A Direct Aspiration, First Pass Technique (ADAPT) versus Stent Retrievers for Acute Stroke Therapy: An Observational Comparative Study.

BACKGROUND AND PURPOSE: Mechanical thrombectomy with stent retrievers is now the standard therapy for selected patients with ischemic stroke. The technique of A Direct Aspiration, First Pass Technique for the Endovascular Treatment of Stroke (ADAPT) appears promising with a high rate of recanalization. We compared ADAPT versus stent retrievers (the Solitaire device) for efficacy and safety as a front-line endovascular procedure. MATERIALS AND METHODS: We analyzed 243 consecutive patients with large intracranial artery occlusions of the anterior circulation, treated within 6 hours with mechanical thrombectomy by either ADAPT or the Solitaire stent. Th primary outcome was complete recanalization (modified TICI ≥ 2b); secondary outcomes included complication rates and procedural and clinical outcomes. RESULTS: From November 2012 to June 2014, 119 patients were treated with stent retriever (Solitaire FR) and 124 by using the ADAPT with Penumbra reperfusion catheters. The median baseline NIHSS score was the same for both groups (Solitaire, 17 [interquartile range, 11-21] versus ADAPT, 17 [interquartile range, 12-21]). Time from groin puncture to recanalization (Solitaire, 50 minutes [range, 25-80 minutes] versus ADAPT, 45 minutes [range, 27-70 minutes], P = .42) did not differ significantly. However, compared with the Solitaire group, patients treated with ADAPT achieved higher final recanalization rates (82.3% versus 68.9%; adjusted relative risk, 1.18; 95% CI, 1.02-1.37; P = .022), though differences in clinical outcomes between the cohorts were not significant. Use of an adjunctive device was more frequent in the ADAPT group (45.2% versus 13.5%, P < .0001). The rate of embolization in new territories or symptomatic hemorrhage did not differ significantly between the 2 groups. CONCLUSIONS: Front-line ADAPT achieved higher recanalization rates than the Solitaire device. Further randomized controlled trials are warranted to define the best strategy for mechanical thrombectomy.

Impact of thrombolysis in acute ischaemic stroke without occlusion: an observational comparative study.

BACKGROUND AND PURPOSE: The impact of intravenous recombinant tissue plasminogen activator (IV-rtPA) in patients with acute ischaemic stroke (AIS) but no arterial occlusion is currently a matter of debate. This study aimed to assess functional outcome of such patients with respect to IV-rtPA use. METHODS: A retrospective case-control analysis was performed comparing the outcome of AIS patients without arterial occlusion with or without IV-rtPA use. Patients were selected from prospective consecutive observational registries of five European university hospitals. The primary study outcome was excellent outcome at 3 months after stroke, as defined by a modified Rankin Scale (mRS) 0-1. RESULTS: A total of 488 patients without arterial occlusion documented by angiography were included in the present study; 300 received IV-rtPA and 188 did not. No between-group difference was found for excellent outcome before and after adjustment for baseline characteristics (adjusted odds ratio for no IV-rtPA use 0.79, 95% confidence interval 0.51-1.24, P = 0.31). Similar results were found for favourable outcome (defined as a 90-day mRS of 0-2) whereas a higher rate of early neurological improvement was found in IV-rtPA-treated patients (adjusted odds ratio 1.99; 95% confidence interval 1.29-3.07, P = 0.002). Sensitivity analyses yielded similar results. CONCLUSIONS: Our study suggests that AIS patients without visible arterial occlusion treated with IV-rtPA may have no better outcome at 3 months than those untreated. However, only a randomized controlled trial would provide a definitive answer about the impact of rtPA in acute stroke patients without occlusion. Until then, these patients should be treated by rtPA as recommended.

[Pupil-sparing painful oculomotor neuropathy due to a carotico-cavernous aneurysm]. / Ophtalmoplégie extrinsèque pure douloureuse du nerf moteur oculaire commun révélant un anévrysme de la carotide.

INTRODUCTION: In third cranial nerve palsy, the lack of mydriasis evokes a noncompressive mechanism. Case report. We report a case of a slightly painful, pure extrinsic third-nerve palsy, complete except for the partial ptosis secondary to the compression by an intracavernous carotid aneurysm. Percutaneous endovascular embolization was followed by complete regression of the palsy within 4 weeks. The pupil may have been spared by the mechanism of compression after the separation of the pupillomotor and extrinsic fibers or the ischemia of the third nerve by its arterial trunk lesion. CONCLUSION: This case report underlines that brain radiological explorations are necessary in some third-nerve pupil-sparing palsies.

[Cerebral infarct and pure sensory deficit]. / Infarctus cérébraux et déficit sensitif pur.

Twenty cases of pure sensory deficit of vascular origin are reported in patients aged 36 to 79 years. This type of attack in usually presumed to be due to a thalamic lacuna in the ventro-postero-lateral nucleus. However, other reported cases have shown other causal mechanisms and lesional sites. In the present series, CT scan and MRI in 11 cases demonstrated: infarctions in 9 and hemorrhages in 2 patients. The ventro-postero-lateral nucleus was involved in only 4 cases. An infarct of the posterior limb of the internal capsule (anterior choroidal artery territory) was present in 4 cases. The lesions in the other patients were: a thalamic hemorrhage and a small pontine hemorrhage lesion. The likely cause was embolism of cardiac origin in 4 cases, hypertension in 11 cases and diabetes in 4. One patient had an aneurysm of the posterior cerebral artery.

[Cranial pachymeningitis of unknown origin. Study of 3 cases]. / Pachyméningites crâniennes de cause indéterminée. Etude de 3 cas.

The clinical picture in three cases of chronic cranial pachymeningitis of unknown origin was dominated by headache, disturbed balance, a confusional state and cranial nerve lesions. The erythrocyte sedimentation rate was increased and the CSF showed inflammatory changes. CT scan imaging showed thickening of the tentorium cerebelli, which took up contrast intensely. Meningeal biopsy showed the dura-mater to be the site of a non-specific inflammatory process. No precise cause was found. Clinical manifestations in these three patients were remarkably corticosensitive but lesions did not regress on CT. The development of a state of corticodependence led to an attempt at treatment with radiotherapy and/or azathioprine, but follow up is insufficient to evaluate results.

[Auditory hallucinations in lesions of the brain stem]. / Hallucinose auditive dans les lésions du tronc cérébral.

Since the publication by Jean Lhermitte in 1922 of his paper on hallucinosis, the peduncular type has been described as a purely visual phenomenon. However, limited brain stem lesions can give rise to analogous manifestations in the auditory field. Five cases of auditory hallucinosis are reviewed, the first four resulting from a lesion of tegmentum of pons responsible for contralateral hemi-anesthesia and homolateral facial palsy with paralysis of laterality. Central type hypoacusis and a severe disorder of localization of sounds revealed a lesion of trapezoid body. The fifth case resulted from a peduncular lesion in region supplied by superior cerebellar artery, the auditory deficit being related to a lesion of inferior corpus quadrigeminum. In one patient, the auditory hallucinosis was followed by a period of visual hallucinations and oneiric delusions. Both auditory and visual hallucinosis can be related to hypnagogic hallucinations. Dream mechanisms (the geniculo-occipital spikes system) escape from normal inhibitory control exerted by the raphe nuclei. Auditory deafferentation could predispose to auditory hallucinosis.

Infarction in the territory of the anterior choroidal artery. A clinical and computerized tomographic study of 16 cases.

Sixteen cases of the anterior choroidal artery syndrome are reported. In its completed form, this rare syndrome combines the triad of hemiplegia, hemianaesthesia, and homonymous hemianopia. CT examination confirms the diagnosis by revealing an area of reduced density situated in the posterior limb of the internal capsule, sparing the thalamus medially and encroaching upon the tip of the globus pallidus laterally, and corresponding to the distribution of the anterior choroidal artery. Incomplete forms of the syndrome are more frequent. Left-sided spatial neglect may accompany right-sided lesions, as may slight disorders of speech in left-sided lesions. Clinical-anatomical correlations are discussed.

[Isolated sensory deficit of 1 side of the body as a result of a hematoma of the pons]. / Déficit sensitif isolé d'un hémicorps par hématome du pont.

In a patient with a history of sudden onset of an isolated sensory syndrome of the right side of the body the sensory deficit was exclusively related to lemniscal sensitivity. NMR imaging showed a small hemorrhage in the left paramedian portion of the pontine tegmentum, corresponding precisely to the location of the median lemniscus.

[The anterior choroidal artery syndrome]. / Le syndrome de l'artère choroïdienne antérieure.

The anterior choroidal artery syndrome is extremely rare. When complete, it includes hemiplegia, hemianaesthesia and homonymous lateral hemianopsia. The diagnosis is provided by computerized tomography which shows a low-density area located in the posterior part of the posterior limb of the internal capsule, sparing the thalamus medially but involving the tip of the pallidum externally and corresponding to the territory of the anterior choroidal artery. Incomplete forms of the syndrome have been described. The syndrome may also be associated with neuropsychological disorders, including left neglect syndrome in right-sided lesions and disorders of speech in left-sided lesions. The anatomico-clinical correlations are discussed.

[Primary cerebral lymphoma. Development of CT X-scanner data under corticoid treatment]. / Lymphome cérébral primitif. Evolution des données du scanner X sous traitement corticoïde.

CT showed a rapid and almost total regression of the lesions of a primary cerebral lymphoma during corticoid therapy. Such results assists the evaluation of changes provoked by radiotherapy and chemotherapy, since corticoids are often combined with these treatments.

[Brown-Séquard syndrome caused by a spinal cord infarction]. / Syndrome de Brown-Séquard dû a un infarctus spinal.

A 77-year old woman presented a Brown-Séquard syndrome of sudden onset at level C4, and a few days later a tetraplegia. Postmortem findings demonstrated, at C3-C4, a left spinal cord infarct accounting for the Brown-Séquard syndrome, and a second C5-C6 bilateral infarct responsible for the tetraplegia. Alternating distribution of sulcal arteries explains the limitation of the first lesion to one half of the spinal cord.

[Anterior choroidal artery syndrome. Clinical and computed tomography study of 4 cases]. / Syndrome de l' artère choroïdienne antérieure. Etude clinique et tomodensitométrique de 4 cas.

The author choroidal artery syndrome is a rare disorder associating, in its complete form, a hemiplegia, a hemianesthesia, and a homonymous lateral hemianopia. Four cases are reported in which the diagnosis was confirmed by a CT scan, which demonstrated a low density area in the posterior part of the posterior limb of the internal capsule, sparing the thalamus medially, and extending laterally to the apex of the pallidum thus corresponding to the area supplied by the anterior choroidal artery. The incomplete forms of this syndrome and clinicopathological correlations are discussed.

[Anterior choroidal artery syndrome. Neuropsychological study of 4 cases]. / Le syndrome de l'artère choroïdienne antérieure. Etude neuropsychologique de 4 cas.

A neuropsychological study was carried out in 4 cases of infarction in the territory of the anterior choroïdal artery. In 3 cases the lesions were on the right side. A syndrome of the minor hemisphere was present with severe visual neglect, constructional apraxia, alexia due to disorders of visuo-spatial strategy, anosognosia and motor impersistence. In the case with a left-sided lesion there was no neglect but a mild aphasia with impaired fluency, semantic paraphasias, perseveration and a decreased psycho-linguistic ability. The mechanisms of neglect in right-sided lesions are considered.