Alain Bonafe - Academia.edu (original) (raw)
Papers by Alain Bonafe
Age and ageing, 2020
BACKGROUND AND PURPOSE The benefit of endovascular thrombectomy (EVT) among nonagenarians (90 yea... more BACKGROUND AND PURPOSE The benefit of endovascular thrombectomy (EVT) among nonagenarians (90 years or older) is poorly documented. We aimed to investigate the clinical and imaging factors associated with good outcomes and mortality at 90 days in nonagenarians undergoing EVT for acute ischemic stroke (AIS). METHODS Data from a prospectively maintained institutional registry of consecutive AIS patients treated with EVT from January 2012 to December 2018 were retrospectively analysed. Comorbid conditions were classified with a modified version of the Charlson Comorbidity Index (CCI). The degree of disability was assessed by the modified Rankin Scale (mRS). Outcomes included good functional outcome (mRS scores of 0-3) and mortality at 90 days. RESULTS Among 110 patients (age, 92.3 ± 2.5 years; men, 28.2%) treated with EVT, good outcome was achieved in 39 (35.5%) patients, successful reperfusion (modified Thrombolysis in Cerebral Infarction grades of 2b-3) was achieved in 78 (70.9%) pat...
Stroke, 2016
Background and Purpose: The SWIFT PRIME trial demonstrated superior outcomes in patients presenti... more Background and Purpose: The SWIFT PRIME trial demonstrated superior outcomes in patients presenting with disabling acute ischemic stroke (AIS) who underwent endovascular therapy vs. intravenous tissue plasminogen activator (t-PA) alone. We sought to understand the relationship between functional independence and time to reperfusion in study patients assigned to thombectomy. Methods: SWIFT PRIME is a global, multi-center, prospective, randomized, open, blinded endpoint study comparing functional outcomes in AIS subjects treated with either IV t-PA alone or IV t-PA in combination with Solitaire stent retriever device. Among patients in whom substantial reperfusion (TICI 2b/3) was achieved, we analyzed the effect onindependent outcome (mRS 0-2) of time from stroke onset to reperfusion (OTR) and from qualifying imaging to reperfusion Results: Among 83 patients undergoing thrombectomy, substantial reperfusion was achieved in 73 (88%). A marked effect of OTR was noted (Figure 1A). The rat...
Journal of NeuroInterventional Surgery
BackgroundThe use of flow diversion to treat intracranial aneurysms has increased in recent years... more BackgroundThe use of flow diversion to treat intracranial aneurysms has increased in recent years.ObjectiveTo assess the safety and angiographic efficacy of the p64 flow modulation device.MethodsDiversion-p64 is an international, prospective, multicenter, single-arm, study conducted at 26 centers. The p64 flow modulation device was used to treat anterior circulation aneurysms between December 2015 and January 2019. The primary safety endpoint was the incidence of major stroke or neurologic death at 3–6 months, with the primary efficacy endpoint being complete aneurysm occlusion (Raymond-Roy Occlusion Classification 1) on follow-up angiography.ResultsA total of 420 patients met the eligibility criteria and underwent treatment with the p64 flow modulation device (mean age 55±12.0 years, 86.2% female). Mean aneurysm dome width was 6.99±5.28 mm and neck width 4.47±2.28 mm. Mean number of devices implanted per patient was 1.06±0.47, with adjunctive coiling performed in 14.0% of the cases...
Neurology: Clinical Practice
BackgroundThis study assessed whether a quality improvement (QI) process to streamline transfer f... more BackgroundThis study assessed whether a quality improvement (QI) process to streamline transfer from a primary stroke center (PSC) to a comprehensive stroke center (CSC) could reduce the delay of reperfusion by mechanical thrombectomy (MT).MethodsFrom 2015 to 2017, a QI process was implemented with specific interventions to reduce door-in-to-door-out (DIDO) time in a high volume PSC, and speed up interhospital transfer and inhospital processes at the CSC. Clinical characteristics and time metrics were compared in the QI (2015–2017; n = 157) and pre-QI cohorts (2012–2014; n = 121).ResultsDuring the QI process, the median symptom onset to reperfusion time was reduced by 50 minutes (367 vs 417 minutes in the pre-QI cohort, p < 0.04), with a substantial 40-minute DIDO reduction (78 vs 118 minutes, p < 0.01), related to the faster administration of IV thrombolysis (median door-to-needle time: 49 vs 82 minutes, p = 0.0001). The door-to-door time was shortened (170 vs 205 minutes, p ...
Annals of Physical and Rehabilitation Medicine
Objective To evaluate the additional value of adding movement kinematics into the design matrix i... more Objective To evaluate the additional value of adding movement kinematics into the design matrix in order to gain fine-grained insight in motor control strategies. Methods Ten healthy volunteers (age 41.8 ± 14.5, 5 males) performed a continuous elbow flexion/extension within a 1.5 MRI system. Movement kinematics were registered with the Zebris, a MRI compatible 3D motion capture system. Results Without taking the movement kinematics into consideration we found the expected systematic activation of the primary sensorimotor network, thought to generate movement execution [1] . By adding the kinematics to the fMRI design matrix we unmasked the involvement of fronto-cerebellar circuits and of the sensory cortex, as a function of both the irregularity and the frequency of movement, highlighting underlying processes of error-control to ensure optimal execution [2] . Discussion Our results reveal the modular and hierarchical structure of rhythmic motor control within brain networks: rhythmical movement generation relies on the activation of the primary sensorimotor network and error control of that movement results from the trade-off between automatically driven intermittent control involving cerebellar-frontal loops and continuous feedback involving the sensory cortex. Motor planning and error-control are important process involved in recovery post-stroke, and the detailed kinematic analysis during fMRI measurements seems to have an additional value possibly contributing to further understanding motor learning post-stroke.
European Radiology
To establish whether imaging assessments of irreversibly injured ischemic core and potentially sa... more To establish whether imaging assessments of irreversibly injured ischemic core and potentially salvageable penumbral volumes and collateral circulation were associated with functional outcome in nonagenarians (90 years or older) undergoing endovascular thrombectomy (EVT). Data from a prospectively maintained institutional registry of consecutive stroke patients treated with EVT from January 2012 to December 2018 were retrospectively analyzed. Functional outcome was evaluated with the modified Rankin scale (mRS) at 3 months. mRS score of 0–3 was defined as a good clinical outcome. Ischemic core and penumbral volumes were calculated using the RAPID software. Quantification of collateral circulation was performed using a fluid-attenuated inversion recovery vascular hyperintensity (FVH)–Alberta Stroke Program Early CT Score (ASPECTS) rating system. Among 85 patients (age, 92.4 ± 2.6 years; men, 30.6%) treated with EVT, good outcome (mRS 0–3) was achieved in 29 (34.1%) patients and 31 (36.5%) patients died at 90 days. The median estimated ischemic core volume was 15 mL (IQR, 7–27 mL). The median mismatch volume was 83 mL (IQR, 43–120 mL). The median FVH score was 4 (IQR, 3–4). FVH score was independently associated with good functional outcome (adjusted OR = 1.96 [95% CI, 1.16–3.32]; p = 0.01 per 1-point increase) and mortality (adjusted OR = 0.54 [95% CI, 0.34–0.85]; p = 0.007 per 1-point increase). Ischemic core and mismatch volumes were associated with neither good outcome nor mortality. In nonagenarians with anterior circulation large-vessel ischemic stroke, good collaterals as measured by the FVH–ASPECTS rating system are independently associated with improved outcomes and may help select patients for reperfusion therapy in this frail population. • Endovascular thrombectomy can allow at least 1 in 3 patients older than 90 years of age to achieve good functional outcome (modified Rankin scale of 0–3) at 3 months. • Functional outcome at 3 months is associated with pre-stroke status (number and severity of patients’ comorbidities). • A higher FVH score (as reflected by higher FLAIR vascular hyperintensity [FVH]–Alberta Stroke Program Early CT Score [ASPECTS] values) is independently associated with better 3-month functional outcome and mortality in nonagenarians with anterior circulation ischemic stroke.
Stroke
Background and Purpose: The impact of baseline ischemia on Alberta Stroke Program Early CT Score ... more Background and Purpose: The impact of baseline ischemia on Alberta Stroke Program Early CT Score (ASPECTS) and evolution over 24 hours may be distinct in late thrombectomy. We analyzed predictors of serial ASPECTS and clinical outcomes in the DAWN trial (Diffusion-Weighted Imaging or CTP Assessment With Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention With Trevo). Methods: The DAWN Imaging Core Laboratory independently scored ASPECTS at baseline and 24 hours. Descriptive statistics characterized ASPECTS on computed tomography/magnetic resonance imaging at baseline and 24 hours, delineating ASPECTS change over 24 hours. Results: 206 subjects (mean age 70.0±13.7 years; 54.9% (n=113) female; baseline National Institutes of Health Stroke Scale median (interquartile range) 17 (13, 21) were included. Baseline ASPECTS was median (interquartile range) 8.0 (7–8), with 92/205 (44.9%) between 0 and 7 and 113/205 (55.1%) 8 and 10. 24-hour ASPEC...
Stroke
Background and Purpose: Collaterals govern the pace and severity of cerebral ischemia, distinguis... more Background and Purpose: Collaterals govern the pace and severity of cerebral ischemia, distinguishing fast or slow progressors and corresponding therapeutic opportunities. The fate of sustained collateral perfusion or collateral failure is poorly characterized. We evaluated the nature and impact of collaterals on outcomes in the late time window DAWN trial (Diffusion-Weighted Imaging or Computed Tomography Perfusion Assessment With Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention With Trevo). Methods: The DAWN Imaging Core Lab prospectively scored collateral grade on baseline computed tomography angiography (CTA; endovascular and control arms) and digital subtraction angiography (DSA; endovascular arm only), blinded to all other data. CTA collaterals were graded with the Tan scale and DSA collaterals were scored by ASITN grade (American Society of Interventional and Therapeutic Neuroradiology collateral score). Descriptive statistic...
Stroke
Background and Purpose: The clinical efficacy of mechanical thrombectomy (MT) has been unequivoca... more Background and Purpose: The clinical efficacy of mechanical thrombectomy (MT) has been unequivocally demonstrated in multiple randomized clinical trials (RCTs). However, these studies were performed in carefully selected centers and utilized strict inclusion criteria. We aim to assess the clinical effectiveness of MT by comparing the specific RCT populations with corresponding patient cohorts derived from a prospective registry. Methods: A total of 2008 patients from 76 sites across 12 countries were enrolled in a prospective open-label MT registry. Patients were categorized into the corresponding cohorts of the SWIFT-Prime, DAWN, and DEFUSE 3 trials based on the age, baseline NIHSS, occlusion site, IV tPA use, pre-morbid mRS and time to treatment criteria used in the RCTs without considering specific parenchymal imaging findings. Baseline and outcome variables were compared across the corresponding groups. Results: As compared to the treated patients in the actual trials, registry-...
Stroke
Background and Purpose: Advanced imaging has been increasingly used for patient selection in endo... more Background and Purpose: Advanced imaging has been increasingly used for patient selection in endovascular stroke therapy. The impact of imaging selection modality on endovascular stroke therapy clinical outcomes in extended time window remains to be defined. We aimed to study this relationship and compare it to that noted in early-treated patients. Methods: Patients from a prospective multicentric registry (n=2008) with occlusions involving the intracranial internal carotid or the M1- or M2-segments of the middle cerebral arteries, premorbid modified Rankin Scale score 0 to 2 and time to treatment 0 to 24 hours were categorized according to treatment times within the early (0–6 hour) or extended (6–24 hour) window as well as imaging modality with noncontrast computed tomography (NCCT)±CT angiography (CTA) or NCCT±CTA and CT perfusion (CTP). The association between imaging modality and 90-day modified Rankin Scale, analyzed in ordinal (modified Rankin Scale shift) and dichotomized (f...
Stroke
Background and Purpose: White matter hyperintensity (WMH), a marker of chronic cerebral small ves... more Background and Purpose: White matter hyperintensity (WMH), a marker of chronic cerebral small vessel disease, might impact the recruitment of leptomeningeal collaterals. We aimed to assess whether the WMH burden is associated with collateral circulation in patients treated by endovascular thrombectomy for anterior circulation acute ischemic stroke. Methods: Consecutive acute ischemic stroke due to anterior circulation large vessel occlusion and treated with endovascular thrombectomy from January 2015 to December 2017 were included. WMH volumes (periventricular, deep, and total) were assessed by a semiautomated volumetric analysis on fluid-attenuated inversion recovery–magnetic resonance imaging. Collateral status was graded on baseline catheter angiography using the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology grading system (good when ≥3). We investigated associations of WMH burden with collateral status. Results: A total of ...
Journal of NeuroInterventional Surgery
BackgroundNo randomized trial of intracranial aneurysm coiling has compared long-term efficacy of... more BackgroundNo randomized trial of intracranial aneurysm coiling has compared long-term efficacy of polymer-modified coils to bare metal coils (BMCs). We report 5-year results comparing Matrix2 coils to BMCs. The primary objective was to compare the rates of target aneurysm recurrence (TAR) at 12 months. Secondary objectives included angiographic outcomes at TAR or 12 months and TAR at 5 years.MethodsA total of 626 patients were randomized to BMCs or Matrix2 coils. Detailed methods and 1-year results have been published previously.ResultsOf 580 patients eligible for 5-year follow-up, 431 (74.3%) completed follow-up or reached TAR. Matrix2 coils were non-inferior to BMCs (P=0.8) but did not confer any benefit. Core lab reported post-treatment residual aneurysm filling (Raymond III) correlated with TAR (P<0.0001) and with aneurysm hemorrhage after treatment (P<0.008). Repeat aneurysmal hemorrhage after treatment, but before hospital discharge, occurred in three patients treated fo...
Journal of Neurology
Objective To perform an updated review of the literature on the neurological manifestations of CO... more Objective To perform an updated review of the literature on the neurological manifestations of COVID-19-infected patients Methods A PRISMA-guideline-based systematic review was conducted on PubMed, EMBASE, and SCOPUS. Series reporting neurological manifestations of COVID-19 patients were studied. Results 39 studies and 68,361 laboratory-confirmed COVID-19 patients were included. Up to 21.3% of COVID-19 patients presented neurological symptoms. Headache (5.4%), skeletal muscle injury (5.1%), psychiatric disorders (4.6%), impaired consciousness (2.8%), gustatory/olfactory dysfunction (2.3%), acute cerebrovascular events (1.4%), and dizziness (1.3%), were the most frequently reported neurological manifestations. Ischemic stroke occurred among 1.3% of COVID-19 patients. Other less common neurological manifestations were cranial nerve impairment (0.6%), nerve root and plexus disorders (0.4%), epilepsy (0.7%), and hemorrhagic stroke (0.15%). Impaired consciousness and acute cerebrovascular events were reported in 14% and 4% of patients with a severe disease, respectively, and they were significantly higher compared to non-severe patients (p < 0.05). Individual patient data from 129 COVID-19 patients with acute ischemic stroke (AIS) were extracted: mean age was 64.4 (SD ± 6.2), 78.5% had anterior circulation occlusions, the mean NIHSS was 15 (SD ± 7), and the intra-hospital mortality rate was 22.8%. Admission to the intensive care unit (ICU) was required among 63% of patients. Conclusion This updated review of literature, shows that headache, skeletal muscle injury, psychiatric disorders, impaired consciousness, and gustatory/olfactory dysfunction were the most common neurological symptoms of COVID-19 patients. Impaired consciousness and acute cerebrovascular events were significantly higher among patients with a severe infection. AIS patients required ICU admission in 63% of cases, while intra-hospital mortality rate was close to 23%.
Journal of NeuroInterventional Surgery
BackgroundClinical and hemodynamic consequences of flow diverters extending from the M1 to the in... more BackgroundClinical and hemodynamic consequences of flow diverters extending from the M1 to the internal carotid artery (ICA), covering the A1 segment, have rarely been investigated. We aimed to provide angiographic and clinical data about flow modifications on the covered A1.MethodsConsecutive patients receiving M1-ICA flow diverters for unruptured aneurysms were collected from our prospective database (2014–2020).Results42 A1 arteries covered with a single device were studied. All patients had an angiographic detected contralateral flow from the anterior communicating artery (AcomA). Immediately after flow diversion, 20 (47.6%) covered A1 showed slow flow. During a mean angiographic follow-up of 14 months, 13 (31%) and 22 (52.3%) A1 arteries were occluded and narrowed, respectively. Flow changes were asymptomatic in all cases. Vascular risk factors, sex, oversized compared with not oversized stents, immediate A1 slow flow, age, diameter of the A1, length of follow-up, and platelet ...
Journal of NeuroInterventional Surgery
BackgroundEvidence about the safety and the efficacy of flow diversion for distal anterior cerebr... more BackgroundEvidence about the safety and the efficacy of flow diversion for distal anterior cerebral artery (DACA) aneurysms is scant. To provide further insight into flow diversion for aneurysms located at, or distal to, the A2 segment.MethodsConsecutive patients receiving flow diversion for DACA aneurysms were retrieved from our prospective database (2014–2020). A PRISMA guidelines-based systematic review of the literature was performed. Aneurysm occlusion (O’Kelly–Marotta=OKM) and clinical outcomes were evaluated.ResultsTwenty-three patients and 25 unruptured saccular DACA aneurysms treated with flow diversion were included. Aneurysm size ranged from 2 mm to 9 mm (mean size 4.5 mm, SD ±1.6). Mean parent artery diameter was 1.8 mm (range, 1.2–3 mm, SD ±0.39). Successful stent deployment was achieved in all cases. Angiographic adequate occlusion (OKM C–D) at follow-up (14 months) was 79% (19/24 available aneurysms). No cases of aneurysm rupture or retreatment were reported. Univaria...
Journal of Neuroradiology
Journal of Neuroradiology
Journal of NeuroInterventional Surgery
IntroductionDuring flow diversion, the choice of the length, diameter, and location of the deploy... more IntroductionDuring flow diversion, the choice of the length, diameter, and location of the deployed stent are critical for the success of the procedure. Sim&Size software, based on the three-dimensional rotational angiography (3D-RA) acquisition, simulates the release of the stent, suggesting optimal sizing, and displaying the degree of the wall apposition.ObjectiveTo demonstrate technical and clinical impacts of the Sim&Size simulation during treatment with the Pipeline Flex Embolization Device.MethodsConsecutive patients who underwent aneurysm embolization with Pipeline at our department were retrospectively enrolled (January 2015–December 2017) and divided into two groups: treated with and without simulation. Through univariate and multivariate models, we evaluated: (1) rate of corrective intervention for non-optimal stent placement, (2) duration of intervention, (3) radiation dose, and (4) stent length.Results189 patients, 95 (50.2%) without and 94 (49.7%) with software assistan...
Prehospital Emergency Care
Age and ageing, 2020
BACKGROUND AND PURPOSE The benefit of endovascular thrombectomy (EVT) among nonagenarians (90 yea... more BACKGROUND AND PURPOSE The benefit of endovascular thrombectomy (EVT) among nonagenarians (90 years or older) is poorly documented. We aimed to investigate the clinical and imaging factors associated with good outcomes and mortality at 90 days in nonagenarians undergoing EVT for acute ischemic stroke (AIS). METHODS Data from a prospectively maintained institutional registry of consecutive AIS patients treated with EVT from January 2012 to December 2018 were retrospectively analysed. Comorbid conditions were classified with a modified version of the Charlson Comorbidity Index (CCI). The degree of disability was assessed by the modified Rankin Scale (mRS). Outcomes included good functional outcome (mRS scores of 0-3) and mortality at 90 days. RESULTS Among 110 patients (age, 92.3 ± 2.5 years; men, 28.2%) treated with EVT, good outcome was achieved in 39 (35.5%) patients, successful reperfusion (modified Thrombolysis in Cerebral Infarction grades of 2b-3) was achieved in 78 (70.9%) pat...
Stroke, 2016
Background and Purpose: The SWIFT PRIME trial demonstrated superior outcomes in patients presenti... more Background and Purpose: The SWIFT PRIME trial demonstrated superior outcomes in patients presenting with disabling acute ischemic stroke (AIS) who underwent endovascular therapy vs. intravenous tissue plasminogen activator (t-PA) alone. We sought to understand the relationship between functional independence and time to reperfusion in study patients assigned to thombectomy. Methods: SWIFT PRIME is a global, multi-center, prospective, randomized, open, blinded endpoint study comparing functional outcomes in AIS subjects treated with either IV t-PA alone or IV t-PA in combination with Solitaire stent retriever device. Among patients in whom substantial reperfusion (TICI 2b/3) was achieved, we analyzed the effect onindependent outcome (mRS 0-2) of time from stroke onset to reperfusion (OTR) and from qualifying imaging to reperfusion Results: Among 83 patients undergoing thrombectomy, substantial reperfusion was achieved in 73 (88%). A marked effect of OTR was noted (Figure 1A). The rat...
Journal of NeuroInterventional Surgery
BackgroundThe use of flow diversion to treat intracranial aneurysms has increased in recent years... more BackgroundThe use of flow diversion to treat intracranial aneurysms has increased in recent years.ObjectiveTo assess the safety and angiographic efficacy of the p64 flow modulation device.MethodsDiversion-p64 is an international, prospective, multicenter, single-arm, study conducted at 26 centers. The p64 flow modulation device was used to treat anterior circulation aneurysms between December 2015 and January 2019. The primary safety endpoint was the incidence of major stroke or neurologic death at 3–6 months, with the primary efficacy endpoint being complete aneurysm occlusion (Raymond-Roy Occlusion Classification 1) on follow-up angiography.ResultsA total of 420 patients met the eligibility criteria and underwent treatment with the p64 flow modulation device (mean age 55±12.0 years, 86.2% female). Mean aneurysm dome width was 6.99±5.28 mm and neck width 4.47±2.28 mm. Mean number of devices implanted per patient was 1.06±0.47, with adjunctive coiling performed in 14.0% of the cases...
Neurology: Clinical Practice
BackgroundThis study assessed whether a quality improvement (QI) process to streamline transfer f... more BackgroundThis study assessed whether a quality improvement (QI) process to streamline transfer from a primary stroke center (PSC) to a comprehensive stroke center (CSC) could reduce the delay of reperfusion by mechanical thrombectomy (MT).MethodsFrom 2015 to 2017, a QI process was implemented with specific interventions to reduce door-in-to-door-out (DIDO) time in a high volume PSC, and speed up interhospital transfer and inhospital processes at the CSC. Clinical characteristics and time metrics were compared in the QI (2015–2017; n = 157) and pre-QI cohorts (2012–2014; n = 121).ResultsDuring the QI process, the median symptom onset to reperfusion time was reduced by 50 minutes (367 vs 417 minutes in the pre-QI cohort, p < 0.04), with a substantial 40-minute DIDO reduction (78 vs 118 minutes, p < 0.01), related to the faster administration of IV thrombolysis (median door-to-needle time: 49 vs 82 minutes, p = 0.0001). The door-to-door time was shortened (170 vs 205 minutes, p ...
Annals of Physical and Rehabilitation Medicine
Objective To evaluate the additional value of adding movement kinematics into the design matrix i... more Objective To evaluate the additional value of adding movement kinematics into the design matrix in order to gain fine-grained insight in motor control strategies. Methods Ten healthy volunteers (age 41.8 ± 14.5, 5 males) performed a continuous elbow flexion/extension within a 1.5 MRI system. Movement kinematics were registered with the Zebris, a MRI compatible 3D motion capture system. Results Without taking the movement kinematics into consideration we found the expected systematic activation of the primary sensorimotor network, thought to generate movement execution [1] . By adding the kinematics to the fMRI design matrix we unmasked the involvement of fronto-cerebellar circuits and of the sensory cortex, as a function of both the irregularity and the frequency of movement, highlighting underlying processes of error-control to ensure optimal execution [2] . Discussion Our results reveal the modular and hierarchical structure of rhythmic motor control within brain networks: rhythmical movement generation relies on the activation of the primary sensorimotor network and error control of that movement results from the trade-off between automatically driven intermittent control involving cerebellar-frontal loops and continuous feedback involving the sensory cortex. Motor planning and error-control are important process involved in recovery post-stroke, and the detailed kinematic analysis during fMRI measurements seems to have an additional value possibly contributing to further understanding motor learning post-stroke.
European Radiology
To establish whether imaging assessments of irreversibly injured ischemic core and potentially sa... more To establish whether imaging assessments of irreversibly injured ischemic core and potentially salvageable penumbral volumes and collateral circulation were associated with functional outcome in nonagenarians (90 years or older) undergoing endovascular thrombectomy (EVT). Data from a prospectively maintained institutional registry of consecutive stroke patients treated with EVT from January 2012 to December 2018 were retrospectively analyzed. Functional outcome was evaluated with the modified Rankin scale (mRS) at 3 months. mRS score of 0–3 was defined as a good clinical outcome. Ischemic core and penumbral volumes were calculated using the RAPID software. Quantification of collateral circulation was performed using a fluid-attenuated inversion recovery vascular hyperintensity (FVH)–Alberta Stroke Program Early CT Score (ASPECTS) rating system. Among 85 patients (age, 92.4 ± 2.6 years; men, 30.6%) treated with EVT, good outcome (mRS 0–3) was achieved in 29 (34.1%) patients and 31 (36.5%) patients died at 90 days. The median estimated ischemic core volume was 15 mL (IQR, 7–27 mL). The median mismatch volume was 83 mL (IQR, 43–120 mL). The median FVH score was 4 (IQR, 3–4). FVH score was independently associated with good functional outcome (adjusted OR = 1.96 [95% CI, 1.16–3.32]; p = 0.01 per 1-point increase) and mortality (adjusted OR = 0.54 [95% CI, 0.34–0.85]; p = 0.007 per 1-point increase). Ischemic core and mismatch volumes were associated with neither good outcome nor mortality. In nonagenarians with anterior circulation large-vessel ischemic stroke, good collaterals as measured by the FVH–ASPECTS rating system are independently associated with improved outcomes and may help select patients for reperfusion therapy in this frail population. • Endovascular thrombectomy can allow at least 1 in 3 patients older than 90 years of age to achieve good functional outcome (modified Rankin scale of 0–3) at 3 months. • Functional outcome at 3 months is associated with pre-stroke status (number and severity of patients’ comorbidities). • A higher FVH score (as reflected by higher FLAIR vascular hyperintensity [FVH]–Alberta Stroke Program Early CT Score [ASPECTS] values) is independently associated with better 3-month functional outcome and mortality in nonagenarians with anterior circulation ischemic stroke.
Stroke
Background and Purpose: The impact of baseline ischemia on Alberta Stroke Program Early CT Score ... more Background and Purpose: The impact of baseline ischemia on Alberta Stroke Program Early CT Score (ASPECTS) and evolution over 24 hours may be distinct in late thrombectomy. We analyzed predictors of serial ASPECTS and clinical outcomes in the DAWN trial (Diffusion-Weighted Imaging or CTP Assessment With Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention With Trevo). Methods: The DAWN Imaging Core Laboratory independently scored ASPECTS at baseline and 24 hours. Descriptive statistics characterized ASPECTS on computed tomography/magnetic resonance imaging at baseline and 24 hours, delineating ASPECTS change over 24 hours. Results: 206 subjects (mean age 70.0±13.7 years; 54.9% (n=113) female; baseline National Institutes of Health Stroke Scale median (interquartile range) 17 (13, 21) were included. Baseline ASPECTS was median (interquartile range) 8.0 (7–8), with 92/205 (44.9%) between 0 and 7 and 113/205 (55.1%) 8 and 10. 24-hour ASPEC...
Stroke
Background and Purpose: Collaterals govern the pace and severity of cerebral ischemia, distinguis... more Background and Purpose: Collaterals govern the pace and severity of cerebral ischemia, distinguishing fast or slow progressors and corresponding therapeutic opportunities. The fate of sustained collateral perfusion or collateral failure is poorly characterized. We evaluated the nature and impact of collaterals on outcomes in the late time window DAWN trial (Diffusion-Weighted Imaging or Computed Tomography Perfusion Assessment With Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention With Trevo). Methods: The DAWN Imaging Core Lab prospectively scored collateral grade on baseline computed tomography angiography (CTA; endovascular and control arms) and digital subtraction angiography (DSA; endovascular arm only), blinded to all other data. CTA collaterals were graded with the Tan scale and DSA collaterals were scored by ASITN grade (American Society of Interventional and Therapeutic Neuroradiology collateral score). Descriptive statistic...
Stroke
Background and Purpose: The clinical efficacy of mechanical thrombectomy (MT) has been unequivoca... more Background and Purpose: The clinical efficacy of mechanical thrombectomy (MT) has been unequivocally demonstrated in multiple randomized clinical trials (RCTs). However, these studies were performed in carefully selected centers and utilized strict inclusion criteria. We aim to assess the clinical effectiveness of MT by comparing the specific RCT populations with corresponding patient cohorts derived from a prospective registry. Methods: A total of 2008 patients from 76 sites across 12 countries were enrolled in a prospective open-label MT registry. Patients were categorized into the corresponding cohorts of the SWIFT-Prime, DAWN, and DEFUSE 3 trials based on the age, baseline NIHSS, occlusion site, IV tPA use, pre-morbid mRS and time to treatment criteria used in the RCTs without considering specific parenchymal imaging findings. Baseline and outcome variables were compared across the corresponding groups. Results: As compared to the treated patients in the actual trials, registry-...
Stroke
Background and Purpose: Advanced imaging has been increasingly used for patient selection in endo... more Background and Purpose: Advanced imaging has been increasingly used for patient selection in endovascular stroke therapy. The impact of imaging selection modality on endovascular stroke therapy clinical outcomes in extended time window remains to be defined. We aimed to study this relationship and compare it to that noted in early-treated patients. Methods: Patients from a prospective multicentric registry (n=2008) with occlusions involving the intracranial internal carotid or the M1- or M2-segments of the middle cerebral arteries, premorbid modified Rankin Scale score 0 to 2 and time to treatment 0 to 24 hours were categorized according to treatment times within the early (0–6 hour) or extended (6–24 hour) window as well as imaging modality with noncontrast computed tomography (NCCT)±CT angiography (CTA) or NCCT±CTA and CT perfusion (CTP). The association between imaging modality and 90-day modified Rankin Scale, analyzed in ordinal (modified Rankin Scale shift) and dichotomized (f...
Stroke
Background and Purpose: White matter hyperintensity (WMH), a marker of chronic cerebral small ves... more Background and Purpose: White matter hyperintensity (WMH), a marker of chronic cerebral small vessel disease, might impact the recruitment of leptomeningeal collaterals. We aimed to assess whether the WMH burden is associated with collateral circulation in patients treated by endovascular thrombectomy for anterior circulation acute ischemic stroke. Methods: Consecutive acute ischemic stroke due to anterior circulation large vessel occlusion and treated with endovascular thrombectomy from January 2015 to December 2017 were included. WMH volumes (periventricular, deep, and total) were assessed by a semiautomated volumetric analysis on fluid-attenuated inversion recovery–magnetic resonance imaging. Collateral status was graded on baseline catheter angiography using the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology grading system (good when ≥3). We investigated associations of WMH burden with collateral status. Results: A total of ...
Journal of NeuroInterventional Surgery
BackgroundNo randomized trial of intracranial aneurysm coiling has compared long-term efficacy of... more BackgroundNo randomized trial of intracranial aneurysm coiling has compared long-term efficacy of polymer-modified coils to bare metal coils (BMCs). We report 5-year results comparing Matrix2 coils to BMCs. The primary objective was to compare the rates of target aneurysm recurrence (TAR) at 12 months. Secondary objectives included angiographic outcomes at TAR or 12 months and TAR at 5 years.MethodsA total of 626 patients were randomized to BMCs or Matrix2 coils. Detailed methods and 1-year results have been published previously.ResultsOf 580 patients eligible for 5-year follow-up, 431 (74.3%) completed follow-up or reached TAR. Matrix2 coils were non-inferior to BMCs (P=0.8) but did not confer any benefit. Core lab reported post-treatment residual aneurysm filling (Raymond III) correlated with TAR (P<0.0001) and with aneurysm hemorrhage after treatment (P<0.008). Repeat aneurysmal hemorrhage after treatment, but before hospital discharge, occurred in three patients treated fo...
Journal of Neurology
Objective To perform an updated review of the literature on the neurological manifestations of CO... more Objective To perform an updated review of the literature on the neurological manifestations of COVID-19-infected patients Methods A PRISMA-guideline-based systematic review was conducted on PubMed, EMBASE, and SCOPUS. Series reporting neurological manifestations of COVID-19 patients were studied. Results 39 studies and 68,361 laboratory-confirmed COVID-19 patients were included. Up to 21.3% of COVID-19 patients presented neurological symptoms. Headache (5.4%), skeletal muscle injury (5.1%), psychiatric disorders (4.6%), impaired consciousness (2.8%), gustatory/olfactory dysfunction (2.3%), acute cerebrovascular events (1.4%), and dizziness (1.3%), were the most frequently reported neurological manifestations. Ischemic stroke occurred among 1.3% of COVID-19 patients. Other less common neurological manifestations were cranial nerve impairment (0.6%), nerve root and plexus disorders (0.4%), epilepsy (0.7%), and hemorrhagic stroke (0.15%). Impaired consciousness and acute cerebrovascular events were reported in 14% and 4% of patients with a severe disease, respectively, and they were significantly higher compared to non-severe patients (p < 0.05). Individual patient data from 129 COVID-19 patients with acute ischemic stroke (AIS) were extracted: mean age was 64.4 (SD ± 6.2), 78.5% had anterior circulation occlusions, the mean NIHSS was 15 (SD ± 7), and the intra-hospital mortality rate was 22.8%. Admission to the intensive care unit (ICU) was required among 63% of patients. Conclusion This updated review of literature, shows that headache, skeletal muscle injury, psychiatric disorders, impaired consciousness, and gustatory/olfactory dysfunction were the most common neurological symptoms of COVID-19 patients. Impaired consciousness and acute cerebrovascular events were significantly higher among patients with a severe infection. AIS patients required ICU admission in 63% of cases, while intra-hospital mortality rate was close to 23%.
Journal of NeuroInterventional Surgery
BackgroundClinical and hemodynamic consequences of flow diverters extending from the M1 to the in... more BackgroundClinical and hemodynamic consequences of flow diverters extending from the M1 to the internal carotid artery (ICA), covering the A1 segment, have rarely been investigated. We aimed to provide angiographic and clinical data about flow modifications on the covered A1.MethodsConsecutive patients receiving M1-ICA flow diverters for unruptured aneurysms were collected from our prospective database (2014–2020).Results42 A1 arteries covered with a single device were studied. All patients had an angiographic detected contralateral flow from the anterior communicating artery (AcomA). Immediately after flow diversion, 20 (47.6%) covered A1 showed slow flow. During a mean angiographic follow-up of 14 months, 13 (31%) and 22 (52.3%) A1 arteries were occluded and narrowed, respectively. Flow changes were asymptomatic in all cases. Vascular risk factors, sex, oversized compared with not oversized stents, immediate A1 slow flow, age, diameter of the A1, length of follow-up, and platelet ...
Journal of NeuroInterventional Surgery
BackgroundEvidence about the safety and the efficacy of flow diversion for distal anterior cerebr... more BackgroundEvidence about the safety and the efficacy of flow diversion for distal anterior cerebral artery (DACA) aneurysms is scant. To provide further insight into flow diversion for aneurysms located at, or distal to, the A2 segment.MethodsConsecutive patients receiving flow diversion for DACA aneurysms were retrieved from our prospective database (2014–2020). A PRISMA guidelines-based systematic review of the literature was performed. Aneurysm occlusion (O’Kelly–Marotta=OKM) and clinical outcomes were evaluated.ResultsTwenty-three patients and 25 unruptured saccular DACA aneurysms treated with flow diversion were included. Aneurysm size ranged from 2 mm to 9 mm (mean size 4.5 mm, SD ±1.6). Mean parent artery diameter was 1.8 mm (range, 1.2–3 mm, SD ±0.39). Successful stent deployment was achieved in all cases. Angiographic adequate occlusion (OKM C–D) at follow-up (14 months) was 79% (19/24 available aneurysms). No cases of aneurysm rupture or retreatment were reported. Univaria...
Journal of Neuroradiology
Journal of Neuroradiology
Journal of NeuroInterventional Surgery
IntroductionDuring flow diversion, the choice of the length, diameter, and location of the deploy... more IntroductionDuring flow diversion, the choice of the length, diameter, and location of the deployed stent are critical for the success of the procedure. Sim&Size software, based on the three-dimensional rotational angiography (3D-RA) acquisition, simulates the release of the stent, suggesting optimal sizing, and displaying the degree of the wall apposition.ObjectiveTo demonstrate technical and clinical impacts of the Sim&Size simulation during treatment with the Pipeline Flex Embolization Device.MethodsConsecutive patients who underwent aneurysm embolization with Pipeline at our department were retrospectively enrolled (January 2015–December 2017) and divided into two groups: treated with and without simulation. Through univariate and multivariate models, we evaluated: (1) rate of corrective intervention for non-optimal stent placement, (2) duration of intervention, (3) radiation dose, and (4) stent length.Results189 patients, 95 (50.2%) without and 94 (49.7%) with software assistan...
Prehospital Emergency Care