✓ Acute ischemic infarction of the posterolateral bulbomedullary junction occurred in a 28-year-old man who underwent arterial embolization for the treatment of an intracranial dural arteriovenous malformation. The migration of the embolic agent in the posterior spinal artery via a peripheral anastomosis between the middle meningeal artery and the posterior meningeal artery was responsible for this complication. The cast of glue in the radiculopial system at the upper cervical level was visible on computed tomography scanning, and magnetic resonance imaging demonstrated circumscribed signal changes and restricted diffusion in the arterial territory of the bulbomedullary junction. The authors discuss the anatomical, clinical, and technical issues of this rare complication.
Raphaël Blanc, Hassan Hosseini, Caroline Le Guerinel, Pierre Brugières and André Gaston
Frédéric Clarençon, Raphaël Blanc, Sophie Gallas, Hassan Hosseini and André Gaston
Basilar artery occlusion is a dramatic clinical event with a high mortality rate if patients are treated by standard medical therapy, including anticoagulation agents. The use of intravenous tissue plasminogen activator or intraarterial thrombolysis recanalizes 30–53 and 64%, respectively, of patients with basilar stroke. Mechanical endovascular treatments allow tailored procedures with quicker results and higher recanalization rates. The authors describe a successful mechanical removal of an obstruction in an acute occlusion of the basilar artery tip involving both proximal segments of posterior cerebral arteries in a 20-year-old man. They used 2 Merci retriever devices at the same time, and performed bilateral proximal vertebral artery occlusion for temporary flow reversal and aspiration.
Benjamin Gory, Mikael Mazighi, Raphael Blanc, Julien Labreuche, Michel Piotin, Francis Turjman and Bertrand Lapergue
Several randomized trials have been focused on patients with anterior circulation stroke, whereas few data on posterior circulation stroke are available. Thus, new mechanical thrombectomy (MT) strategies, including a direct-aspiration first-pass technique (ADAPT), remain to be evaluated in basilar artery occlusion (BAO) patients. The authors here assessed the influence of reperfusion on outcome in BAO patients and examined whether ADAPT improves the reperfusion rate compared with stent retriever devices.
Three comprehensive stroke centers prospectively collected individual data from BAO patients treated with MT. Baseline characteristics as well as radiographic and clinical outcomes were compared between the 2 MT strategies. The primary outcome measure was the rate of successful reperfusion, defined as a modified Thrombolysis in Cerebral Infarction (mTICI) grade of 2b–3. Favorable outcome was defined as a 90-day modified Rankin Scale score of 0–2.
Among the 100 adult patients included in the study, 46 were treated with first-line ADAPT (median age 61 years, IQR 53–71 years; stent-retriever rescue therapy was secondarily used in 12 [26.1%]) and 54 were treated with a primary stent retriever (median age 67 years, IQR 53–78 years). There was no difference in baseline characteristics between the 2 treatment groups, except for the rate of diabetes (19.6% vs 5.7%, respectively, p = 0.035). Successful reperfusion was achieved in 79% of the overall study sample. Overall, the rate of favorable outcome was 36.8% and 90-day all-cause mortality was 44.2%. Successful reperfusion positively impacted favorable outcome (OR 4.57, 95% CI 1.24–16.87, p = 0.023). A nonsignificant trend toward a higher successful reperfusion rate (unadjusted OR 2.56, 95% CI 0.90–7.29, p = 0.071) and a significantly higher rate of complete reperfusion (mTICI grade 3; unadjusted OR 2.59, 95% CI 1.14–5.86, p = 0.021) was found in the ADAPT group. The procedure duration was also significantly lower in the ADAPT group (median 45 minutes, IQR 34 to 62 minutes vs 56 minutes, IQR 40 to 90 minutes; p = 0.05), as was the rate of periprocedural complications (4.3% vs 25.9%, p = 0.003). Symptomatic intracranial hemorrhage (0.0% vs 4.0%, p = 0.51) and 90-day all-cause mortality (46.7% vs 42.0%, p = 0.65) were similar in the 2 groups.
Among BAO patients, successful reperfusion is a strong predictor of a 90-day favorable outcome, and the choice of ADAPT as the first-line strategy achieves a significantly higher rate of complete reperfusion with a shorter procedure duration.
Etienne Lefevre, Thomas Robert, Simon Escalard, Robert Fahed, Stanislas Smajda, Gabriele Ciccio, Jean-Philippe Desilles, Mikael Mazighi, Raphaël Blanc and Michel Piotin
Treatment of posterior fossa arteriovenous malformations (PFAVMs) remains controversial as it is always challenging and may lead to major complications. Nonetheless, these lesions are more likely to bleed and generate poorer outcomes than other brain AVMs. The aim of this study was to evaluate the effect of endovascular treatment on long-term outcomes and identify the patient subgroups that might benefit from endovascular treatment.
The authors performed a retrospective analysis of all consecutive cases of PFAVM managed at the Fondation Rothschild Hospital between 1995 and 2018. Clinical, imaging, and treatment data were prospectively gathered; these data were analyzed with respect to long-term outcomes.
Among the 1311 patients with brain AVMs, 114 (8.7%) had a PFAVM, and 88 (77.2%) of these patients had a history of bleeding. Of the 114 PFAVMs, 101 (88.6%) were treated (83 ruptured and 18 unruptured). The mean duration of follow-up was 47.6 months (range 0–240 months). Good neurological outcome at last follow-up was achieved in 79 cases (78.2%). Follow-up angiography showed obliteration of the PFAVM in 68.3% of treated cases. The presence of direct vertebrobasilar perforator feeders was associated with neurological deterioration (OR 5.63, 95% CI 11.15–30.76) and a lower obliteration rate (OR 15.69, 95% CI 2.52–304.03) after endovascular treatment. Other predictors of neurological deterioration and obliteration rate were consistent with the Spetzler-Martin grading system.
Advances in endovascular techniques have enabled higher obliteration rates in the treatment of PFAVMs, but complication rates are still high. Subgroups of patients who might benefit from treatment must be carefully selected and the presence of direct vertebrobasilar perforator feeders must call into question the indication for endovascular treatment.