ARTICLE IN PRESS+ModelNEURAD-450; No. of Pages 9

Journal of Neuroradiology (2014) xxx, xxx—xxx

Available online at

ScienceDirectwww.sciencedirect.com

ORIGINAL ARTICLE

Endovascular treatment of acute ischemicstroke in France: A nationwide survey

Sébastien Soizea, Olivier Naggarab, Hubert Desal c,Vincent Costalatd, Frédéric Ricolfie, Laurent Pierota,∗

a Department of radiology, hôpital Maison-Blanche, université de Champagne-Ardenne, CHU de Reims, 45,rue Cognacq-Jay, 51092 Reims, Franceb Inserm U894, department of neuroradiology, université Paris Descartes, Sorbonne Paris Cité, centrehospitalier Sainte-Anne, Paris, Francec Department of neuroradiology, hôpital G.-et-R.-Laënnec, CHU de Nantes, Nantes, Franced Department of neuroradiology, hôpital Gui-de-Chauliac, CHU de Montpellier, Montpellier, Francee Department of neuroradiology, CHU de Dijon, Dijon, France

KEYWORDSStroke;Thrombectomy;Endovascular;Report;Survey

SummaryBackground and purpose: Developments in endovascular treatment have opened new promisingprospects for treating acute ischemic stroke. In France, EVT is increasingly used, especially whenintravenous thrombolysis is contraindicated or has failed. However, it has not been documentedhow neurointerventional centers are organized practically for the treatment of AIS. The presentsurvey aims to address this.Materials and methods: The centers in France that are authorized to perform EVT for AIS wereinvited to participate to an electronic survey. The survey was composed of 33 questions, dividedinto 6 subheadings: (1) general information, (2) imaging modalities, (3) patient selection, (4)anesthesiology, (5) endovascular procedure and (6) imaging follow-up.Results: The response rate was high at 93.9%. Neuroradiology centers are organized to performmechanical thrombectomy around the clock in 80.6% of the institutions. MRI was the mostcommonly used imaging modality to examine acute stroke, alone in 64.5% or in combination

with CT in 22.6%. The median number of neurointerventionalists was 3 per center and themedian number of procedures performed in 2012 was 925. Since the medical treatment is complex, an anesthesiologist is often required during the procedure (87.1%). Technical issues

Please cite this article in press as: Soize S, et al. Endovascular treatment of acute ischemic stroke in France: A nationwidesurvey. J Neuroradiol (2014), http://dx.doi.org/10.1016/j.neurad.2013.12.002

are also developed in the manuscript.

Abbreviations: AIS, Acute ischemic stroke; ASPECTS, Alberta stroke program early CT score; EVT, Endovascular treatment; IA, Intra-arterial; ICA, Internal carotid artery; LWMH, Low weight molecular heparin; MCA, Middle cerebral artery; NIs, Neurointerventionists; sICH,symptomatic intracranial hemorrhage.

∗ Corresponding author. Tel.: +33 0 326787566; fax: +33 0 326787594.E-mail address: lpierot@gmail.com (L. Pierot).

0150-9861/$ – see front matter © 2014 Published by Elsevier Masson SAS.http://dx.doi.org/10.1016/j.neurad.2013.12.002

ARTICLE IN PRESS+ModelNEURAD-450; No. of Pages 9

2 S. Soize et al.

Conclusions: This survey shows that French neuroradiology departments have made importantefforts to implement EVT of AIS with a high quality of care for the patients; the majority of thecenters used MRI to evaluate the disease and anesthesiologists are involved in order to optimizemedical care during EVT.© 2014 Published by Elsevier Masson SAS.

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m(f7il((btin the centers who answered the questionnaire was about925 [525—1325] procedures in 2012. The median number ofprocedures per center was about 30 [17—43]. Results of thecenters organization are summarized in the Fig. 1. Concern-ing the proportion of patients involved in clinical research,25/31 centers (80.6%) included their patients in randomizedtrials or registries: 20/31 centers (64.5%) in a randomized

ntroduction

troke is the first cause of acquired disability and the thirdause of adult death in France [1]. Intravenous fibrinoly-is using recombinant tissue plasminogen activator within.5 hours from the onset of symptoms is the standard treat-ent of acute ischemic stroke (AIS), according to recentlyublished high-profile trials [2,3]. Over the last decade,ndovascular therapy evolved rapidly from IA fibrinolysiso first and then second generation of mechanical clotemoval devices and opened new promising prospects forreating AIS [4—14]. Recent randomized trials have neitherhowed deleterious effect of EVT nor its superiority, takingnto account that they did not evaluate the latest devicesvailable [15—18]. On the other hand, with the collabora-ion between vascular neurologists and neuroradiologists,echanical thrombectomy becomes a mainstream offering

t many centers and seems to be already performed whenntravenous thrombolysis is contraindicated or failed. How-ver, practical organization of neurointerventional centersor acute stroke treatment and modalities of managementf patients are not well known. The present survey aimedo clarify these points.

aterials and methods

n electronic survey was distributed to the centers autho-ized for the activity of neurointerventional radiology inrance. The survey was the result of a collaborative work ofeveral neuroradiology departments. One practitioner perenter was asked to summarize the organization of strokereatment in his institution, the place of endovascular ther-py and the detailed practices from pre-treatment imagingo the follow-up. The final survey was in French and com-rised a set of 33 questions, divided into 6 subheadings:

general information; imaging modalities; patients selection; anesthetic consideration; endovascular procedure; imaging follow-up.

The whole questionnaire is available in supplementaryaterial. Questions were developed as single and multiple

tem responses, with an option for a free text response.oogle DriveTM was used to distribute the questionnaire andollect responses. For some questions, if two responses wereiven by a center (reflecting the variability of the practicen the center), half a point was given to each response. Theenters, which answered the questionnaire, as well as the

Please cite this article in press as: Soize S, et al. Endovascular tsurvey. J Neuroradiol (2014), http://dx.doi.org/10.1016/j.neu

ractitioners participating in the endovascular treatment ofIS, are available in the supplementary material. Statisticalnalysis was performed with MedCalc statistical software11.4.3.0, MedCalc Software, Mariakerke, Belgium) forindows.

Fr

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he response rate was high at 93.9% (31/33 centers).

eneral information (survey questions 1 to 6)

echanical thrombectomy was available around the clockn 25/31 institutions (80.6%). Each of the six centers (19.4%)n which thrombectomy was not available anytime treatedess than 25 patients in 2012. They were composed of morehan 3 interventionalists (NIs) involved in the endovascularreatment of AIS in one center, 3 NIs in 2 centers, 2 NIs in 1enter and only one NI in 2 centers.

The mean number of NIs performing endovascular treat-ent of AIS was 2.9 ± 0.9, median 3 [2—4]. Eight centers

25.8%) had a workforce of more than 3 NIs available to per-orm this procedure, 14 centers (45.2%) had 3 NIs involved,

centers (22.6%) had 2 NIs and 2 centers (6.4%) had 1 NInvolved. Majority of the centers (28/31, 90.3%) treatedess than 50 patients during the year 2012. Fifteen centers48.3%) treated less than 25 patients last year, 13 centers42.0%) treated between 25 and 50 patients, 2 centers (6.4%)etween 50 and 100 patients and one center (3.3%) morehan 100 patients. Then the median number of procedures

reatment of acute ischemic stroke in France: A nationwiderad.2013.12.002

igure 1 Summary of the general information subpartesponses.

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ARTICLENEURAD-450; No. of Pages 9

Endovascular treatment of acute ischemic stroke in France:

trial and 18/31 (58.1%) in a register. There were 5 centers(16.1%), which did not include in randomized trial but did inregistries. Another important point was that majority of thecenters included only part of their patients in randomizedtrials because their local indications of EVT were larger thanthose of the trial.

Imaging modalities (survey questions 7 to 9)

The most important result of this subsection was that MRIwas the most common modality to evaluate acute strokewithin 4.5 hours from the onset of symptoms. A total of20/31 (64.5%) centers used only MRI, 7/31 (22.6%) used MRIor CT depending on availability and only 4 (12.9%) centersonly used CT (Fig. 2). This highlights the effort made togeneralize the access to MRI for patient suspected of acutestroke and the importance given to advance imaging in thedecision to treat.

Among MRI users, the proportion of 1.5 Tesla and 3Tesla magnets was balanced (Fig. 2). The usefulness of DWI(29/31, 93.5%), Flair (29/31, 93.5%), T2* (28/31, 90.3%)and intracranial MRA (28/31, 90.3%) sequences was almostunanimous. Less used sequences were T1-wheighted (7/31,22.6%), T2-wheighted (2/31, 6.4%) and rho/proton density-weighted images (3/31, 9.7%).The use of cervical MRA(11/31, 35.5%) in the same time as morphological sequenceswas less frequent. The place given to advanced imaging wasrelatively important, with perfusion imaging used by 11/26(42.3%) of the centers using MRI (i.e. 11/35, 35.5% of allcenters).

Eleven centers (11/31, 35.5%) used CT to select patients:4/11 (36.4%) performed only CT in routine and 7/11 cen-ters (63.6%) used CT or MRI depending on their availability.Among these eleven centers, 7/11 (63.6%) performed CTAof intracranial vessels to confirm the occlusion and 10/11(90.9%) cervical vessels CTA. There was a clear majority thatpreferred advanced imaging to select patients: 9/11 (81.8%)centers performed perfusion CT and the two centers (2/11,

Please cite this article in press as: Soize S, et al. Endovascular tsurvey. J Neuroradiol (2014), http://dx.doi.org/10.1016/j.neu

18.2%), which did not were using CT or MRI according to localconditions.

Figure 2 Imaging modalities to evaluate acute ischemicstroke.

PRESStionwide survey 3

atient selection (survey questions 10 to 13)

atient selection can be based on clinical and/or imagingata. Available imaging data can vary depending on the pro-ocol applied in each center. The proposed clinical selectionriteria were far from unanimous and imaging criteria wereeterogeneous but three exclusion criteria were exceed-ng the average. It was hemorrhagic transformation (27/31,7.1%), ASPECTS on DWI < 5 (21/31, 67.8%) and midline dis-lacement (20/31, 64.5%), which is an indirect sign of largetroke volume. The free text option was used by two respon-ents who proposed other criteria: a stroke volume > 70 cc,bsence of mismatch between DWI and Flair and absencef mismatch between CBV and CBF on perfusion CT wereroposed. Some centers had few exclusion criteria whereasthers had many (range: 2—9). The number of exclusionriteria did not differ according to the preferred imag-ng modality (P = 0.63). Another interesting point was thatmong CT users, 8/11 (72.7%) did not exclude patients ifSPECTS was lesser than 7. Responses to the question of theontraindications of the endovascular treatment of AIS areummarized in Table 1.

In case of significant clinical improvement or poor sym-tomatology (NIHSS < 4), 17/31 respondents (54.8%) did noterform thrombectomy, whereas 13 (41.9%) and 8 (25.8%)id if there was an occlusion of the basilar artery or M1espectively (Fig. 3). For an occlusion of the anterior circula-ion, 6/31 (19.4%) start the thrombectomy before 4:30 hoursrom the onset of symptoms, 22/31 (70.9%) within 6 hours,/31 within 8 hours (3.2%) and responses were not availableor 2 centers (6.5%). So there was a clear trend for startingreating patients within 6 hours from the onset of symptoms.n 3/31 centers (9.7%), the time from onset of symptoms wasot taken into account if there was evidence of DWI-PWI

reatment of acute ischemic stroke in France: A nationwiderad.2013.12.002

Table 1 Contraindications of the endovascular treatmentof acute ischemic stroke according to the interviewedpractitioners.

Parameters Number ofresponse

Percentage(%)

Clinical examinationLow NIHSS (i.e. < 8—10) 15 48.4Previous autonomy loss

(mRS > 2)15 48.4

High NIHSS (i.e. > 25) 9 29.0Age > 80 years 8 25.8

ImagingHemorragic transformation 27 87.1ASPECTS on DWI < 5 21 67.7Midline displacement 20 64.5Flair positivity 13 41.9No DWI-PWI mismatch 12 38.7ASPECTS on CT < 7 10 32.2Severe leukoaraiosis 3 9.7Microbleeds 2 6.4Tandem occlusion 2 6.4Carotid-T occlusion 0 0Other 2 6.4

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4 S. Soize et al.

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9.7%) that started the treatment before 6 hours from thenset of symptoms, 8/31 (25.8%) before 8 hours, 10.5/31enters (33.9%) before 12 hours and 9.5/31 centers (30.6%)p to 24 hours.

nesthetic considerations (survey questions 14 and5)

ain part of the respondents (27/31, 87.1%) benefited from dedicated anesthesia team available anytime. Withoutonsidering anesthesia availability, the greater part preferseneral anesthesia to perform the EVT (15/31, 48.4%),ollowed by those who decide the appropriate anestheticodality based on the clinical status (13/31, 41.9%). Two of

he 4 centers with no dedicated anesthesia team performedhe thrombectomy always under conscious sedation and onender local anesthesia. Answers to the general informationubpart are summarized in the Fig. 4.

ndovacular treatment/procedure (surveyuestions 16 to 31)

eurointerventionalists were asked to precise the placeiven to mechanical thrombectomy in the treatment ofcute ischemic stroke (Fig. 5). Main indications were whenV fibrinolysis was contraindicated (28/31, 90.3%) or failed20/31, 64.5%). Immediate combination of IV thrombolysisnd mechanical thrombectomy was performed routinely in1/31 centers (35.5%). When the patient received intra-enous fibrinolysis, he was transferred immediately to the

Please cite this article in press as: Soize S, et al. Endovascular tsurvey. J Neuroradiol (2014), http://dx.doi.org/10.1016/j.neu

ngio suite in 12.5/31 centers (40.3%), after 30 minutes for3/31 centers (41.9%) and at the end of intravenous fibri-olysis (approximately one hour) for 5.5 centers (17.8%). Inase of IV fibrinolysis prior to EVT, 22/31 (70.9%) respondents

igure 4 Answers to the ‘‘anesthetic modality’’ subpart.

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ave full dose of IV tPA while 6/31 (19.4%) gave a reducedose (one provided 1/3 dose, one gave 1/2 dose, 3 gave 2/3ose and one provided less than 20 mg). This informationas not available for 3 centers (9.7%).

Concerning the devices, all surveyed centers used sten-rievers in their standard practice, especially the first oneo be marketed, the Solitaire FRTM device (ev3/Covidien,lymouth, MN, USA). First generation devices such as theerci retriever were no more used. The detailed list ofevices used with their respective percentage is available inhe Table 2. When thrombectomy with a first device failed,5/31 (48.4%) of the respondents tried a second device.

For technical considerations, 17.5/31 surveyed centers56.5%) used a balloon-catheter (Fig. 6) and 100% providedn aspiration during the clot retrieval: 28/31 (90.3%) with ayringe, 2.5/31 (8.1%) with the penumbra aspiration devicend 0.5/31 (1.6%) with the injector in aspiration. The num-er of maximum deployment of the device to restore theow varied from 3 (11/31, 35.5%), 4 (7/31, 22.6%), 5 (9/31,9.0%), up to more than 5 deployments (4/31, 12.9%). Athe beginning of the endovascular procedure 20/3 (64.5%)eurointerventionists catheterized solely the occluded ves-el whereas 11/31 (35.5%) evaluated the whole intracranialirculation to assess the collateral flow. In case of ICA/MCAandem occlusion, 21/31 (67.7%) attempted to recanalizehe distal occlusion first, 6/31 (19.4%) treat the proximalne at first, for 3/31 (9.7%) it depends on the technicalonditions and 1/31 (3.2%) treat the distal lesion and thenometimes the proximal one.

During the EVT, 16.5/31 (53.2%) did not use heparin dur-ng the endovascular procedure, 12.5/31 (40.3%) use a singleolus and 2/31 (6.5%) a bolus with a maintained dose. Then,fter mechanical thrombectomy, 16/31 (51.6%) neurointer-entionist sometimes used intra-arterial tPA (Fig. 7). Theirndications were to treat distal embolization (13/31, 41.9%)r in case of thrombectomy failure (11/31, 35.5%).

fter the procedure (survey questions 32 and 33)

eurointerventionists were queried about anti-thromboticanticoagulation and platelet antiaggregation) drugs admin-

reatment of acute ischemic stroke in France: A nationwiderad.2013.12.002

stered after the procedure. Two centers did not providenswers. Concerning the 24 hours following the thrombec-omy, 14/29 (48.3%) did not start these drugs, whereas2/29 (41.4%) started antiplatelet therapy, 4/29 (13.8%)

Figure 6 Frequency of balloon-catheter use.

ARTICLE IN PRESS+ModelNEURAD-450; No. of Pages 9

Endovascular treatment of acute ischemic stroke in France: a nationwide survey 5

Table 2 Devices currently used for endovascular treatment of acute ischemic stroke.

Devices Number Percentage of center (%)

Solitaire FRTM (ev3/Covidien) 30 96.8ReviveTM (Codman/Johnson & Johnson) 9 29.0TrevoTM (Concentric europe/Stryker) 5 16.1Penumbra TM (Penumbra europe GmbH) 4 12.9Capture LPTM (Mindframe/Covidien) 4 12.9MinicatchTM(Balt extrusion) 1 3.2Microsnare 1 3.2MerciTM retrieval system (Concentric europe/Stryker)

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Figure 7 Frequency and reasons for intra-arterial tPA injec-tion.

started anticoagulation (heparin/LWMH) and 2/29 (6.9%)started both therapies. After 24 hours, responses were morehomogenous, with a large majority of practitioners prescrib-ing platelet antiaggregation (22/30, 73.3%), 3/30 (10.0%)anticoagulation and 5/30 (16.7%) both.

Concerning imaging modalities for early follow-up,results were more balanced than for the diagnosis, with12/31 (38.7%) centers using MRI or CT, 11/31 (35.5%)using CT and 8/31 (25.8%) using MRI (Fig. 8). The earliestpost-procedural imaging examination was performed imme-diately after the procedure for 8/31 (25.8%), after 24—48 hfor 22/31 (71.0%) and at 3 months for 1/31 (3.2%). Moregenerally, 27/31 (87.1%) centers performed imaging follow-up at 24—48 hours, before the end of hospitalization in 6/31(19.4%) institutions and at 3 months in 8/31 (25.8%) centers.

Discussion

Please cite this article in press as: Soize S, et al. Endovascular tsurvey. J Neuroradiol (2014), http://dx.doi.org/10.1016/j.neu

This survey was designed to evaluate the current situ-ation of the endovascular treatment of AIS in France.Neurointerventionalists were asked about the organizationof stroke treatment at their institution, about the place

Figure 8 Imaging modalities for the early follow-up afterendovascular treatment for AIS.

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f endovascular therapy and their detailed practices fromre-treatment imaging to the follow-up.

Generally speaking, stroke concern around 150,000 newatients in France each year, in which 80% are ischemicnd about 3 to 5% of them are treated with IV fibrinolysis,eading to an estimated number of IV thrombolysis com-rised between 3000 and 5000 per year [1]. Actually, thelace of EVT is defined by local multidisciplinary consensusith vascular neurologists, interventional neuroradiologistsnd sometimes anesthesiologists, reflecting the importancef common decision-making and care for stroke patients.t is also important to underline the role of the neuroin-erventionists in the clinical evaluation of stroke patientsecause the decision to treat involves mainly clinical crite-ia. In this way, it will be necessary for neurointerventionalenters to evolve toward a clinical structuration and organi-ation. According to our evaluation, the estimated numberf endovascular procedures for AIS performed in 2012 wasbout 925 [525—1325]. Furthermore, the survey showed that/31 (19.4%) of the centers treated patients out of clini-al trials or registries. This reflects the numerous exclusionriteria of prospective clinical trials. To better evaluatehe whole population of patients treated by mechanicalhrombectomy, the national register NTF (NeuroThrombec-omie France) has been created and is already includingatients.

When queried about their practice to image AIS, theajority responded that they use MRI (always in 64.5%

nd up to 87.1% taking into account those who use some-imes CT). The use of advanced imaging is also underlinedy the rate of 35.5% (11/31) of centers which performR perfusion-weighted imaging in routine (whether 11/26

42.3%) of MRI users) to depict the penumbra from the coref the infarct. On the contrary, many countries mainly useT scans prior to endovascular treatment of AIS. For exam-le, in the IMS III Trial investigational sites, mainly locatedn United States, Canada and Australia, only non-contrast CTas required at baseline, though CTA and CT perfusion werellowed [15,19]. In the German and Austrian Endostroke reg-stry, 83% of the included patients were initially imaged withT and 78% with CTA [20]. Furthermore, in some studies,

maging was performed but not used for selection, such asn Synthesis expansion [16]. Thus, the results of this sur-ey showed the efforts made by the French neuroradiologyommunity to provide high performance imaging to patientsuspected of stroke, with an increasing number of centerssing multimodal MRI-based brain imaging. MRI including

DWI sequence is the only modality giving a very early

reatment of acute ischemic stroke in France: A nationwiderad.2013.12.002

isualization of the ischemic lesion and has a substantiallyetter sensitivity and accuracy than CT [21,22]. MRI is alsouch more appropriate to depict multiple or small sized

nfarcts, to evaluate precisely the infarct volume, to exclude

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troke mimics and to improve the selection of patients whoill have a potential benefit of a treatment (IV fibrinolysisnd/or EVT) [23—25]. However, there are twice fewer MRIn France than the european average. Insufficient and over-oaded MRI leads sometimes to use CT to evaluate AIS whileRI is not available (11/31, 35.5%).

Another very important issue is that there is still fewenters (4/31, 12.9%) that does not have a dedicated anes-hesia team for the endovascular treatment of AIS. Even ift has been shown that treatment under conscious sedationan influence positively the outcome compared to generalnesthesia, in cases of serious agitation, respiratory failure,onsciousness trouble, coma and comprehension difficulties,he resort to anesthetic care is mandatory [26,27]. If thenesthetic support is not available, it can deprive theseatients from the endovascular treatment. Moreover, therocedure will be performed in better conditions of safetyith conscious sedation provided and watched over by annesthesiologist, who can also take care of hemodynamics,hich is also a key to prevent from early intracranial hem-rrhage [28]. Thus, there is a strong necessity for anestheticupport for these procedures, whatever it is conductednder conscious sedation or general anesthesia. For morenformation on the anesthetic management of patients withIS treated in French interventional neuroradiology centers,etails are available in a recent published survey [29].

Important technical points are the different modalities ofspiration and the use of a balloon-tipped guide catheter.alloon guide catheter has been used as a cerebral pro-ection device during carotid angioplasty and stenting torevent debris releasing in the intracranial circulation. Onhe same basis, it is supposed to make cerebral protectionuring the thrombectomy. If some studies have providedvidence that the use of an embolic protection deviceecreases the incidence of cerebral embolic events dur-ng carotid stenting in both symptomatic and asymptomaticatients, there is still a doubt about the usefulness ofhese devices [30—32]. In AIS interventions, a balloon guideatheter is used to apply negative suction and reverse theow within the cervical arteries, thus minimizing the chancef antegrade blood flow dislodging the thrombus from thetent. But the clot retrieval can also be done while applyinguction with a large syringe, without proximal flow arresti.e. without balloon guide catheter). Actually, there is norial that have studied balloon-catheter usefulness in suchnterventions. In this survey, 17.5/31 center (56.5%) used aalloon-catheter and 100% provided an aspiration during thelot retrieving: 28/31 (90.3%) with a syringe, 2.5/31 (8.1%)ith the penumbra aspiration device and 0.5/31 (1.6%) with

he injector in aspiration.Recently, several publications underlined that the tech-

ique with which stentrievers are used may be as crucial ashe device itself. Different new techniques trying to reducelot burden using aspiration prior to stentriever deploy-ent were described with promising results. Turk et al.

howed that a direct aspiration first pass with a large borespiration catheter prior to stentriever use reached 75% ofecanalization [33]. Eesa et al. performed a manual suc-ion using a 60 ml-syringe applied through an 8-F balloonuide catheter positioned in the cervical carotid with prox-mal flow arrest to treat carotid-T or L occlusion, resultingn a significant reduction of the clot burden and facilitat-ng further interventions leading to full recanalization [34].eshaies et al. developed a 6-French co-axial system to per-

Please cite this article in press as: Soize S, et al. Endovascular tsurvey. J Neuroradiol (2014), http://dx.doi.org/10.1016/j.neu

it intracranial aspiration in close proximity to the stent.hey used a Penumbra Aspiration Microcatheter (Penumbra,

nc., Alameda, CA, USA) in which the stentriever could beassed through [35].

Dwls

PRESSS. Soize et al.

Another important issue concerns the selection of theatients who are most likely to benefit from the endovascu-ar treatment. When asked to define their contraindicationo mechanical thrombectomy, most cited responses were:emorrhagic transformation (27/31, 87.1%), ASPECTS onWI < 5 (21/31, 67.7%), midline displacement (20/31,4.5%), a low NIHSS (i.e. < 8—10) on admission (15/31,8.4%) and previous autonomy loss (mRS > 2 on admission)15/31, 48.4%). There is evidence that hemorrhagic trans-ormation and midline displacement (as the result of aarge ischemic infarct) are attenuators of outcome. Largernfarcts (ASPECT < 7 on CT or < 5 on DWI) are associatedith an increased risk of thrombolysis-related hemor-

hage and worse clinical outcomes, as well as higher sICHates and poorer outcomes after mechanical thrombectomy28,36,37]. Moreover, Yoo et al. showed that patients with ancute DWI lesion volume < 70 cm3 recanalized early and hadhe best clinical outcomes after intra-arterial therapy [38].n the other hand, non-consensual responses were: Flair-eighted images positivity (13/31, 41.9%), high NIHSS ondmission (9/31, 29.0%) and age > 80 years old (8/31, 25.8%).hese responses are related to different prognostic factorshat emerged from EVT case series. Indeed, elderly patients> 80 years old) seem to have worse clinical outcomes andortality rates following multimodal intra-arterial therapy

nd mechanical thrombectomy [36,37,39]. This may be dueo many factors such as greater medical comorbidities,orse baseline independence, decreased cerebral reservend more difficult catheterization. Consequently, patientslder than 80 years of age are often excluded from random-zed trials [15,16,40]. The presence of a DWI-Flair mismatchs able to identify stroke onset of < 4.5 hours and Flair posi-ivity is a prognostic factor of bad functional outcome in aase series of patients treated with mechanical thrombec-omy [37,40,41]. Patients with an NIHSS greater than 25ave traditionally been excluded from IV tPA trials [2,42].vidence from case series shows that they can be treatedffectively by endovascular methods; nevertheless, patientsith NIHSS > 25 and/or < 10 are sometimes excluded from

andomized trials [15,43]. In several case series baseline,IHSS was proportionally correlated with the 3 months out-ome [36,44,45]. Half of the surveyed don’t treat patientsith low NIHSS (< 8—10) and on the contrary 23% treat ancclusion of M1 when the NIHSS is lesser than 4. Several stud-es have reported that approximately one third of patientsho are not treated with intravenous tPA because of mild or

apidly improving stroke symptoms on hospital arrival have poor final stroke outcome [46,47]. This is supported byhe hypothesis that a persistent large-artery occlusion onmaging, despite minor symptoms or clinical improvement,ay identify patients at increased risk of subsequent dete-

ioration. There is actually no evidence that EVT is lessseful in case of low NIHSS and lower scores were moreikely to have good outcomes [36,44,45]. On the other hand,eukoaraiosis is not considered as limiting factor, even if

study showed that it predicted parenchymal hematomamergence after mechanical thrombectomy [48]. Carotid-

and tandem occlusions, even if known to have poorerutcomes are treated by almost every respondent and EVThowed to improve their outcomes with careful and techni-ally appropriate treatment [49—52].

The limit to start the EVT in anterior circulation strokess unanimously defined as less than 6 hours after the onset ofymptoms, while it can go up to 8 hours in the USA [53,54].

reatment of acute ischemic stroke in France: A nationwiderad.2013.12.002

ata from IMS I and II trials, in which patients were treatedith IV fibrinolysis within 3 hours from stroke onset and fol-

owed by IA rt-PA up to 7 hours after onset of symptoms,howed that the odds of achieving a good clinical outcome

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Endovascular treatment of acute ischemic stroke in France:

progressively decreased with time elapsed to attain reper-fusion. After 6 hours, the probability of good outcome wasthe same as if there was no reperfusion [55]. There is lessdata in the literature about posterior circulation strokes.The responses varied from 8 to 24 hour after stroke onsetto begin EVT, as it can be seen in the literature [56—58].Eckert et al. showed that early treatment onset (≤ 6 h) ledto a significantly better neurologic outcome than delayedtreatment onset (> 6 h). More recent case series usingstentrievers showed improvement of clinical outcome inposterior strokes treated up to 24 hours, with a median timeto recanalization of 7h41 and 9h22 respectively [56—58].

Another topic is the optimal dose of IV fibrinolysis deliv-ered before potential EVT. Majority (22/31, 70.9%) of NIsprovide EVT after full dose of IV fibrinolysis. This accord withNogueira et al. study which showed that combined treat-ment with full dose intravenous rt-PA (0.9 mg/kg) followedby multimodal endovascular therapy seems to be associatedwith similar rates of sICH to that of bridging therapy withreduced rt-PA dosage (0.6 mg/kg) [59].

This survey has some limits. The first one is linked to theintrinsic nature of the questionnaire because declarationsof the respondents cannot be controlled. Secondly, only oneneurointerventionist per center was allowed to respond andhad to summarize the practices of his center while therecould have been other point of view in the same center.Several responses per center were accepted with division ofthe attributed point, to try to take into account this het-erogeneity. Moreover, this potential bias is limited by theuse of protocols in most of the departments. Then, on-callmodalities (safety, operational or on-site daycare) were notspecified on this survey.

Conclusions

This survey, with the participation of 31/33 (93.9%) cen-ters intended to clarify the actual place of the endovasculartreatment of stroke in France, because this procedure hasan impact in the general policy of health. First, it underlinesthat interventional neuroradiology centers got organized tomake available the mechanical thrombectomy everywhere.Moreover, they are highly involved in clinical research. Ifthis technology tended to develop, it will be probably nec-essary to resize the centers — actually composed by a meanof 3 neurointerventionists — to ensure it continued availabil-ity and to evolve toward a clinical structuration. Secondly,the complex medical care of these patients requires theclose collaboration of neurologists, anesthesiologists andinterventional neuroradiologists before and during the pro-cedure for an optimal care. Then, this is also important toplace emphasis on the fundamental role of MRI and advancedimaging modalities in AIS evaluation and in the selection ofpatients who will benefit from endovascular treatment.

Disclosure of interest

The authors declare that they have no conflicts of interestconcerning this article.

Acknowledgments

Please cite this article in press as: Soize S, et al. Endovascular tsurvey. J Neuroradiol (2014), http://dx.doi.org/10.1016/j.neu

The authors thank all their colleagues who agreed to partic-ipate to this survey. The whole list of participating centersis available in the Appendix A.

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ppendix A. Supplementary data

upplementary data associated with this article can beound, in the online version, at http://dx.doi.org/10.016/j.neurad.2013.12.002.

eferences

[1] La prévention et la prise en charge des accidents vasculairescérébraux en France: rapport à Madame la ministre de lasanté et des sports. Présenté par la docteure Élisabeth Fery-Lemonnier, conseillère générale des établissements de santéjuin 2009 ISRN SAN-DHOS/RE-09-2-FR.

[2] Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase3 to 4.5 hours after acute ischemic stroke. N Engl J Med2008;389:1317—20.

[3] Bluhmki E, Chamorro A, Dávalos A, et al. Stroke treatmentwith alteplase given 3.0—4.5 h after onset of acute ischaemicstroke (ECASS III): additional outcomes and subgroup analysis ofa randomised controlled trial. Lancet Neurol 2009;8:1092—102.

[4] Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prouroki-nase for acute ischemic stroke: the PROACT II study: arandomized controlled trial. JAMA 1999;282:2003—11.

[5] Alexandrov AV, Molina CA, Grotta JC, et al. Ultrasound-enhanced systemic thrombolysis for acute ischemic stroke. NEngl J Med 2004;351:2170—8.

[6] Smith WD, Sung G, Saver J, et al. Mechanical thrombectomyfor acute ischemic stroke: final results of the Multi MERCI trial.Stroke 2008;39:1205—12.

[7] The Penumbra Pivotal Stroke Trial Investigator. The penumbrapivotal stroke trial: safety and effectiveness of a new genera-tion of mechanical devices for clot removal in intracranial largevessel occlusive disease. Stroke 2009;40:2761—8.

[8] Castano C, Dorado L, Guerrero C, et al. Mechanicalthrombectomy with the solitaire AB device in large arteryocclusions of the anterior circulation. A pilot study. Stroke2010;41:1836—40.

[9] Rouchaud A, Mazighi M, Labreuche J, et al. Outcomes ofmechanical endovascular therapy for acute ischemic stroke:a clinical registry study and systematic review. Stroke2011;42:1289—94.

10] Machi P, Costalat V, Lobotesis K, et al. Solitaire FR thrombec-tomy system: immediate results in 56 consecutive acuteischemic stroke patients. J Neurointerv Surg 2012;4:62—6.

11] Galimanis A, Jung S, Mono ML, et al. Endovascular ther-apy of 623 patients with anterior circulation stroke. Stroke2012;43:1052—7.

12] Soize S, Kadziolka K, Estrade L, et al. Mechanical thrombec-tomy in acute stroke: prospective pilot trial of the SolitaireFRTM device while under conscious sedation. AJNR Am J Neu-roradiol 2013;34:360—5.

13] Saver JL, Jahan R, Levy EI, et al. Solitaire flow restora-tion device versus the Merci Retriever in patients with acuteischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet 2012;380:1241—9.

14] Mokin M, Dumont TM, Veznedaroglu E, et al. Solitaire flowrestoration thrombectomy for acute ischemic stroke: retro-spective multicenter analysis of early postmarket experienceafter FDA approval. Neurosurgery 2013;73:19—26.

15] Broderick JP, Palesch YY, Demchuk AM, For the InterventionalManagement of Stroke (IMS) III Investigators. Endovasculartherapy after intravenous t-PA versus t-PA alone for stroke. N

reatment of acute ischemic stroke in France: A nationwiderad.2013.12.002

Engl J Med 2013;368:893—903.16] Ciccone A, Valvassori L, Nichelatti M, For the SYNTHESIS expan-

sion investigators. Endovascular treatment for acute ischemicstroke. N Engl J Med 2013;368:904—13.

IN+ModelN

8

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

[

Radiol 2012;81:3479—84.

ARTICLEEURAD-450; No. of Pages 9

17] Pierot L, Gralla J, Cognard C, White P. Mechanical thrombec-tomy after IMS III, synthesis, and MR-RESCUE. AJNR Am JNeuroradiol 2013;34:1671—3.

18] Pierot L, Söderman M, Bendszus M, et al. Statement of ESMINTand ESNR regarding recent trials evaluating the endovasculartreatment at the acute stage of ischemic stroke. Neuroradiol-ogy 2013;55:1313—8.

19] Mackey J, Khatri P, Broderick JP, Investigators III IMS. Increasinguse of CT angiography in interventional study sites: the IMS IIIexperience. AJNR Am J Neuroradiol 2010;31:E34.

20] Singer OC, Haring HP, Trenkler J, et al. Periprocedural aspectsin mechanical recanalization for acute stroke: data from theENDOSTROKE registry. Neuroradiology 2013;55:1143—51.

21] Lövblad KO, Altrichter S, Viallon M, et al. Neuro-imaging ofcerebral ischemic stroke. J Neuroradiol 2008;35:197—209.

22] Fiebach JB, Schellinger PD, Jansen O, et al. CT and diffusion-weighted MR imaging in randomized order: diffusion-weightedimaging results in higher accuracy and lower interrater vari-ability in the diagnosis of hyperacute ischemic stroke. Stroke2002;33:2206—10.

23] Chalela JA, Kidwell CS, Nentwich LM, et al. Magnetic resonanceimaging and computed tomography in emergency assessmentof patients with suspected acute stroke: a prospective com-parison. Lancet 2007;369:293—8.

24] Lansberg MG, Albers GW, Beaulieu C, Marks MP. Comparisonof diffusion-weighted MRI and CT in acute stroke. Neurology2000;54:1557—61.

25] Lansberg MG, Straka M, Kemp S, et al. MRI profile and responseto endovascular reperfusion after stroke (DEFUSE 2): a prospec-tive cohort study. Lancet Neurol 2012;11:860—7.

26] John N, Mitchell P, Dowling R, et al. Is general anaes-thesia preferable to conscious sedation in the treatmentof acute ischaemic stroke with intra-arterial mechanicalthrombectomy? A review of the literature. Neuroradiology2013;55:93—100.

27] Pereira VM, Gralla J, Davalos A, et al. Prospective, multi-center single-arm study of mechanical thrombectomy usingsolitaire flow restoration in acute ischemic stroke. Stroke2013;44:2802—7.

28] Soize S, Barbe C, Kadziolka K, et al. Predictive factors of out-come and hemorrhage after acute ischemic stroke treated bymechanical thrombectomy with a stent-retriever. Neuroradiol-ogy 2013;55:977—87.

29] Gakuba C, Le Mauff de Kergal C, Labeyrie PE, BarbierC, Courthéoux P, Hanouz JL. Prise en charge anesthésiquede l’infarctus cérébral en neuroradiologie interventionnelle :enquête nationale de pratiques. Ann Fr Anesth Reanim2013;32:A233.

30] Kastrup A, Gröschel K, Krapf H, et al. Early outcome of carotidangioplasty and stenting with and without cerebral protec-tion devices: a systematic review of the literature. Stroke2003;34:813—9.

31] Tallarita T, Rabinstein AA, Cloft H, et al. Are distal protectiondevices ‘‘protective’’ during carotid angioplasty and stenting?Stroke 2011;42:1962—6.

32] Cloft HJ. Distal protection: maybe less than you think. AJNRAm J Neuroradiol 2008;29:407—8.

33] Turk AS, Spiotta A, Frei D, et al. Initial clinical experiencewith the ADAPT technique: a direct aspiration first pass tech-nique for stroke thrombectomy. J Neurointerv Surg 2013,http://dx.doi.org/10.1136/neurintsurg-2013-010713.

34] Eesa M, Almekhlafi MA, Mitha AP, et al. Manual aspirationthrombectomy through balloon-tipped guide catheter for rapidclot burden reduction in endovascular therapy for ICA L/T

Please cite this article in press as: Soize S, et al. Endovascular tsurvey. J Neuroradiol (2014), http://dx.doi.org/10.1016/j.neu

occlusion. Neuroradiology 2012;54:1261—5.35] Deshaies EM. Tri-axial system using the Solitaire-FR and

penumbra aspiration microcatheter for acute mechanicalthrombectomy. J Clin Neurosci 2013;20:1303—5.

[

PRESSS. Soize et al.

36] Rai AT, Jhadhav Y, Domico J, et al. Procedural predictors ofoutcome in patients undergoing endovascular therapy for acuteischemic stroke. Cardiovasc Intervent Radiol 2012;35:1332—9.

37] Raoult H, Eugène F, Ferré JC, et al. Prognosticfactors for outcomes after mechanical thrombec-tomy with solitaire stent. J Neuroradiol 2013,http://dx.doi.org/10.1016/j.neurad.04.2013001.

38] Yoo AJ, Verduzco LA, Schaefer PW, Hirsch JA, Rabinov JD,González RG. MRI-based selection for intra-arterial stroketherapy: value of pre-treatment diffusion-weighted imag-ing lesion volume in selecting patients with acute strokewho will benefit from early recanalization. Stroke 2009;40:2046—54.

39] Loh Y, Kim D, Shi ZS, et al. Higher rates of mortality but notmorbidity follow intracranial mechanical thrombectomy in theelderly. AJNR Am J Neuroradiol 2010;31:1181—5.

40] Thomalla G, Cheng B, Ebinger M, et al. DWI-FLAIR mismatchfor the identification of patients with acute ischaemic strokewithin 4·5 h of symptom onset (PRE-FLAIR): a multicentreobservational study. Lancet Neurol 2011;10:978—86.

41] Emeriau S, Serre I, Toubas O, Pombourcq F, OppenheimC, Pierot L. Can diffusion-weighted imaging-fluid-attenuatedinversion recovery mismatch (positive diffusion-weightedimaging/negative fluid-attenuated inversion recovery) at 3Tesla identify patients with stroke at < 4.5 hours? Stroke2013;44:1647—51.

42] Wahlgren N, Ahmed N, Dávalos A, et al. Thrombolysis withalteplase for acute ischaemic stroke in the safe implementa-tion of thrombolysis in stroke-monitoring study (SITS-MOST):an observational study. Lancet 2007;369:275—82.

43] THRACE: Trial and cost effectiveness evaluation ofintra-arterial thrombectomy in acute ischemic stroke.http://clinicaltrials.gov/ct2/show/NCT01062698. AvailableFebruary 3, 2010.

44] Costalat V, Lobotesis K, Machi P, et al. Prognostic fac-tors related to clinical outcome following thrombectomy inischemic stroke (RECOST study). Fifty patients prospectivestudy. Eur J Radiol 2012;81:4075—82.

45] Tuilier T, Gallas S, Hosseini H, et al. Mechanical thrombectomyin acute embolic stroke: results of a single centre retrospectiveanalysis of 36 patients treated with the SolitaireTM FR device.EJMINT 2013 [Original Article 1305000102 (28th January 2013)].

46] Smith EE, Fonarow GC, Reeves MJ, et al. Outcomes in mild orrapidly improving stroke not treated with intravenous recombi-nant tissue-type plasminogen activator: findings from get withthe guidelines-stroke. Stroke 2011;42:3110—5.

47] Urra X, Arino H, Llull L, et al. The outcome of patients with mildstroke improves after treatment with systemic thrombolysis.PLoS One 2013;8:e59420.

48] Shi ZS, Loh Y, Liebeskind DS, et al. Leukoaraiosis predictsparenchymal hematoma after mechanical thrombectomy inacute ischemic stroke. Stroke 2012;43:1806—11.

49] Mpotsaris A, Bussmeyer M, Buchner H, et al. Clinicaloutcome of neurointerventional emergency treat-ment of extra- or intracranial tandem occlusions inacute major stroke: antegrade approach with wallstentand solitaire stent retriever. Clin Neuroradiol 2013,http://dx.doi.org/10.1007/s00062-013-0197-y.

50] Fischer U, Mono ML, Schroth G, et al. Endovascular therapy in201 patients with acute symptomatic occlusion of the internalcarotid artery. Eur J Neurol 2013;20:1017—24 [e87].

51] Machi P, Lobotesis K, Maldonado IL, et al. Endovascular treat-ment of tandem occlusions of the anterior circulation withsolitaire FR thrombectomy system. Initial experience. Eur J

reatment of acute ischemic stroke in France: A nationwiderad.2013.12.002

52] Soize S, Kadziolka K, Estrade L, et al. Outcome aftermechanical thrombectomy using a stent retriever under con-scious sedation: Comparison between tandem and single

IN+Model

a na

[

[

[

ARTICLENEURAD-450; No. of Pages 9

Endovascular treatment of acute ischemic stroke in France:

occlusion of the anterior circulation. J Neuroradiol 2013,http://dx.doi.org/10.1016/j.neurad.2013.07.001.

[53] Jovin TG, Liebeskind DS, Gupta R, et al. Imaging-basedendovascular therapy for acute ischemic stroke due to prox-imal intracranial anterior circulation occlusion treated beyond8 hours from time last seen well: retrospective multicenteranalysis of 237 consecutive patients. Stroke 2011;42:2206—11.

[54] Natarajan SK, Snyder KV, Siddiqui AH, et al. Safety andeffectiveness of endovascular therapy after 8 hours ofacute ischemic stroke onset and wake-up strokes. Stroke

Please cite this article in press as: Soize S, et al. Endovascular tsurvey. J Neuroradiol (2014), http://dx.doi.org/10.1016/j.neu

2009;40:3269—74.[55] Khatri P, Abruzzo T, Yeatts SD, et al. Good clinical

outcome after ischemic stroke with revascularization is time-dependent. Neurology 2009;73:1066—72.

[

PRESStionwide survey 9

56] Bergui M, Stura G, Daniele D, et al. Mechanical thrombolysisin ischemic stroke attributable to basilar artery occlusion asfirst-line treatment. Stroke 2006;37:145—50.

57] Mordasini P, Brekenfeld C, Byrne JV, et al. Technical feasibilityand application of mechanical thrombectomy with the SolitaireFR revascularization device in acute basilar artery occlusion.AJNR Am J Neuroradiol 2013;34:159—63.

58] Eckert B, Kucinski T, Pfeiffer G, et al. Endovascular therapy ofacute vertebrobasilar occlusion: early treatment onset as themost important factor. Cerebrovasc Dis 2002;14:42—50.

reatment of acute ischemic stroke in France: A nationwiderad.2013.12.002

59] Nogueira RG, Yoo AJ, Masrur S, et al. Safety of full-dose intra-venous recombinant tissue plasminogen activator followed bymultimodal endovascular therapy for acute ischemic stroke. JNeurointerv Surg 2013;5:298—301.