Explore the vast range of titles available.

BackgroundThe adequacy of leptomeningeal collateral flow has a pivotal role in determining clinical outcome in acute ischemic stroke. The American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) collateral score is among the most commonly used scales for measuring this flow. It is based on the extent and rate of retrograde collateral flow to the impaired territory on angiography.ObjectiveTo evaluate inter- and intraobserver agreementin angiographic leptomeningeal collateral flow assessment.Materials and methodsThirty pretreatment angiogram video loops (frontal and lateral view), chosen from the randomized controlled trial THRombectomie des Artères CErebrales (THRACE), were sent for grading in an electronic file. 19 readers participated, including eight who had access to a training set before the first grading. 13 readers made a double evaluation, 3 months apart.ResultsOverall agreement among the 19 observers was poor (κ = 0,16 ± 6,5.10 -3), and not improved with prior training (κ = 0,14 ± 0,016). Grade 4 showed the poorest interobserver agreement (κ=0.18±0.002) while grades 0 and 1 were associated with the best results (κ=0.52±0.001 and κ=0.43±0.004, respectively). Interobserver agreement increased (κ = 0,27± 0,014) when a dichotomized score, ‘poor collaterals’ (score of 0, 1 or 2) versus ‘good collaterals’ (score of 3 or 4) was used. The intraobserver agreements varied between slight (κ=0.18±0.13) and substantial (κ=0.74±0.1), and were slightly improved with the dichotomized score (from κ=0.19±0.2 to κ=0.79±0.11).ConclusionInter- and intraobserver agreement of collateral circulation grading using the ASITN/SIR score was poor, raising concerns about comparisons among publications. A simplified dichotomized judgment may be a more reproducible assessment when images are rated by the same observer(s) in randomized trials.

BackgroundThe rate of thromboembolic events (TEEs) associated with endovascular treatment (EVT) of intracranial aneurysms is not reported uniformly in the literature due to the various ways that are used to evaluate them. Analysis of Thromboembolic Complications after Endovascular Treatment of Unruptured Intracranial Aneurysms study (ACET) is a prospective, multicenter study, which analyzes the rate of TEEs using diffusion-weighted imaging (DWI) magnetic resonance imaging (MRI) in patients treated for unruptured aneurysms with different endovascular techniques.MethodsPatients were prospectively included in six French centers. Postoperative DWI-MRI was performed within 72 hours post-procedure and independently evaluated. Univariate and multivariate analyses were conducted to determine factors associated with the occurrence of DWI lesions.ResultsOf the 233 included patients (54.5±11.2 years, 162 women, (69.5%)), 226 were effectively treated by EVT (coiling: 90 patients, 39.8%; balloon-assisted coiling (BAC): 62, 27.4%; stent-assisted coiling (SAC): 10, 4.4%; flow diversion (FD): 21, 9.3%; intrasaccular flow disruption (ISFD): 43, 19.0%) and had a postoperative MRI showing DWI lesions in 133 patients (58.8%). Univariate and multivariate analyses show the rate of patients with DWI lesions to be significantly higher with BAC (75.8%, P=0.001), SAC (90.0%, P=0.02), and FD (95.2%, P=0.001) compared with coiling alone (41.1%).ConclusionsThe rate of DWI lesions after EVT of unruptured aneurysms is primarily influenced by the EVT technique used. Techniques using transient (BAC) or permanent (SAC and FD) device placement in the parent artery are associated with a higher rate of DWI lesions.Trial registration numberACET: Unique identifier: NCT02862756.

BackgroundAround 10% of Woven EndoBridge device (WEB)-treated intracranial aneurysms will need retreatment, and it is generally believed to be more challenging than retreatment after an initial coiling. We aim to report retreatment strategies and outcomes after initial WEB embolizations.MethodsDatabases from four treatment centers, containing consecutive aneurysms treated with a WEB between 2013 and 2022, were reviewed. Demographics, aneurysm characteristics, retreatment strategies and outcomes were collected and analyzed.ResultsFrom a 756 WEB database, 57 aneurysms were included. The global retreatment rate was 7.5% (95% CI 5.6% to 9.4%). The retreatment rate was significantly higher in the ruptured compared with the unruptured population (13% vs 3.9%, respectively, P<0.0001). Aneurysms were retreated on average 21.2 months after the initial WEB treatment (range 4.8–70 months). Surgery was performed in 11% and endovascular treatment in 89% of cases, consisting of flow diversion (48%), stent-assisted coiling (30%), coiling (12%), and second WEB placement (10%). Imaging follow-up was available in 88% of all WEB retreatments (50/57) (average 17 months, 49% digital subtraction angiography), demonstrating complete occlusion in 56% and ‘adequate’ occlusion in 88%. Morbidity was 5.3% (95% CI 0% to 12.0%) and mortality 0%. No patient experienced rebleeding during the follow-up period.ConclusionThe retreatment rate after an initial WEB treatment seems to compare favorably with that of coiling. Endovascular treatment of recurrence following WEB implantation is feasible in most situations; it generally requires the use of a stent and leads to a high rate of satisfactory occlusion.

Background There are little available data regarding the influence of intravenous thrombolysis (IVT) on the efficacy of different first line endovascular treatment (EVT) techniques. Methods We used the dataset of the SWIFT-DIRECT trial which randomized 408 patients to IVTâ¯+ EVT or EVT alone at 48 international sites. The protocol required the use of a stent retriever (SR), but concomitant use of a balloon guide catheter (BGC) and/or distal aspiration (DA) catheter was left to the discretion of the operators. Four first line techniques were applied in the study population: SR, SRâ¯+ BGC, SRâ¯+ DA, SRâ¯+ DAâ¯+ BGC. To assess whether the effect of allocation to IVTâ¯+ EVT versus EVT alone was modified by the first line technique, interaction models were fitted for predefined outcomes. The primary outcome was first pass mTICI 2câ3 reperfusion (FPR). Results This study included 385 patients of whom 172 were treated with SRâ¯+ DA, 121 with SRâ¯+ DAâ¯+ BGC, 57 with SRâ¯+ BGC and 35 with SR. There was no evidence that the effect of IVTâ¯+ EVT versus EVT alone would be modified by the choice of first line technique; however, allocation to IVTâ¯+ EVT increased the odds of FPR by a factor of 1.68 (95% confidence interval, CI 1.11-2.54). Conclusion This post hoc analysis does not suggest treatment effect heterogeneity of IVTâ¯+ EVT vs EVT alone in different stent retriever techniques but provides evidence for increased FPR if bridging IVT is administered before stent retriever thrombectomy.

BackgroundEndovascular treatment (EVT) failures and early reocclusions in stroke often result from arterial wall disease, incomplete thrombus withdrawal, or acute endothelial injury. Intracranial and extracranial atherosclerosis, in particular, poses a risk of reocclusion, sometimes requiring tailored interventions (eg, angioplasty, stenting). While glycoprotein (GP) IIb/IIIa inhibitors have been widely studied in ischemic stroke, cangrelor remains less explored.ObjectiveTo evaluate the safety and efficacy of cangrelor compared with GPIIb/IIIa inhibitors in large vessel occlusion stroke (LVOS).MethodsThis retrospective analysis from the Endovascular Treatment in Ischemic Stroke Registry included patients from 34 French centers who received cangrelor or GPIIb/IIIa inhibitors during EVT between July 2018 and September 2023. Eligible cases had refractory occlusions or arterial disease at risk of reocclusion. The primary outcome was a 90-day favorable outcome. Secondary outcomes included excellent functional outcome, early neurological improvement, intracranial hemorrhage (ICH), procedural complications, and day 1 arterial patency. Propensity score overlap weighting was used for comparisons.ResultsOf 559 patients, 160 received GPIIb/IIIa inhibitors and 399 received cangrelor. Favorable outcomes were comparable (41.7% vs 43.7%; OR=1.1; 95% CI 0.61 to 1.93), as were rates of excellent functional outcome and early neurological improvement. Angiographic efficacy was similar, with modified Thrombolysis in Cerebral Infarction ≥2b rates of 89.5% for GPIIb/IIIa and 90.1% for cangrelor. No significant differences were observed in day 1 patency, 90-day mortality, or symptomatic ICH.ConclusionsCangrelor showed comparable safety and efficacy to GPIIb/IIIa inhibitors. These results, along with the specific pharmacodynamics, make this drug a promising agent in the acute management of complex intracranial and extracranial LVOS.Trial registration numberNCT03776877.

Introduction The study attempts to identify notable factors predicting poor outcome, death, and intracranial hemorrhage in patients with acute ischemic stroke undergoing mechanical thrombectomy with stent retriever. These data could be useful to improve the selection of patients for thrombectomy. Methods Patients with acute ischemic stroke treated with the Solitaire FR device were retrospectively analyzed from a prospectively collected database. We assessed the effect of selected demographic characteristics, clinical and imaging factors on poor outcome at 3 months (modified Rankin score 3–6), mortality at 3 months, and hemorrhage at day 1 (symptomatic and asymptomatic). Results From May 2010 to April 2012, 59 consecutive patients with an acute ischemic stroke underwent mechanical thrombectomy. At 3 months, 57.6 % of the patients were functionally independent (modified Rankin Scale 0–2) and mortality was 20.4 %. Multivariate analyses revealed that a thrombus length > 14 mm ( p  = 0.02; OR 7.55; 95 % CI 1.35–42.31) and longer endovascular procedure duration ( p  = 0.01; OR 1.04; 95 % CI 1.01–1.07) were independently associated with poor outcome. A higher baseline Alberta Stroke Program Early CT (ASPECT) score ( p  = 0.04; OR 0.79 per point; 95 % CI 0.63–0.99) and successful recanalization ( p  = 0.02; OR 0.07; 95 % CI 0.01–0.72) were independent predictors of good functional outcome. Baseline ASPECT score ( p  < 0.01; OR 0.65; 95 % CI 0.54–0.78) independently predicted symptomatic intracranial hemorrhage at day 1. Conclusion Absolute baseline ASPECT score reflects early symptomatic hemorrhage risk and functional outcome at 3 months. Thrombus length measured on MRI play an important role on functional outcome at 3 months after thrombectomy. Further analyses are needed to determine its importance in the selection of patients for mechanical thrombectomy.

Background and purposeFollow-up of intracranial aneurysms treated by flow diverter with MRI is complicated by imaging artifacts produced by these devices. This study compares the diagnostic accuracy of three-dimensional time-of-flight MR angiography (3D-TOF-MRA) and contrast-enhanced MRA (CE-MRA) at 3 T for the evaluation of aneurysm occlusion and parent artery patency after flow diversion treatment, with digital subtraction angiography (DSA) as the gold standard.Materials and methodsPatients treated with flow diverters between January 2009 and January 2013 followed by MRA at 3 T (3D-TOF-MRA and CE-MRA) and DSA within a 48 h period were included in a prospective single-center study. Aneurysm occlusion was assessed with full and simplified Montreal scales and parent artery patency with three-grade and two-grade scales.ResultsTwenty-two patients harboring 23 treated aneurysms were included. Interobserver agreement using simplified scales for occlusion (Montreal) and parent artery patency were higher for DSA (0.88 and 0.61) and CE-MRA (0.74 and 0.55) than for 3D-TOF-MRA (0.51 and 0.02). Intermodality agreement was higher for CE-MRA (0.88 and 0.32) than for 3D-TOF-MRA (0.59 and 0.11). CE-MRA yielded better accuracy than 3D-TOF-MRA for aneurysm remnant detection (sensitivity 83% vs 50%; specificity 100% vs 100%) and for the status of the parent artery (specificity 63% vs 32%; sensitivity 100% vs 100%).ConclusionsAt 3 T, CE-MRA is superior to 3D-TOF-MRA for the evaluation of aneurysm occlusion and parent artery patency after flow diversion treatment. However, intraluminal evaluation remains difficult with MRA regardless of the sequence used.

BackgroundIntrasaccular flow disruption with WEB is a safe and efficacious technique that has significantly changed endovascular management of wide-neck bifurcation aneurysms (WNBAs). Use of stent in combination with WEB is occasionally required. We analyzed the frequency of use, indications, safety, and efficacy of the WEB–stent combination.MethodsAll aneurysms treated with WEB and stent were extracted from a prospectively maintained database. Patient and aneurysm characteristics, complications, and anatomical results were independently analyzed by a physician independent of the procedures.ResultsFrom June 2011 to January 2020, 152 patients with 157 aneurysms were treated with WEB. Of these, 17/152 patients (11.2%) with 19/157 aneurysms (12.1%) were treated with WEB device and stent. Indications were very wide neck with a branch emerging from the neck in 1/19 (5.2%) aneurysms and WEB protrusion in 18/19 (94.7%). At 1 month, no morbimortality was reported. At 6 months, anatomical results were complete aneurysm occlusion in 15/17 aneurysms (88.2%), neck remnant in 1/17 (5.9%), and aneurysm remnant in 1/17 (5.9%). At 12 months, there was complete aneurysm occlusion in 13/14 aneurysms (92.9%) and neck remnant in 1/14 (7.1%).ConclusionsCombining WEB and stent is a therapeutic strategy to manage WNBA. In our series, this combination was used in 11.2% of patients treated with WEB, resulting in no morbidity or mortality with a high efficacy at 6 and 12 months (complete aneurysm occlusion in 88.2% and 92.9%, respectively).

Whether thrombectomy alone is equally as effective as intravenous alteplase plus thrombectomy remains controversial. We aimed to determine whether thrombectomy alone would be non-inferior to intravenous alteplase plus thrombectomy in patients presenting with acute ischaemic stroke. In this multicentre, randomised, open-label, blinded-outcome trial in Europe and Canada, we recruited patients with stroke due to large vessel occlusion confirmed with CT or magnetic resonance angiography admitted to endovascular centres. Patients were randomly assigned (1:1) via a centralised web server using a deterministic minimisation method to receive stent-retriever thrombectomy alone or intravenous alteplase plus stent-retriever thrombectomy. In both groups, thrombectomy was initiated as fast as possible with any commercially available Solitaire stent-retriever revascularisation device (Medtronic, Irvine, CA, USA). In the combined treatment group, intravenous alteplase (0·9 mg/kg bodyweight, maximum dose 90 mg per patient) was administered as early as possible after randomisation for 60 min with 10% of the calculated dose given as an initial bolus. Personnel assessing the primary outcome were masked to group allocation; patients and treating physicians were not. The primary binary outcome was a score of 2 or less on the modified Rankin scale at 90 days. We assessed the non-inferiority of thrombectomy alone versus intravenous alteplase plus thrombectomy in all randomly assigned and consenting patients using the one-sided lower 95% confidence limit of the Mantel-Haenszel risk difference, with a prespecified non-inferiority margin of 12%. The main safety endpoint was symptomatic intracranial haemorrhage assessed in all randomly assigned and consenting participants. This trial is registered with ClinicalTrials.gov, NCT03192332, and is closed to new participants. Between Nov 29, 2017, and May 7, 2021, 5215 patients were screened and 423 were randomly assigned, of whom 408 (201 thrombectomy alone, 207 intravenous alteplase plus thrombectomy) were included in the primary efficacy analysis. A modified Rankin scale score of 0–2 at 90 days was reached by 114 (57%) of 201 patients assigned to thrombectomy alone and 135 (65%) of 207 patients assigned to intravenous alteplase plus thrombectomy (adjusted risk difference −7·3%, 95% CI −16·6 to 2·1, lower limit of one-sided 95% CI −15·1%, crossing the non-inferiority margin of −12%). Symptomatic intracranial haemorrhage occurred in five (2%) of 201 patients undergoing thrombectomy alone and seven (3%) of 202 patients receiving intravenous alteplase plus thrombectomy (risk difference −1·0%, 95% CI −4·8 to 2·7). Successful reperfusion was less common in patients assigned to thrombectomy alone (182 [91%] of 201 vs 199 [96%] of 207, risk difference −5·1%, 95% CI −10·2 to 0·0, p=0·047). Thrombectomy alone was not shown to be non-inferior to intravenous alteplase plus thrombectomy and resulted in decreased reperfusion rates. These results do not support omitting intravenous alteplase before thrombectomy in eligible patients. Medtronic and University Hospital Bern.

ObjectiveWe aimed to determine in the “THRACE” trial, the clinical and MRI technical parameters associated with the two-layered susceptibility vessel sign (TL-SVS) and the overestimation ratio (overR).Materials and methodsPatients with pre-treatment brain gradient echo (GRE) sequence and an etiological work-up were identified. Two readers reviewed TL-SVS, i.e., a SVS with a linear low-intense signal core surrounded by a higher intensity and measured the overR as the width of SVS divided by the width of the artery. Binomial and ordinal logistic regression respectively tested the association between TL-SVS and quartiles of overR with patient characteristics, cardioembolic stroke (CES), time from onset to imaging, and GRE sequence parameters (inter slice gap, slice thickness, echo time, flip angle, voxel size, and field strength).ResultsAmong 258 included patients, 102 patients were examined by 3 Tesla MRI and 156 by 1.5 Tesla MRI. Intra- and inter-reader agreements for quartiles of overR and TL-SVS were good to excellent. The median overR was 1.59 (IQR, 1.30 to 1.86). TL-SVS was present in 101 patients (39.2%, 95%CI, 33.1 to 45.1%). In multivariate analysis, only CES was associated with overR quartiles (OR, 1.83; 95%CI, 1.11 to 2.99), and every 60 min increase from onset to MRI time was associated with TL-SVS (OR, 1.72; 95%CI, 1.10 to 2.67). MRI technical parameters were statistically associated with neither overR nor TL-SVS.ConclusionIndependent of GRE sequence parameters, an increased overR was associated to CES, while the TL-SVS is independently related to a longer time from onset to MRI.Key Points• An imaging biomarker would be useful to predict the etiology of stroke in order to adapt secondary prevention of stroke.• The two-layered susceptibility vessel sign and the overestimation ratio are paramagnetic effect derived markers that vary according to the MRI machines and sequence parameters.• Independent of sequence parameters, an increased overestimation ratio was associated to cardioembolic stroke, while the two-layered susceptibility vessel sign is independently related to a longer time from onset to MRI.