A Pragmatic Randomized Trial Comparing Surgical Clipping and Endovascular Treatment of Unruptured Intracranial Aneurysms.

BACKGROUND AND PURPOSE: Surgical clipping and endovascular treatment are commonly used in patients with unruptured intracranial aneurysms. We compared the safety and efficacy of the 2 treatments in a randomized trial. MATERIALS AND METHODS: Clipping or endovascular treatments were randomly allocated to patients with one or more 3- to 25-mm unruptured intracranial aneurysms judged treatable both ways by participating physicians. The study hypothesized that clipping would decrease the incidence of treatment failure from 13% to 4%, a composite primary outcome defined as failure of aneurysm occlusion, intracranial hemorrhage during follow-up, or residual aneurysms at 1 year, as adjudicated by a core lab. Safety outcomes included new neurologic deficits following treatment, hospitalization of >5 days, and overall morbidity and mortality (mRS > 2) at 1 year. There was no blinding. RESULTS: Two hundred ninety-one patients were enrolled from 2010 to 2020 in 7 centers. The 1-year primary outcome, ascertainable in 290/291 (99%) patients, was reached in 13/142 (9%; 95% CI, 5%-15%) patients allocated to surgery and in 28/148 (19%; 95% CI, 13%-26%) patients allocated to endovascular treatments (relative risk: 2.07; 95% CI, 1.12-3.83; P = .021). Morbidity and mortality (mRS >2) at 1 year occurred in 3/143 and 3/148 (2%; 95% CI, 1%-6%) patients allocated to surgery and endovascular treatments, respectively. Neurologic deficits (32/143, 22%; 95% CI, 16%-30% versus 19/148, 12%; 95% CI, 8%-19%; relative risk: 1.74; 95% CI, 1.04-2.92; P = .04) and hospitalizations beyond 5 days (69/143, 48%; 95% CI, 40%-56% versus 12/148, 8%; 95% CI, 5%-14%; relative risk: 0.18; 95% CI, 0.11-0.31; P < .001) were more frequent after surgery. CONCLUSIONS: Surgical clipping is more effective than endovascular treatment of unruptured intracranial aneurysms in terms of the frequency of the primary outcome of treatment failure. Results were mainly driven by angiographic results at 1 year.

Safety and outcome of mechanical thrombectomy in ischaemic stroke related to carotid artery dissection.

BACKGROUND: The net clinical benefit of mechanical thrombectomy (MT) in patients with anterior circulation ischaemic stroke associated with large vessel occlusion (AIS-LVO) related to carotid artery dissection (CAD) is uncertain. The aim of the study was to investigate the safety and clinical outcomes of patients treated by MT for a CAD-related stroke. METHODS: We included consecutive patients with AIS-LVO treated by MT between 1st 2015 and January 1st 2020 at Lille University Hospital. We compared the safety and clinical outcomes, including successful recanalisation, defined as a modified thrombolysis in cerebral infarction (mTICI) ≥ 2b and favourable functional outcome at 3 months (defined as a modified Rankin Scale (mRS) ≤ 2 or equal to pre-stroke), in patients with CAD-related stroke versus patients with other aetiologies. RESULTS: We included 1422 patients, among them, 43 patients with CAD-related AIS-LVO were matched to 86 patients with other aetiologies. Procedural complications, sICH (ECASS-3 criteria) and mortality rates were similar in the two groups (OR 0.85, 95% CI 0.21-3.49, p = 0.82; OR 1.54 95% CI 0.33-2.79, p = 0.58; OR 0.18 95% CI 0.02-1.46, p = 0.11, respectively), as well as the rates of intracranial angiographic successful recanalisation and favourable functional outcome (OR 0.67 (95% CI 0.26-1.73, p = 0.41; OR 1.26 (95% CI 0.61-2.64, p = 0.53). In patients with CAD-related stroke, intracranial angiographic success after MT was significantly associated with favourable functional outcome. CONCLUSIONS: In patients with AIS-LVO related to CAD, safety profiles and clinical outcomes after MT are similar compared to matched patients with other stroke aetiologies.

Impact of recanalisation by mechanical thrombectomy in mild acute ischemic stroke with large anterior vessel occlusion.

BACKGROUND: The net clinical benefit of mechanical thrombectomy (MT) in patients presenting acute anterior circulation ischemic stroke with large-vessel occlusion (AIS-LVO) and mild neurological deficit is uncertain. AIMS: To investigate efficacy and safety of MT in patients with acute AIS-LVO and mild neurological deficit by evaluating i) the influence of recanalisation on three-month outcome and ii) mortality, symptomatic intracerebral hemorrhage (sICH) and procedural complications. METHODS: We included consecutive patients with acute AIS-LVO and National Institute of Stroke Scale (NIHSS) score<8, treated by MT at Lille University Hospital. Recanalisation was graded according to modified thrombolysis in cerebral infarction (mTICI) score, mTICI 2b/2c/3 being considered successful. We recorded procedural complications and classified intra-cerebral hemorrhages (ICH) and sICH according with European Cooperative Acute Stroke Study (ECASS) and ECASS2 criteria. Three-month outcome was evaluated by modified Rankin scale (mRS). Excellent and favourable outcomes were respectively defined as mRS 0-1 and 0-2 (or similar to pre-stroke). RESULTS: We included 95 patients. At three months, 56 patients (59. 0%) achieved an excellent outcome and 69 (72, 6%) a favourable outcome, both being more frequent in patients with successful recanalisation than in patients without (excellent outcome 71, 1% versus 10, 5%, P<0.001 and favourable outcome 82.9% versus 31.6%, P<0.001). The difference remained unchanged after adjustment for age and pre-MT infarct volume. Similar results were observed in patients with pre-MT NIHSS ≤5. Death occurred in five patients (5.3%), procedural complications in 12 (12.6%), any ICH in 38 (40.0%), including 3 (3.2%) sICH. CONCLUSIONS: Achieving successful recanalisation appears beneficial and safe in acute AIS-LVO patients with NIHSS<8 before MT.

Benefit of first-pass complete reperfusion in thrombectomy is mediated by limited infarct growth.

BACKGROUND AND PURPOSE: The number of clot retrieval attempts required to achieve complete reperfusion by mechanical thrombectomy impacts functional outcome in acute ischaemic stroke (AIS). Complete reperfusion [expanded Treatment In Cerebral Infarction (eTICI) score = 3] at first pass (FP), is associated with the highest rates of favorable outcome compared to complete reperfusion by multiple passes. The aim of the present study was to investigate the relationship between FP complete reperfusion and infarct growth (IG). METHODS: Anterior AIS patients with baseline and 24-h diffusion-weighted magnetic resonance imaging were included from two prospective registries. IG was measured by voxel-based segmentation of initial and 24-h diffusion-weighted imaging lesions. IG and favorable 3-month modified Rankin Scale (mRS) score (≤ 2) were compared between patients in whom complete reperfusion (eTICI 3) was achieved with a single pass (FP group) and those for whom multiple passes were required (MP group), after matching for confounding factors. Mediation analysis was performed to examine the association between FP and 3-month mRS score, with IG as mediating variable. RESULTS: A total of 200 patients were included, of whom 118 (28.9%) had FP complete reperfusion. In case-control analysis, the FP group had lower IG than the MP group [8.7 (5.4-12.9) ml vs. 15.2 (11-22.6) ml, respectively; P = 0.03). Favorable outcome was higher in the FP population compared to a matched MP population (70.9% vs. 53.2%, respectively; P = 0.04). FP compete reperfusion (eTICI 3) was independently associated with favorable outcome in multivariable regression analysis [odds ratio 1.86, 95% confidence interval (CI) 1.01-4.39; P = 0.04]. The effect of complete reperfusion at FP on functional outcome was explained by limited IG in mediation analysis [indirect effect: -0.32 (95% CI -0.47 to -0.09)]. CONCLUSION: Complete reperfusion at FP is independently associated with significant decrease in IG compared to complete reperfusion by multiple attempts, explaining better functional outcomes.

Follow-Up MRI for Small Brain AVMs Treated by Radiosurgery: Is Gadolinium Really Necessary?

BACKGROUND AND PURPOSE: Follow-up MR imaging of brain AVMs currently relies on contrast-enhanced sequences. Noncontrast techniques, including arterial spin-labeling and TOF, may have value in detecting a residual nidus after radiosurgery. The aim of this study was to compare noncontrast with contrast-enhanced MR imaging for the differentiation of residual-versus-obliterated brain AVMs in radiosurgically treated patients. MATERIALS AND METHODS: Twenty-eight consecutive patients with small brain AVMs (<20 mm) treated by radiosurgery were followed with the same MR imaging protocol. Three neuroradiologists, blinded to the results, independently reviewed the following: 1) postcontrast images alone (4D contrast-enhanced MRA and postcontrast 3D T1 gradient recalled-echo), 2) arterial spin-labeling and TOF images alone, and 3) all MR images combined. The primary end point was the detection of residual brain AVMs using a 5-point scale, with DSA as the reference standard. RESULTS: The highest interobserver agreement was for arterial spin-labeling/TOF (κ = 0.81; 95% confidence interval, 0.66-0.93). Regarding brain AVM detection, arterial spin-labeling/TOF had higher sensitivity (sensitivity, 85%; specificity, 100%; 95% CI, 62-97) than contrast-enhanced MR imaging (sensitivity, 55%; specificity, 100%; 95% CI, 27-73) and all MR images combined (sensitivity, 75%; specificity, 100%; 95% CI, 51-91) (P = .008). All nidus obliterations on DSA were detected on MR imaging. In 6 patients, a residual brain AVM present on DSA was only detected with arterial spin-labeling/TOF, including 3 based solely on arterial spin-labeling images. CONCLUSIONS: In this study of radiosurgically treated patients with small brain AVMs, arterial spin-labeling/TOF was found to be superior to gadolinium-enhanced MR imaging in detecting residual AVMs.

Endovascular Stroke Therapy with a Novel 6-French Aspiration Catheter.

BACKGROUND AND PURPOSE: Direct thrombus aspiration is increasingly used as a first-line therapy in acute ischemic stroke with large vessel occlusion. We assessed the performance and safety of a novel aspiration catheter available: the 6-French AXS Catalyst catheter. MATERIALS AND METHODS: We conducted a cohort study from a prospective clinical registry of consecutive stroke patients treated by mechanical thrombectomy between March 2016 and July 2016. Baseline clinical and imaging characteristics, recanalization rates, complications, and clinical outcomes were analyzed. RESULTS: Among the 60 patients included, 30 were treated using aspiration alone, 14 were treated using aspiration and then stent retriever as a rescue therapy, and 16 were treated using aspiration combined with a stent retriever straightaway. Successful recanalization (mTICI2b/3) was achieved in 85% patients and functional independence in 48.3%. We observed one intracranial perforation and one vertebral artery dissection. Symptomatic intracranial hemorrhage occurred in 5% and mortality in 21.7%. CONCLUSION: Endovascular stroke therapy using the AXS Catalyst catheter seems safe and effective, with similar performance than other reperfusion catheters.

Reduced-dose CT protocol for the assessment of cerebral vasospasm.

INTRODUCTION: Despite the increased radiation dose, multimodal CT including noncontrast CT (NCT), CT angiography (CTA), and perfusion CT (PCT) remains a useful tool for the diagnosis of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). The aim of this study was to assess the radiation dose and the image quality between a standard-dose and a reduced-dose multimodal CT protocol. METHODS: The study group consisted of 26 aSAH patients with a suspicion of DCI on clinical examination and transcranial doppler. Two different CT protocols were used: a standard-dose protocol (NCT 120 kV, 350 mAs; CTA 100 kV, 250 mAs; PCT 80 kV, 200 mAs) from August 2011 to October 2013 (n = 13) and a reduced-dose protocol (NCT 100 kV, 400 mAs; CTA 100 kV, 220 mAs; PCT 80 kV, 180 mAs) from November 2013 to May 2014 (n = 13). Dose-length product (DLP), effective dose, volume CT dose index (CTDI), signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and overall image quality were determined for each examination. RESULTS: The overall image quality was judged as good or excellent in all cases. The reduced-dose protocol allowed a 15 % decrease in both the median total DLP (2438 vs 2898 mGy cm, p < 0.0001) and the effective dose as well as a significant decrease in median CTDI of 23, 31, and 10 % for NCT, CTA, and CTP, respectively. This dose reduction did not result in significant alteration of SNR (except for NCT) or CNR between groups. CONCLUSION: The present study showed that the reduced-dose multimodal CT protocol enabled a significant reduction of radiation dose without image quality impairment.

[Chest morphology and breast augmentation]. / Morphologie thoracique et prothèses mammaires.

When one considers breast augmentation, it is quite important to study the patient thoracic morphology, since the ribs are the base on which the implant rests. They are responsible for the implant orientation, and, in part, for the breast projection. Some malformations are obvious, neither the surgeon nor the patient underestimates the difficulties... However, often exist discreet abnormalities, which don't stick out right away. One must not ignore them, because they affect the result of an ordinary augmentation procedure. They must be identified and evaluated prior surgery. Thus, she will not be surprised or disappointed if the result is not exactly symmetrical, or what she was expecting. Aesthetic surgery requires the same demand than reconstructive surgery. The physical examination must be very thorough, looking for any asymmetry, even minimal, concerning volume, skin and bone. The position of the implants must be discussed not only according to the type of implants (inflatable or gel filled) but also according to the state of the skin, the thickness of the subcutaneous tissue, the amount of gland and the shape of the thorax.

[Esthetic surgery of the breast]. / Chirurgie esthétique du sein.

The aesthetic surgery of the breast goes from one side to the other: make it bigger if it is too small, make it smaller if it is too big, tighten the skin if it falls. The situation is very complex because of the facts that these disgraces can be associated with different levels of severity, and that woman has two breasts each one often different from the other. But, if natural asymmetry is found so often, the surgeon should not reproduce it. Some problems cannot be solved yet: long time tolerance to the breast implants, unknowledge of the way the skin would heal, a very important factor for the reduction plasties. This surgery is a balance with two dishes: for example, the result that we are waiting for must not to be spoiled by a too big scar to obtain a small cosmetic benefit. The indications to operate should be given after they have been judged carefully and notified the patient very clearly about the advantages, inconveniences and expected complications.

[Breast reconstruction after mastectomy. Critical analysis of 240 cases]. / Reconstrução da mama pós-mastectomia. Análise crítica de 240 casos.

A retrospective study on 240 cases of breast reconstruction was undertaken in order to make a critical analysis of the results of different techniques as silicone prosthesis, tissue expanders, and the myocutaneous flaps of latissimus dorsi and rectus abdominis. The authors discuss the indications, advantages, inconveniences and complications of each technique and point out the particular indications for each one, depending on the type of mastectomy performed and the quality of the remaining tissues. Good results can be obtained using prosthesis, or flaps, but the indications must be very criterious, as the number of complications may be high, and many operations might be needed to achieve a satisfactory result.

[Technic of tissue expansion]. / Technique de l'expansion tissulaire.

The technique of tissue expansion is rapidly developing. It resolves certain problems encountered in plastic and reconstructive surgery, in the scalp, for example, which constitutes an ideal indication. A correct strategy and technique, together with well defined indications allows a very significant reduction in the complication rate. The choice of prosthesis and its location also play an important role. There are many indications in the scalp, but tissue expansion may also be useful in Poland's syndrome, in giant naevi in children and for expansion of certain flaps. Rapid intra-operative expansion also appears to be a promising technique.

Tamoxifen and hydroxytamoxifen isomers versus estradiol effects on normal human breast cells in culture.

Estradiol and triphenylethylene antiestrogen actions have been studied extensively in breast cancer cell lines. However, their effects are still poorly understood on normal human breast cells. We have developed a culture system of normal human breast epithelial (HBE) cells. It has been shown previously that cultured HBE cells were hormone dependent and well adapted for the study of hormone/antihormone actions. However, until now, no data were available on estradiol receptor (ER) in HBE cells. In this study, the presence of ER was demonstrated by (a) whole-cell biochemical assay on breast cells after enzymatic tissue dissociation and (b) an immunocytochemical method using an anti-ER monoclonal antibody both on enzymatically dissociated cells and on 8-day cultured cells. Immunostaining was nuclear and cell positivity was heterogeneous. However, the percentage of positive cells and staining intensity were far greater in the presence of estradiol in the culture, indicating estradiol stimulation of ER. Moreover, HBE cells were used to study the action on cell growth of estradiol versus trans-tamoxifen (TAM), trans-4-hydroxytamoxifen (trans-4OHTAM), and cis-4-hydroxytamoxifen (cis-4OHTAM) alone or added to estradiol. Cell growth was estimated daily by a histometric method and by DNA assay at the end of the 7-day study. When the medium was minimally supplemented with human serum (1%), estradiol stimulated cell growth in a dose-dependent manner at concentrations varying from 10(-9) to 10(-7) M. TAM and trans-4OHTAM clearly inhibited mammary cell division when estradiol was added to the medium and, to a lesser extent, in the absence of estradiol. This inhibitory effect was dose dependent. trans-4OHTAM was 100 times more active than trans-TAM. cis-4OHTAM also clearly inhibited breast cell division at 10(-7) and 10(-6) M concentrations but was 3-fold less efficient than trans-4OHTAM. In conclusion, (a) the presence and estradiol dependence of ER have been demonstrated in HBE cells, which constitute a fruitful model for the study of hormone/antihormone actions, and (b) in these normal cells, estradiol stimulates growth, whereas TAM and the 4OHTAM isomers are potent inhibitors of cell multiplication, as they are in breast cancer cell lines in culture.