Campbell, B. C.V. et al. (2019) Penumbral imaging and functional outcome in patients with anterior circulation ischaemic stroke treated with endovascular thrombectomy versus medical therapy: a meta-analysis of individual patient-level data.ABSTRACT Background: CT-perfusion (CTP) and MRI may assist patient selection for endovascular thrombectomy. We aimed to establish whether imaging assessments of ischaemic core and penumbra volumes were associated with functional outcomes and treatment effect.

Campbell, B. C. V. et al. (2018) Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data. Lancet Neurology, 17(1), pp. 47-53. (doi:10.1016/S1474-4422(17)30407-6) This is the author's final accepted version.There may be differences between this version and the published version. You are advised to consult the publisher's version if you wish to cite from it.http://eprints.gla.ac.uk/149670/ variables. An alternative approach using propensity-score stratification was also used. To account for between-trial variance we used mixed-effects modeling with a random effect for trial incorporated in all models. Bias was assessed using the Cochrane tool.Findings: Of 1764 patients in 7 trials, 871 were allocated to endovascular thrombectomy. After exclusion of 74 patients (72 who did not undergo the procedure and 2 with missing data on anaesthetic strategy), 236/797 (30%) of endovascular patients were treated under GA. At baseline, GA patients were younger and had shorter time to randomisation but similar pre-treatment clinical severity compared to non-GA. Endovascular thrombectomy improved functional outcome at 3 months versus standard care in both GA (adjusted common odds ratio (cOR) 1·52, 95%CI 1·09-2·11, p=0·014) and non-GA (adjusted cOR 2·33, 95%CI 1·75-3·10, p<0·001) patients. However, outcomes were significantly better for those treated under non-GA versus GA (covariate-adjusted cOR 1·53, 95%CI 1·14-2·04, p=0·004; propensitystratified cOR 1·44 95%CI 1·08-1·92, p=0·012). The risk of bias and variability among studies was assessed to be low.Interpretation: Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons. Funding:The HERMES collaboration was funded by an unrestricted grant from Medtronic to the University of Calgary. Research in contextEvidence before this study between abolition of the thrombectomy treatment effect in MR CLEAN and no effect in THRACE. Three single-centre randomised trials of general anaesthesia versus conscious sedation found either no difference in functional outcome between groups or a slight benefit of general anaesthesia. Added value of this studyThese data from contemporary, high quality randomised trials form the largest study to date of the association between general anesthesia and the benefit of endovascular thrombectomy versus standard care. We used two different approaches to adjust for baseline imbalances (multivariable logistic regression and propensity-score stratification). We found that GA for endovascular thrombectomy, as practiced in contemporary clinical care across a wide range of expert centres during the rand...

Three-dimensional DSA is valuable for evaluating the potential for EVT, finding a working view, and performing accurate measurements.

S urgical clipping of MCA aneurysms is usually preferred to EVT. This preference is largely the result of a relatively easy surgical access and unfavorable endovascular approach due to the complex branching pattern of the MCA. As of this writing, no direct comparison between results of endovascular and surgical treatment of MCA aneurysms has been published in the literature, leaving the optimal treatment strategy unclear and choices depending mainly on the practice at the different centers. We therefore considered it important to study procedure-related risks as well as the immediate and midterm angiographic and clinical results after EVT of MCA aneurysms. MethodsFrom October 1992 to October 2001, a total of 940 patients with 1120 cerebral aneurysms were seen in our institute. Of these 940 patients, 202 (21.5%) were found to have MCA aneurysms (a total of 238 [21.3% of all identified aneurysms]). The closing date was chosen to have more than 5 years of follow-up data.Since the first use of detachable coils in our department in October 1992, data pertaining to all patients referred for EVT has been prospectively recorded. These data include: patients' demographic characteristics, mode of presentation, aneurysmal angiographic features, angiographic outcome at immediate post-EVT and follow-up examinations, procedure-related complications, and clinical status, using Hunt and Hess grading (in case of hemorrhage) on admission and GOS scores upon discharge Object. The object of this study was to evaluate the initial and mid-term angiographic and clinical results after endovascular coil occlusion of middle cerebral artery (MCA) aneurysms at the authors' institution.Methods. The authors conducted a retrospective analysis of a consecutive series of 152 MCA aneurysms (73 ruptured) treated by endovascular coiling in 140 patients. Angiographic and clinical data at initial and midterm follow-up as well as procedure-related complications were prospectively registered.Results. At discharge, favorable clinical outcomes (Glasgow Outcome Scale score of 1 or 2) were obtained in 89.3% of patients (125/140). Seven patients (5%) were in a vegetative state or had died. Complications were encountered in association with 11.8% of the procedures (18/152), and most (13/18) involved thromboembolic events (which led to permanent ischemia in 4 cases and death in 1). The overall procedure-related mortality rate was 0.7%, and the rates of permanent and transient morbidity were 2.6 and 2%, respectively. At a mean follow-up duration of 4.3 years there had been 4 cases of rebleeding: early rebleeding occurred during the initial postoperative period in 3 cases and later in 1. Total or subtotal occlusion was obtained in 84.2% of aneurysms (128/152). At follow-up, this satisfactory occlusion persisted in 83.3% of aneurysms (110/132) at 1 year posttreatment, 79.5% (89/112) at 3 years, and 80.2% (73/91) at 5 years.Conclusions. Risks and initial and midterm angiographic and clinical results after endovascular treatment of MCA aneurysms are nearly identi...

The immediate and long-term outcomes, complications, recurrences and the need for retreatment were analyzed in a series of 280 consecutive patients with anterior communicating artery aneurysms treated with the endovascular technique. From October 1992 to October 2001 280 patients with 282 anterior communicating artery aneurysms were addressed to our center. For the analysis, the population was divided into two major groups: group 1, comprising 239 (85%) patients with ruptured aneurysms and group 2 comprising of 42 (15%) patients with unruptured aneurysms. In group 1, 185 (77.4%) patients had a good initial pre-treatment Hunt and Hess grade of I-III. Aneurysm size was divided into three categories according to the larger diameter: less than 4 mm, between 4 and 10 mm and larger than 10 mm. The sizes of aneurysms in groups 1 and 2 were identical but a less favorable neck to depth ratio of 0.5 was more frequent in group 2. Endovascular treatment was finally performed in 234 patients in group 1 and 34 patients in group 2. Complete obliteration was more frequently obtained in group 2 unlike a residual neck or opacification of the sac that were more frequently seen in group 1. No peri-treatment complications were recorded in group 2. In group 1 the peri-treatment mortality and overall peri-treatment morbidity were 5.1% and 8.1% respectively. Eight patients (3.4%) in group 1 presented early post treatment rebleeding with a mortality of 88%. The mean time to follow-up was 3.09 years. In group 1, 51 (21.7%) recurrences occurred of which 14 were minor and 37 major. In group 2, eight (23.5%) recurrences occurred, five minor and three major. Two patients (0.8%) presented late rebleeding in group 1. Twenty-seven second endovascular retreatments were performed, 24 (10.2%) in group 1 and three (8.8%) in group 2, seven third endovascular retreatments and two surgical clippings in group 1 only. There was no additional morbidity related to retreatments. Endovascular treatment is an effective method for the treatment of anterior communicating artery aneurysms allowing late rebleeding prevention. Peri-treatment rebleeding warrants caution in anticoagulation management. This is a single center experience and the follow-up period is limited. Patients should be followed-up in the long-term as recurrences may occur and warrant additional treatment.