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1.
AJNR Am J Neuroradiol ; 40(10): 1695-1700, 2019 10.
Article in English | MEDLINE | ID: mdl-31537518

ABSTRACT

BACKGROUND AND PURPOSE: Empty sella has been reported in patients with idiopathic intracranial hypertension and is thought to be a sign of elevation of intracranial pressure. However, it can also be found in patients with lateral sinus stenosis presenting with isolated pulsatile tinnitus without signs of intracranial hypertension. We hypothesized that the volume of the sella turcica would be similar in both groups of patients undergoing stent placement for lateral sinus stenosis. MATERIALS AND METHODS: Consecutive patients with idiopathic intracranial hypertension or isolated venous pulsatile tinnitus and undergoing lateral sinus stent placement from January 2012 to December 2017 were included. The primary outcome was the estimated volume of the sella turcica based on preoperative CTA measurements. The ratio of the pituitary gland height/sellar height was calculated on preoperative MR imaging. Sellar volumes were compared among the 3 groups: pulsatile tinnitus, idiopathic intracranial hypertension, and a control group, matched by age and sex. RESULTS: Eighty-eight patients underwent lateral sinus stent placement. The median age was 37 years, and 94% were women. No difference in age, sex, or body mass index was found among the groups. Patients undergoing venous stent placement had significantly higher sellar volumes than the control group (P < 0.001). There was no difference in the sellar volumes (P = .63) or gland/sellar height ratios (P = .25) between the pulsatile tinnitus and idiopathic intracranial hypertension groups. CONCLUSIONS: Empty sella is found in 2 differing groups of patients undergoing lateral sinus stent placement, suggesting that it is a radiologic sign of symptomatic hemodynamic lateral sinus stenosis rather than elevated intracranial pressure.


Subject(s)
Empty Sella Syndrome/etiology , Pseudotumor Cerebri/complications , Tinnitus/complications , Transverse Sinuses/pathology , Adult , Aged , Constriction, Pathologic/complications , Female , Humans , Male , Middle Aged
2.
AJNR Am J Neuroradiol ; 40(8): 1342-1348, 2019 08.
Article in English | MEDLINE | ID: mdl-31320465

ABSTRACT

BACKGROUND AND PURPOSE: Conventional angioplasty of cerebral vasospasm combines proximal balloon angioplasty (up to the first segment of cerebral arteries) with chemical angioplasty for distal arteries. Distal balloon angioplasty (up to the second segment of cerebral arteries) has been used in our center instead of chemical angioplasty since January 2015. We aimed to assess the effect of this new approach in patients with aneurysmal SAH. MATERIALS AND METHODS: The occurrence, date, territory, and cause of any cerebral infarction were retrospectively determined and correlated to angioplasty procedures. Delayed cerebral infarction, new angioplasty in the territory of a previous angioplasty, angioplasty complications, 1-month mortality, and 6- to 12-month modified Rankin Scale ≤ 2 were compared between 2 periods (before-versus-after January 2015, from 2012 to 2017) with adjustment for age, sex, World Federation of Neurosurgical Societies score, and the modified Fisher grade. RESULTS: Three-hundred-ninety-two patients were analyzed (160 before versus 232 after January 2015). Distal balloon angioplasty was associated with the following: higher rates of angioplasty (43% versus 27%, P < .001) and intravenous milrinone (31% versus 9%, P < .001); lower rates of postangioplasty delayed cerebral infarction (2.2% versus 7.5%, P = .01) and new angioplasty (8% versus 19%, P = .003) independent of the rate of patients treated by angioplasty and milrinone; and the same rates of stroke related to angioplasty (3.6% versus 3.1%, P = .78), delayed cerebral infarction (7.7% versus 12.5%, P = .12), mortality (10% versus 11%, P = .81), and favorable outcome (79% versus 73%, P = .21). CONCLUSIONS: Our study suggests that distal balloon angioplasty is safe and decreases the risk of delayed cerebral infarction and the recurrence of vasospasm compared with conventional angioplasty. It fails to show a clinical benefit possibly because of confounding changes in adjuvant therapies of vasospasm during the study period.


Subject(s)
Angioplasty, Balloon/methods , Cerebral Infarction/prevention & control , Subarachnoid Hemorrhage/surgery , Vasospasm, Intracranial/surgery , Adult , Cerebral Infarction/etiology , Female , Humans , Male , Middle Aged , Retrospective Studies , Subarachnoid Hemorrhage/complications , Treatment Outcome , Vasospasm, Intracranial/complications
3.
Rev Neurol (Paris) ; 175(6): 380-389, 2019 Jun.
Article in English | MEDLINE | ID: mdl-31047687

ABSTRACT

PURPOSE: We aimed to assess agreement on intravenous tissue-plasminogen activator (IV tPA) and mechanical thrombectomy (MT) management decisions in acute ischemic stroke (AIS) patients. Secondary objectives were to assess agreement on Diffusion-Weighted-Imaging-Alberta-Stroke-Program-EArly-CT-Score (DWI-ASPECTS), and clinicians' willingness to recruit patients in a randomized controlled trial (RCT) comparing medical management with or without MT. MATERIALS AND METHODS: Studies assessing agreement of IV tPA and MT were systematically reviewed. An electronic portfolio of 41 AIS patients was sent to randomly selected providers at French stroke centers. Raters were asked 4 questions for each case: (1) What is the DWI-ASPECTS? (2) Would you perform IV tPA? (3) Would you perform MT? (4) Would you include the patient in a RCT comparing standard medical therapy with or without MT? Twenty responders were randomly selected to study intrarater agreement. Agreement was assessed using Fleiss' Kappa statistics. RESULTS: The review yielded two single center studies involving 2-5 raters, with various results. The electronic survey was answered by 86 physicians (60 vascular neurologists and 26 interventional neuroradiologists). The interrater agreement was moderate for IV tPA treatment decisions (κ=0.565 [0.420-0.680]), but only fair for MT (κ=0.383 [0.289-0.491]) and for combined treatment decisions (κ=0.399 [0.320-0.486]). The intrarater agreement was at least substantial for the majority of raters. The interrater agreement for DWI-ASPECTS was fair (κ=0.325 [0.276-0.387]). Physicians were willing to include a mean of 14±9 patients (33.1%±21.7%) in a RCT. CONCLUSION: Disagreements regarding the use of IVtPA or MT in the management of AIS patients remain frequent. Further trials are needed to resolve the numerous areas of uncertainty.


Subject(s)
Brain Ischemia , Fibrinolytic Agents/administration & dosage , Stroke , Thrombectomy/methods , Thrombolytic Therapy/methods , Acute Disease , Administration, Intravenous , Brain Ischemia/drug therapy , Brain Ischemia/pathology , Brain Ischemia/surgery , Consensus , Decision Making , Humans , Infusions, Intravenous , Peer Review , Reproducibility of Results , Stroke/drug therapy , Stroke/pathology , Stroke/surgery
4.
Eur J Neurol ; 26(4): 631-638, 2019 04.
Article in English | MEDLINE | ID: mdl-30431216

ABSTRACT

BACKGROUND AND PURPOSE: The usefulness of plexus magnetic resonance imaging (MRI) in the diagnosis of chronic inflammatory demyelinating polyradiculopathy (CIDP) without definite European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) electrodiagnostic criteria is currently unclear. METHODS: Data from consecutive patients with clinical manifestations suggesting CIDP, with or without (CIDP-D and CIDP-ND, respectively) definite EFNS/PNS electrodiagnostic criteria, and referred for plexus MRI in our imaging centre were retrospectively analysed. An expert committee of neurologists compared the level of suspicion of CIDP in CIDP-ND patients to the blinded/unblinded MRI findings. Plexus MRI was reviewed by a neuroradiologist blinded to the final diagnosis. RESULTS: In all, 38 patients were assessed with suspected CIDP-ND [7/38 (18%) probable; 13/38 (34%) possible; 18/38 (47%), no EFNS/PNS electrodiagnostic criteria], plus 10 with CIDP-D. Thirty-six of the 38 (95%) fulfilled clinical criteria of CIDP variants, including pure sensory neuropathy in 22/36 (61%). Plexus MRI showed abnormalities in 22/38 (58%) patients including increased nerve signal intensity on T2-weighted images in 22/22 (100%), nerve enlargement in 20/22 (91%) and contrast enhancement in 8/22 (36%). Plexus MRI enabled the expert committee's final diagnosis to be adjusted in 7/38 (18%) patients, and in conjunction with nerve conduction studies was a supportive criterion to classify 7/24 (29%) patients as definite CIDP. MRI abnormalities were more asymmetrical (P = 0.03) and less diffuse (P = 0.1) in CIDP-ND than in CIDP-D. CONCLUSIONS: Our observations suggest that plexus MRI makes a valuable contribution to the diagnosis of CIDP-ND patients. Further studies are needed to investigate inter-rater reliability of clinical and imaging criteria of CIDP in these patients, and the impact on outcomes.


Subject(s)
Peripheral Nerves/diagnostic imaging , Polyradiculoneuropathy, Chronic Inflammatory Demyelinating/diagnosis , Adult , Aged , Female , Humans , Magnetic Resonance Imaging , Male , Middle Aged , Neural Conduction/physiology , Peripheral Nerves/physiopathology , Polyradiculoneuropathy, Chronic Inflammatory Demyelinating/diagnostic imaging , Polyradiculoneuropathy, Chronic Inflammatory Demyelinating/physiopathology , Reproducibility of Results , Retrospective Studies
5.
Eur J Neurol ; 25(9): 1115-1120, 2018 09.
Article in English | MEDLINE | ID: mdl-29575634

ABSTRACT

BACKGROUND AND PURPOSE: Tandem anterior circulation lesions in the setting of acute ischemic stroke (AIS) are a complex endovascular situation that has not been specifically addressed in trials. We determined the predictors of successful reperfusion and good clinical outcome at 90 days after mechanical thrombectomy (MT) in patients with AIS with tandem lesions in a pooled collaborative study. METHODS: This was a retrospective analysis of consecutive patients presenting to 18 comprehensive stroke centers with AIS due to tandem lesion of the anterior circulation who underwent MT. RESULTS: A total of 395 patients were included. Successful reperfusion (modified thrombolysis in cerebral infarction score 2b-3) was achieved in 76.7%. At 90 days, 52.2% achieved a good outcome (modified Rankin Scale score 0-2), 13.8% suffered a parenchymal hematoma and 13.2% were dead. Lower National Institutes of Health Stroke Scale score [odds ratio (OR), 1.26; 95% confidence intervals (CI), 1.07-1.48, P = 0.004], Alberta Stroke Program Early CT Score ≥7 (OR, 2.00; 95% CI, 1.07-3.43, P = 0.011), intravenous thrombolysis (OR, 1.47; 95% CI, 1.01-2.12, P = 0.042) and stenting of the extracranial carotid lesion (OR, 1.63; 95% CI, 1.04-2;53, P = 0.030) were independently associated with successful reperfusion. Lower age (OR, 1.58; 95% CI, 1.26-1.97, P < 0.001), absence of hypercholesterolemia (OR, 1.77; 95% CI, 1.10-2.84, P = 0.018), lower National Institutes of Health Stroke Scale scores (OR, 2.04; 95% CI, 1.53-2.72, P < 0.001), Alberta Stroke Program Early CT Score ≥7 (OR, 2.75; 95% CI, 1.24-6.10, P = 0.013) and proximal middle cerebral artery occlusion (OR, 1.59; 95% CI, 1.03-2.44, P = 0.035) independently predicted a good 90-day outcome. CONCLUSIONS: Intravenous thrombolysis and emergent stenting of the extracranial carotid lesion were predictors of a successful reperfusion after MT of patients with AIS with tandem lesion of the anterior circulation.


Subject(s)
Carotid Arteries , Reperfusion Injury/prevention & control , Stents , Stroke/therapy , Thrombectomy/methods , Thrombolytic Therapy/methods , Age Factors , Aged , Aged, 80 and over , Cerebrovascular Circulation , Combined Modality Therapy , Female , Humans , Infarction, Middle Cerebral Artery/complications , Male , Middle Aged , Prognosis , Reperfusion , Retrospective Studies , Treatment Outcome
7.
J Neuroradiol ; 45(3): 196-201, 2018 May.
Article in English | MEDLINE | ID: mdl-29132938

ABSTRACT

BACKGROUND AND PURPOSE: The management of cervical artery occlusions in hyperacute stroke with tandem cervical/intracranial occlusions has not yet become standardized, especially when the circle of Willis is effective. METHODS: We retrospectively analyzed the safety and accuracy of current approaches to manage the cervical occlusion in consecutive patients with tandem occlusions addressed for intracranial mechanical thrombectomy (MT) in our department from January 2012 to May 2017. The different approaches that could be performed in a same patient during the same procedure or hospitalization were analyzed separately. RESULTS: We reported 64 approaches to manage the cervical occlusion in 49 patients with tandem occlusion (14% of MT): medical treatment alone in 16/64 (25%), stenting/angioplasty in 16/64 (25%), occlusion with coils in 12/64 (19%), angioplasty alone in 9/64 (14%), stent-retriever in 8/64 (12%), and/or thromboaspiration in 3/64 (5%). Early ipsilateral embolic recurrence occurred after 9/64 (14%) of them. It was strongly associated with the presence of a cervical intraluminal thrombus (P=0.001) and was then lower after occlusion with coils and stent-retriever compared to medical treatment alone and thromboaspiration (P=0.002). Occlusion with coils had a lower rate of radiological intracranial hemorrhage at 48-hour compared to other approaches (P=0.009). The 3-month rates of favorable outcome (P=0.806) and mortality (P=0.878) were similar. One delayed stroke was imputable to an occlusion with coils, for a median (Q1-Q3) follow-up of 10 (3-20) months. CONCLUSIONS: Cervical occlusion with coils and thrombectomy with stent-retrievers may be relevant to prevent early embolic recurrence in cervical occlusions with intraluminal thrombus. Stent-retrievers should be further assessed as a first-line approach, since delayed stroke may occur following occlusion with coils. Medical treatment alone may be sufficient when no cervical intraluminal thrombus is present, the Willis polygon is effective, and the cervical occlusion can be crossed easily to perform the intracranial thrombectomy.


Subject(s)
Brain Ischemia/complications , Carotid Stenosis/surgery , Endovascular Procedures/methods , Stroke/complications , Aged , Brain Ischemia/diagnostic imaging , Disease Management , Female , Humans , Male , Mechanical Thrombolysis/methods , Middle Aged , Retrospective Studies , Stroke/diagnostic imaging , Treatment Outcome
9.
AJNR Am J Neuroradiol ; 36(1): 140-5, 2015 Jan.
Article in English | MEDLINE | ID: mdl-25082818

ABSTRACT

BACKGROUND AND PURPOSE: Parent artery occlusion has long been considered the reference treatment for large/giant or fusiform aneurysms of the carotid siphon. However, meager recent data exist on this technique, which tends to be replaced by stent-assisted reconstructive techniques. In our department since 2004, we have assessed the safety, efficacy, and complication risk factors of parent artery occlusion by using coils for trapping these aneurysms. MATERIALS AND METHODS: We determined retrospectively the complication rate, factors associated with the occurrence of an ischemic event, changes in symptoms of mass effect, evolution of the aneurysmal size, and the growth of an additional aneurysm after treatment. RESULTS: Fifty-six consecutive patients were included, with a median age of 54 years (range, 25-85 years; 92% women), 48% with giant aneurysms and 75% with infraclinoid aneurysms. There was a permanent morbidity rate of 5% exclusively due to ischemia, a zero mortality rate, an aneurysmal retraction rate of 91%, and an improvement rate for pain of 98% and for cranial nerve palsy of 72%, with a median follow-up of >3 years. Para-/supraclinoid topography of the aneurysm (P = .043) and the presence of cardiovascular risk factors (P = .024) were associated with an excessive risk of an ischemic event, whereas the presence of a mural thrombus had a protective role (P = .033). CONCLUSIONS: In this study, parent artery occlusion by using coils to treat large/giant or fusiform aneurysms of the carotid siphon was safe and effective, especially for giant infraclinoid aneurysms. According to recent meta-analyses, these results suggest that the validation of stent-assisted reconstructive treatments for these aneurysms requires controlled studies with parent occlusion artery.


Subject(s)
Carotid Artery Diseases/therapy , Embolization, Therapeutic/adverse effects , Embolization, Therapeutic/methods , Intracranial Aneurysm/therapy , Adult , Aged , Aged, 80 and over , Carotid Artery Diseases/diagnostic imaging , Cerebral Angiography , Embolization, Therapeutic/instrumentation , Female , Humans , Intracranial Aneurysm/diagnostic imaging , Male , Middle Aged , Retrospective Studies , Risk Factors , Treatment Outcome
10.
Eur J Neurol ; 21(4): 586-93, 2014 Apr.
Article in English | MEDLINE | ID: mdl-24447601

ABSTRACT

BACKGROUND AND PURPOSE: Diaphragms of the internal carotid and vertebral arteries as a cause of ischaemic stroke are reported and stenting of diaphragms as a therapeutic option in stroke secondary prevention is described. METHODS: Five patients were cared for in our institution from 2000 to 2011 for recurrent ischaemic strokes which were classified to be of undetermined aetiology after completion of the usual investigations. Because the patients had already had ischaemic strokes in the territory of the same artery, a conventional digital subtracted angiography was performed. A diaphragm was identified on the artery that supplied the territory in which the stroke occurred. The stroke was therefore attributed to the diaphragm. Clinical and radiological data, treatment and the clinical course of the patients was retrospectively reviewed. RESULTS: The diaphragm was located in the vertebral artery in three cases and in the bulb of the internal carotid artery in two. In all cases cerebral MR showed ischaemic strokes of different ages downstream of the diaphragm. Stenting was performed in four cases. No patient had a symptomatic recurrent ischaemic event after stenting. CONCLUSIONS: Diaphragms are a rare cause of recurrent embolic strokes which are often not detected with non-invasive imaging. Stenting appears to be a therapeutic option in stroke secondary prevention. These observations suggest that conventional angiography should be performed in cases of recurrent ischaemic strokes in the territory of a single artery and in cases of ischaemic stroke of undetermined aetiology in young adults when the usual investigations are negative.


Subject(s)
Carotid Arteries/pathology , Diaphragm/pathology , Stroke/diagnosis , Vertebral Artery/pathology , Adult , Aged , Female , Follow-Up Studies , Humans , Ischemia/complications , Magnetic Resonance Imaging , Male , Middle Aged , Retrospective Studies , Sensitivity and Specificity , Stroke/etiology , Ultrasonography, Doppler , Young Adult
11.
Eur J Neurol ; 21(3): 545-7, 2014 Mar.
Article in English | MEDLINE | ID: mdl-24200460

ABSTRACT

BACKGROUND AND PURPOSE: Venous drainage of dural arteriovenous fistula (DAVF) with dementia has never been reported. The aim of this study was to discover if specific vascular conditions exist to develop dementia in patients with DAVF. METHODS: Venous drainage in patients embolized in our centre between 1996 and 2012 for a DAVF with dementia were qualitatively analyzed and compared with a control group without dementia. RESULTS: Eight patients with dementia and 45 control patients were included. The prevalence of dementia was 4%. Diffuse hemispheric white matter lesions on magnetic resonance imaging (MRI) were consistently associated with dementia. Cognitive symptoms dramatically improved after embolization. The consistent angiographic feature in patients with dementia was drainage of the DAVF into both the straight sinus and the superior sagittal sinuses. Only two patients in the control group had similar abnormalities. CONCLUSIONS: The association of a reflux from the fistula into the straight sinus and the superior sagittal sinuses is a necessary condition to develop such a reversible dementia in DAVF. Venous hypertension in the territory of transparenchymal veins may explain this reversal phenomenon. A rapidly progressive dementia with diffuse white matter lesions on MRI should evoke this diagnosis to the physician.


Subject(s)
Central Nervous System Vascular Malformations/complications , Central Nervous System Vascular Malformations/therapy , Dementia/complications , Drainage/methods , Adolescent , Adult , Aged , Aged, 80 and over , Female , Humans , Magnetic Resonance Angiography , Magnetic Resonance Imaging , Male , Mental Status Schedule , Middle Aged , Retrospective Studies , Young Adult
12.
Diagn Interv Imaging ; 93(12): 935-48, 2012 Dec.
Article in English | MEDLINE | ID: mdl-23084073

ABSTRACT

The French Society of Radiology's guide to good use of medical imaging examinations recommends MRI as the first-line examination for exploring cerebrovascular events or disorders. This paper will discuss the main traps in the images when stroke is suspected and provide the technical tips or knowledge necessary for an optimal radiological report.


Subject(s)
Artifacts , Cerebrovascular Disorders/diagnosis , Magnetic Resonance Imaging , Humans , Magnetic Resonance Imaging/methods
13.
AJNR Am J Neuroradiol ; 33(10): 1932-8, 2012 Nov.
Article in English | MEDLINE | ID: mdl-22555587

ABSTRACT

BACKGROUND AND PURPOSE: Type 2 FCD is one of the main causes of drug-resistant partial epilepsy. Its detection by MR imaging has greatly improved surgical outcomes, but it often remains overlooked. Our objective was to determine the prevalence of typical MR imaging criteria for type 2 FCD, to provide a precise MR imaging pattern, and to optimize its detection. MATERIALS AND METHODS: We retrospectively reviewed 1.5T MR imaging of 71 consecutive patients with histologically proved type 2 FCD. The protocol included millimetric 3D T1-weighted, 2D coronal and axial T2-weighted, and 2D or 3D FLAIR images. Two experienced neuroradiologists looked for 6 criteria: cortex thickening, cortical and subcortical signal changes, blurring of the GWM interface, the "transmantle" sign, and gyral abnormalities. The frequency of each sign and their combination were assessed. We compared the delay between epilepsy onset and surgery, taking into account the time of type 2 FCD detection by MR imaging. RESULTS: Only 42 patients (59%) had positive MR imaging findings. In this group, a combination of at least 3 criteria was always found. Subcortical signal changes were constant. Three characteristic signs (cortical thickening, GWM blurring, and transmantle sign) were combined in 64% of patients, indicating that MR imaging can be highly suggestive. However, typical features of type 2 FCD were overlooked on initial imaging in 40% of patients, contributing to a delay in referral for surgical consideration (17 versus 11.5 years when initial MR imaging findings were positive). CONCLUSIONS: A combination of 3 major MR imaging signs allows type 2 FCD to be recognized in clinical practice, thereby enabling early identification of candidates for surgery.


Subject(s)
Brain Diseases/pathology , Brain/pathology , Image Enhancement/methods , Image Interpretation, Computer-Assisted/methods , Magnetic Resonance Imaging/methods , Malformations of Cortical Development/pathology , Adolescent , Adult , Child , Epilepsy , Female , Humans , Male , Malformations of Cortical Development, Group I , Middle Aged , Reproducibility of Results , Sensitivity and Specificity , Young Adult
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