus stenting is an increasingly recognized intervention for the treatment of lateral sinus stenosis. This procedure can be challenging in tortuous anatomy and in the presence of intraluminal septa because of poor trackability and crossability of long sheath commonly used for stenting. We report a technique using a pilot angioplasty balloon positioned at the distal end of the long sheath that improves its navigability in dural sinuses and facilitated the intervention.

Background Intensive therapies of delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH) have still controversial and unproven benefit. We aimed to compare the overall efficacy of two different center-driven strategies for the treatment of DCI respectively with and without vasospasm angioplasty. Methods Two hundred consecutive patients with aSAH were enrolled in each of two northern European centers. In an interventional center, vasospasm angioplasty was indicated as first line rather than rescue treatment of DCI using distal percutaneous balloon angioplasty technique combined with intravenous milrinone. In non-interventional center, induced hypertension was the only intensive therapy of DCI. Radiological DCI (new cerebral infarcts not visible on immediate post-treatment imaging), death at 1 month, and favorable outcome at 6 months (modified Rankin scale score ≤ 2) were retrospectively analyzed by independent observers and compared between two centers before and after propensity score (PS) matching for baseline characteristics. Results Baseline characteristics only differed between centers for age and rate of smokers and patients with chronic high blood pressure. In the interventional center, vasospasm angioplasty was performed in 38% of patients with median time from bleeding of 8 days (Q1 = 6.5;Q3 = 10). There was no significant difference of incidence of radiological DCI (9% vs.14%, P  = 0.11), death (8% vs. 9%, P  = 0.4), and favorable outcome 74% vs. 72% ( P  = 0.4) between interventional and non-interventional centers before and after PS matching. Conclusions Our results suggest either that there is no benefit, or might be minimal, of one between two different center-driven strategies for intensive treatment of DCI. Despite potential lack of power or unknown confounders in our study, these results question the use of such intensive therapies in daily practice without further optimization and validation.