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Association of preprocedural antiplatelet use with decreased thromboembolic complications for intracranial aneurysms undergoing intrasaccular flow disruption

Jose Danilo Bengzon Diestro, Nimer Adeeb, Basel Musmar, Hamza Salim, Assala Aslan, Nicole M. Cancelliere, Rachel M. McLellan, Oktay Algin, Sherief Ghozy, Sovann V. Lay, Adrien Guenego, Leonardo Renieri, Joseph Carnevale, Guillaume Saliou, Panagiotis Mastorakos, Kareem El Naamani, Eimad Shotar, Kevin Premat, Markus Möhlenbruch, Michael Kral, Joshua D. Bernstock, Omer Doron, Charlotte Chung, Mohamed M. Salem, Ivan Lylyk, Paul M. Foreman, Jay A. Vachhani, Hamza Shaikh, Vedran Župančić, Muhammad U. Hafeez, Joshua Catapano, Muhammad Waqas, Mohamed K. Ibrahim, Marwa A. Mohammed, Cetin Imamoglu, Ahmet Bayrak, James D. Rabinov, Yifan Ren, Clemens M. Schirmer, Mariangela Piano, Anna L. Kühn, Caterina Michelozzi, Stéphanie Elens, Robert M. Starke, Ameer E. Hassan, Mark Ogilvie, Anh Nguyen, Jesse Jones, Waleed Brinjikji, Marie T. Nawka, Marios Psychogios, Christian Ulfert, Bryan Pukenas, Jan-Karl Burkhardt, Thien Huynh, Juan Carlos Martinez-Gutierrez, Muhammed Amir Essibayi, Sunil A. Sheth, Gary Spiegel, Rabih G. Tawk, Boris Lubicz, Pietro Panni, Ajit S. Puri, Guglielmo Pero, Erez Nossek, Eytan Raz, Monika Killer-Oberpfalzer, Christoph J. Griessenauer, Hamed Asadi, Adnan Siddiqui, Allan L. Brook, David Altschul, Julian Spears, Thomas R. Marotta, Andrew F. Ducruet, Felipe C. Albuquerque, Robert W. Regenhardt, Christopher J. Stapleton, Peter Kan, Vladimir Kalousek, Pedro Lylyk, Srikanth Boddu, Jared Knopman, Mohammad A. Aziz-Sultan, Stavropoula I. Tjoumakaris, Pascal M. Jabbour, Frédéric Clarençon, Nicola Limbucci, Hugo H. Cuellar-Saenz, Vitor Mendes Pereira, Aman B. Patel, and Adam A. Dmytriw

OBJECTIVE

This study was conducted to investigate the impact of antiplatelet administration in the periprocedural period on the occurrence of thromboembolic complications (TECs) in patients undergoing treatment using the Woven EndoBridge (WEB) device for intracranial wide-necked bifurcation aneurysms. The primary objective was to assess whether the use of antiplatelets in the pre- and postprocedural phases reduces the likelihood of developing TECs, considering various covariates.

METHODS

A retrospective multicenter observational study was conducted within the WorldWideWEB Consortium and comprised 38 academic centers with endovascular treatment capabilities. Univariable and multivariable logistic regression analyses were performed to determine the association between antiplatelet use and TECs, adjusting for covariates. Missing predictor data were addressed using multiple imputation.

RESULTS

The study comprised two cohorts: one addressing general thromboembolic events and consisting of 1412 patients, among whom 103 experienced TECs, and another focusing on symptomatic thromboembolic events and comprising 1395 patients, of whom 50 experienced symptomatic TECs. Preprocedural antiplatelet use was associated with a reduced likelihood of overall TECs (OR 0.32, 95% CI 0.19–0.53, p < 0.001) and symptomatic TECs (OR 0.49, 95% CI 0.25–0.95, p = 0.036), whereas postprocedural antiplatelet use showed no significant association with TECs. The study also revealed additional predictors of TECs, including stent use (overall: OR 4.96, 95% CI 2.38–10.3, p < 0.001; symptomatic: OR 3.24, 95% CI 1.26–8.36, p = 0.015), WEB single-layer sphere (SLS) type (overall: OR 0.18, 95% CI 0.04–0.74, p = 0.017), and posterior circulation aneurysm location (symptomatic: OR 18.43, 95% CI 1.48–230, p = 0.024).

CONCLUSIONS

The findings of this study suggest that the preprocedural administration of antiplatelets is associated with a reduced likelihood of TECs in patients undergoing treatment with the WEB device for wide-necked bifurcation aneurysms. However, postprocedural antiplatelet use did not show a significant impact on TEC occurrence.

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Intracranial dural arteriovenous fistulas: association with cerebral venous thrombosis, baseline aggressiveness, and clinical outcomes. A retrospective multicenter study on 263 consecutive patients and literature review

Clara Cohen, Stéphanie Lenck, Atika Talbi, Héloïse Ifergan, Kévin Premat, Grégoire Boulouis, Kévin Janot, Anne-Laure Boch, Christophe Magni, Denis Herbreteau, Nader Sourour, Eimad Shotar, Valère Barrot, and Frédéric Clarençon

OBJECTIVE

The pathogenesis of intracranial dural arteriovenous fistulas (icDAVFs) is controversial. Cerebral vein thrombosis (CVT) and venous hypertension are recognized predisposing factors. This study aimed to evaluate the incidence of association between icDAVF and CVT and describe baseline aggressiveness and clinical outcomes for icDAVFs associated with CVT. The authors also performed a literature review of studies reporting icDAVF associated with CVT.

METHODS

Two hundred sixty-three consecutive patients in two university hospitals with confirmed icDAVFs were included. A double-blind imaging review was performed to determine the presence or absence of CVT close or distant to the icDAVF. Location, type (using the Cognard classification), aggressiveness of the icDAVF, clinical presentation, treatment modality, and clinical and/or angiographic outcomes at 6 months were also collected. All prior brain imaging was analyzed to determine the natural history of onset of the icDAVF.

RESULTS

Among the 263 included patients, 75 (28.5%) presented with a CVT concomitant to their icDAVF. For 18 (78.3%) of 23 patients with previous brain imaging available, CVT preceding the icDAVF was proven (6.8% of the overall population). Former/active smoking (OR 2.0, 95% CI 1.079–3.682, p = 0.022) and prothrombogenic status (active inflammation or cancer/coagulation trouble) were risk factors for CVT associated with icDAVF (OR 3.135, 95% CI 1.391–7.108, p = 0.003). One hundred eighty-seven patients (71.1%) had a baseline aggressive icDAVF, not linked to the presence of a CVT (p = 0.546). Of the overall population, 11 patients (4.2%) presented with spontaneous occlusion of their icDAVF at follow-up. Seven patients (2.7%) died during the follow-up period. Intracranial DAVF + CVT was not associated with a worse prognosis (modified Rankin Scale score at 3–6 months: 0 [interquartile range {IQR} 0–1] for icDAVF + CVT vs 0 [IQR 0–0] for icDAVF alone; p = 0.055).

CONCLUSIONS

This was one of the largest studies focused on the incidence of CVT associated with icDAVF. For 6.8% of the patients, a natural history of CVT leading to icDAVF was proven, corresponding to 78.3% of patients with previous imaging available. This work offers further insights into icDAVF pathophysiology, aiding in identifying high-risk CVT patients for long-term follow-up imaging. Annual imaging follow-up using noninvasive vascular imaging (CT or MR angiography) for a minimum of 3 years after the diagnosis of CVT should be considered in high-risk patients, i.e., smokers and those with prothrombogenic status.

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Stent-assisted Woven EndoBridge device for the treatment of intracranial aneurysms: an international multicenter study

Jose Danilo Bengzon Diestro, Mahmoud Dibas, Nimer Adeeb, Robert W. Regenhardt, Justin E. Vranic, Adrien Guenego, Sovann V. Lay, Leonardo Renieri, Ali Al Balushi, Eimad Shotar, Kévin Premat, Kareem El Namaani, Guillaume Saliou, Markus A. Möhlenbruch, Ivan Lylyk, Paul M. Foreman, Jay A. Vachhani, Vedran Župančić, Muhammad U. Hafeez, Caleb Rutledge, Hamid Rai, Vincent M. Tutino, Shervin Mirshahi, Sherief Ghozy, Pablo Harker, Naif M. Alotaibi, James D. Rabinov, Yifan Ren, Clemens M. Schirmer, Oded Goren, Mariangela Piano, Anna L. Kühn, Caterina Michelozzi, Stéphanie Elens, Robert M. Starke, Ameer E. Hassan, Arsalaan Salehani, Anh Nguyen, Jesse Jones, Marios Psychogios, Julian Spears, Thomas Marotta, Vitor Pereira, Carmen Parra-Fariñas, Maria Bres-Bullrich, Michael Mayich, Mohamed M. Salem, Jan-Karl Burkhardt, Brian T. Jankowitz, Ricardo A. Domingo, Thien Huynh, Rabih Tawk, Christian Ulfert, Boris Lubicz, Pietro Panni, Ajit S. Puri, Guglielmo Pero, Christoph J. Griessenauer, Hamed Asadi, Adnan Siddiqui, Andrew F. Ducruet, Felipe C. Albuquerque, Nirav Patel, Peter Kan, Vladimir Kalousek, Pedro Lylyk, Srikanth Boddu, Christopher J. Stapleton, Jared Knopman, Pascal Jabbour, Stavropoula Tjoumakaris, Frédéric Clarençon, Nicola Limbucci, Mohammad A. Aziz-Sultan, Hugo H. Cuellar-Saenz, Christophe Cognard, Aman B. Patel, and Adam A. Dmytriw

OBJECTIVE

The Woven EndoBridge (WEB) device is an intrasaccular flow disruptor designed for wide-necked bifurcation aneurysms. These aneurysms may require the use of a concomitant stent. The objective of this study was to determine the clinical and radiological outcomes of patients undergoing stent-assisted WEB treatment. In addition, the authors also sought to determine the predictors of a concomitant stent in aneurysms treated with the WEB device.

METHODS

The data for this study were taken from the WorldWideWEB Consortium, an international multicenter cohort including patients treated with the WEB device. Aneurysms were classified into two groups based on treatment: stent-assisted WEB and WEB device alone. The authors compared clinical and radiological outcomes of both groups. Univariable and multivariable binary logistic regression analyses were performed to determine factors that predispose to stent use.

RESULTS

The study included 691 intracranial aneurysms (31 with stents and 660 without stents) treated with the WEB device. The adequate occlusion status did not differ between the two groups at the latest follow-up (83.3% vs 85.6%, p = 0.915). Patients who underwent stenting had more thromboembolic (32.3% vs 6.5%, p < 0.001) and procedural (16.1% vs 3.0%, p < 0.001) complications. Aneurysms treated with a concomitant stent had wider necks, greater heights, and lower dome-to-neck ratios. Increasing neck size was the only significant predictor for stent use.

CONCLUSIONS

This study demonstrates that there is no difference in the degree of aneurysm occlusion between the two groups; however, complications were more frequent in the stent group. In addition, a wider aneurysm neck predisposes to stent assistance in WEB-treated aneurysms.

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Endovascular treatment as first-line therapy in Spetzler-Martin grade III brain arteriovenous malformations: a multicenter retrospective study

Julien Burel, Chrysanthi Papagiannaki, Nader Sourour, Atika Talbi, Matthieu Garnier, Capucine Hermary, Maichael Talaat, Anne-Laure Boch, Aurélien Nouet, Stéphanie Lenck, Kévin Premat, Eimad Shotar, and Frédéric Clarençon

OBJECTIVE

The management of Spetzler-Martin grade (SMG) III brain arteriovenous malformations (bAVMs) may be challenging, whatever the exclusion treatment modality chosen. The purpose of this study was to evaluate the safety and effectiveness of endovascular treatment (EVT) as a first-line treatment of SMG III bAVMs.

METHODS

The authors performed a retrospective, two-center, observational cohort study. Cases recorded in institutional databases between January 1998 and June 2021 were reviewed. Patients who were ≥ 18 years of age, had ruptured or unruptured SMG III bAVMs, and received EVT as first-line therapy were included. Baseline characteristics of patients and bAVMs, procedure-related complications, clinical outcome according to the modified Rankin Scale, and angiographic follow-up were assessed. The independent risk factors of procedure-related complications and poor clinical outcome were assessed using binary logistic regression.

RESULTS

One hundred sixteen patients with 116 SMG III bAVMs were included. The mean age of the patients was 41.9 ± 14.0 years. The most common presentation was hemorrhage (66.4%). Forty-nine (42.2%) bAVMs were found to be completely obliterated by EVT alone at follow-up. Complications occurred in 39 patients (33.6%), including 5 (4.3%) major procedure-related complications. There was no independent predictor of procedure-related complication. Age > 40 years and poor preoperative modified Rankin Scale score were the independent predictors of poor clinical outcome.

CONCLUSIONS

EVT of SMG III bAVMs provides encouraging results but needs further improvement. When the embolization procedure performed with intent to cure appears difficult and/or risky, a combined technique (with microsurgery or radiosurgery) may be a safer and more effective strategy. In terms of safety and effectiveness, the benefit of EVT (alone or included in a multimodal management strategy) for SMG III bAVMs needs to be confirmed by randomized controlled trials.

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Whole blood levels of S1PR4 mRNA associated with cerebral vasospasm after aneurysmal subarachnoid hemorrhage

Anne-Sophie Pulcrano-Nicolas, Alice Jacquens, Carole Proust, Frédéric Clarençon, Claire Perret, Eimad Shotar, Louis Puybasset, Wilfried Le Goff, Vincent Degos, David-Alexandre Trégouët, and Sophie Garnier

OBJECTIVE

The authors sought to identify mRNA biomarkers of cerebral vasospasm in whole blood of patients suffering from aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

A prospective transcriptomic study for vasospasm was conducted in whole blood samples of 44 aSAH patients who developed (VSP+ group, n = 22) or did not develop (VSP group, n = 22) vasospasm. Samples from all patients were profiled for 21,460 mRNA probes using the Illumina Human HT12v4.0 array. Differential statistical analysis was performed using a linear mixed model.

RESULTS

Levels of sphingosine-1-phosphate receptor 4 (S1PR4) mRNA were significantly higher (p = 8.03 × 10−6) at presentation in patients who developed vasospasm after aSAH than in patients who did not.

CONCLUSIONS

The results, which are consistent with findings of previous experimental investigations conducted in animal models, support the role of S1PR4 and its ligand, sphingosine-1-phosphate (S1P), in arterial-associated vasoconstriction, which suggests that S1PR4 could be used as a biomarker for cerebral vasospasm in aSAH patients.

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A leap forward in the endovascular management of acute basilar artery occlusion since the appearance of stent retrievers: a single-center comparative study

Robert Fahed, Federico Di Maria, Charlotte Rosso, Nader Sourour, Vincent Degos, Sandrine Deltour, Flore Baronnet-Chauvet, Anne Léger, Sophie Crozier, Joseph Gabrieli, Yves Samson, Jacques Chiras, and Frédéric Clarençon

OBJECTIVE

Contrary to acute ischemic stroke involving the anterior circulation, no randomized trial has yet demonstrated the safety and effectiveness of endovascular management in acute basilar artery occlusion (BAO). Recently developed thrombectomy devices, such as stentrievers and aspiration systems, have helped in improving the endovascular management of acute ischemic stroke. The authors sought to assess the impact of these devices in the endovascular treatment of acute BAO.

METHODS

A retrospective analysis of 34 consecutive patients treated in Pitié-Salpêtrière Hospital for acute BAO was carried out. All patients had undergone an endovascular procedure. In addition to the global results in terms of safety and effectiveness (recanalization rate and 3-month clinical outcome based on the modified Rankin Scale [mRS]), the authors aimed to determine if the patients treated with the most recently developed devices (i.e., the Solitaire stentriever or the ADAPT catheter) had better angiographic and clinical outcomes than those treated with older endovascular strategies.

RESULTS

The overall successful recanalization rate (thrombolysis in cerebral infarction score 2b–3) was 50% (17 of 34 patients). A good clinical outcome (mRS score 0–2 at 3-month follow-up) was achieved in 11 (32.3%) of 34 patients. The mortality rate at 3-month follow-up was 29.4% (10 of 34 patients). Patients treated with the Solitaire stentriever and the ADAPT catheter had a higher recanalization rate (12 [92.3%] of 13 patients vs 5 [23.8%] of 21 patients, p = 0.0002) and a shorter mean (± SD) procedure duration (88 ± 31 minutes vs 126 ± 58 minutes, p = 0.04) than patients treated with older devices.

CONCLUSIONS

The latest devices have improved the effectiveness of mechanical thrombectomy in acute BAO. Their use in further studies may help demonstrate a benefit in the endovascular management of acute BAO.

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Anterior spinal and bulbar artery supply to the posterior inferior cerebellar artery revealed by a ruptured aneurysm: case report

Joseph Gabrieli, Nader-Antoine Sourour, Dorian Chauvet, Federico Di Maria, Jacques Chiras, and Frédéric Clarençon

The posterior inferior cerebellar artery (PICA) is a vessel located between the intra- and extracranial circulation. The artery is characterized by a complex embryological development and numerous anatomical variants. The authors present a case of the PICA supplied by both a hypertrophic anterior spinal artery and a hypoplastic bulbar artery. This unusual arrangement somehow completes the list of previously published variants, and the spontaneous rupture of a related aneurysm confirmed the fragility of this network. The authors discuss anatomical and treatment considerations.

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Retrospective study of long-term outcome after brain arteriovenous malformation rupture: the RAP score

Eimad Shotar, Matthieu Debarre, Nader-Antoine Sourour, Federico Di Maria, Joseph Gabrieli, Aurélien Nouet, Jacques Chiras, Vincent Degos, and Frédéric Clarençon

OBJECTIVE

The authors aimed to design a score for stratifying patients with brain arteriovenous malformation (BAVM) rupture, based on the likelihood of a poor long-term neurological outcome.

METHODS

The records of consecutive patients with BAVM hemorrhagic events who had been admitted over a period of 11 years were retrospectively reviewed. Independent predictors of a poor long-term outcome (modified Rankin Scale score ≥ 3) beyond 1 year after admission were identified. A risk stratification scale was developed and compared with the intracranial hemorrhage (ICH) score to predict poor outcome and inpatient mortality.

RESULTS

One hundred thirty-five patients with 139 independent hemorrhagic events related to BAVM rupture were included in this analysis. Multivariate logistic regression followed by stepwise analysis showed that consciousness level according to the Glasgow Coma Scale (OR 6.5, 95% CI 3.1–13.7, p < 10−3), hematoma volume (OR 1.8, 95% CI 1.2–2.8, p = 0.005), and intraventricular hemorrhage (OR 7.5, 95% CI 2.66–21, p < 10−3) were independently associated with a poor outcome. A 12-point scale for ruptured BAVM prognostication was constructed combining these 3 factors. The score obtained using this new scale, the ruptured AVM prognostic (RAP) score, was a stronger predictor of a poor long-term outcome (area under the receiver operating characteristic curve [AUC] 0.87, 95% CI 0.8–0.92, p = 0.009) and inpatient mortality (AUC 0.91, 95% CI 0.85–0.95, p = 0.006) than the ICH score. For a RAP score ≥ 6, sensitivity and specificity for predicting poor outcome were 76.8% (95% CI 63.6–87) and 90.8% (95% CI 81.9–96.2), respectively.

CONCLUSIONS

The authors propose a new admission score, the RAP score, dedicated to stratifying the risk of poor long-term outcome after BAVM rupture. This easy-to-use scoring system may help to improve communication between health care providers and consistency in clinical research. Only external prospective cohorts and population-based studies will ensure full validation of the RAP scores' capacity to predict outcome after BAVM rupture.

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Very late ischemic complications in flow-diverter stents: a retrospective analysis of a single-center series

Alexis Guédon, Frédéric Clarençon, Federico Di Maria, Charlotte Rosso, Alessandra Biondi, Joseph Gabrieli, Patricia Rojas, Jacques Chiras, and Nader Sourour

OBJECTIVE

The authors evaluate the rate and discuss the pathomechanisms of very late (≥ 4-month) ischemic complications after flow-diverter stent (FDS) placement for intracranial aneurysms.

METHODS

The authors retrospectively reviewed the clinical data of the patients treated at Pitié-Salpêtrière Hospital between January 2010 and September 2014, who underwent FDS placement for intracranial aneurysm. The patients received dual-antiplatelet therapy (clopidogrel and aspirin) 5 days before and 3–6 months after the procedure and then aspirin alone for 6–9 months. An ischemic complication was defined as a sudden focal neurological deficit documented on diffusion-weighted images.

RESULTS

Eighty-six consecutive patients were included. Three (3.5%) patients treated with the Pipeline embolization device experienced a delayed acute ischemic stroke (2 cases of perforator/side-wall branch infarction and 1 case of thromboembolic stroke) with an average delay of 384 days (4 months, 20 months, and 13 months, respectively). The aneurysm locations were the left superior cerebellar artery, the right anterior choroid artery, and the left internal carotid artery (paraclinoid segment), respectively. The complications occurred after the patients had completed the antiaggregation protocol, except for Patient 1, who was receiving aspirin alone because of a spontaneous hematoma. At the acute phase, no in-stent thromboses were found on digital subtraction angiography. In Patient 2, the treated anterior choroid artery was occluded 20 months after the procedure. In Patient 3, a focal stenosis (approximately 40%) of the distal aspect of the FDS, probably caused by intimal hyperplasia, was seen.

CONCLUSIONS

Very late ischemic complications after FDS treatment were observed in 3.5% of the cases in the authors' series, some of which occurred as late as more than 1 year after placement.

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Rescue N-butyl-2 cyanoacrylate embolectomy using a Solitaire FR device after venous glue migration during arteriovenous malformation embolization: technical note

Robert Fahed, Frédéric Clarençon, Nader-Antoine Sourour, Dorian Chauvet, Lise Le Jean, Jacques Chiras, and Federico Di Maria

One of the procedural risks in arteriovenous malformation (AVM) embolization is possible migration of the embolic agent into the venous drainage with an incomplete nidus occlusion, which may lead to severe hemorrhagic complications.

This report presents the case of a 29-year-old man who presented with a deep intraparenchymal hematoma on the left side secondary to the spontaneous rupture of a claustral AVM. Upon resorption of the hematoma, the patient underwent an initial therapeutic session of N-butyl-2 cyanoacrylate endovascular embolization, with the purpose of reducing the AVM volume and flow before performing Gamma Knife radiosurgery. After glue injection into one of the arterial feeders, the control angiography showed a partial migration of the glue cast into the straight sinus, with most of the nidus still visible. Because of the bleeding risk due to possible venous hypertension, it was decided to try to retrieve the glue from the vein by using a stent retriever via jugular access. This maneuver allowed a nearly complete removal of the glue cast, thereby restoring normal venous flow drainage. The patient showed no clinical worsening after the procedure.

To the authors’ knowledge, this is the first report of the use of the Solitaire FR device as a rescue glue retriever. This method should be considered by physicians in cases of unintended glue migration into the venous circulation during AVM embolization.