BACKGROUND AND PURPOSE: Spinal cord (SC) lesions are critical in MS diagnosis and progression, yet their detection remains challenging. Conventional sequences such as 2D T2-weighted FSE and STIR have suboptimal sensitivity, both in the cervical and thoracic spine. This study evaluated the diagnostic performance of a new imaging technique for SC lesion detection, the 3D white-matter-nulled (WMn) MPRAGE sequence, compared with conventional MRI sequences. MATERIALS AND METHODS: Thirty-eight patients with MS or clinically isolated syndrome were prospectively evaluated with 3T SC MRI, acquiring 2D T2-weighted FSE, 2D STIR, 3D MPRAGE, and 3D WMn. A deep learning denoising method was applied to 3D WMn to compensate the inherent low signal. Four blinded neuroradiologists independently assessed lesion count, confidence in lesion detection, and image quality (eg, artifacts). Contrast-to-noise ratio (CNR) was also computed for all lesions detected on all sequences. Statistical comparisons were performed across sequences. RESULTS: In the cervicothoracic spine, the 3D WMn sequence detected significantly more lesions than 2D T2-weighted FSE (+62%; P < .001), STIR (+47%; P < .05), and 3D MPRAGE (+50%; P < .01). In the thoracolumbar spine, the 3D WMn sequence detected significantly more lesions than 2D T2-weighted FSE (+53%, P < .05). The 3D WMn sequence demonstrated a higher CNR and improved lesion conspicuity while exhibiting fewer artifacts than STIR. These advantages contributed to greater rater confidence in lesion detection by using the 3D WMn sequence, with over 75% of strong confidence reported by the 2 most experienced raters, along with the highest interreader agreement. CONCLUSIONS: The 3D WMn sequence associated with deep learning-based denoising significantly improves SC lesion detection, outperforming all conventional sequences. Three-dimensional WMn represents, then, a promising alternative for SC imaging in MS.

Radiologists are witnessing astonishing innovation and advancement of CT technologies and their clinical applications. This review highlights how photon-counting CT (PCCT), upright CT, and artificial intelligence (AI) may impact cardiothoracic CT applications for imaging and diagnosis. PCCT relies on new detectors that can bin the separate photon energies and allow for lower radiation dose and better spatial resolution. The clinical applications of PCCT in the coronary arteries are becoming the new standard for cardiac CT imaging. New upright CT has shown the benefits of imaging in the upright position and offers new insight into how the upright position affects biomechanics and physiology. Four-dimensional CT, which can be used to directly image perfusion, is challenging MRI and MR angiography for primacy in this area. The burgeoning role of AI and informatics is changing the way radiologists interpret and report many imaging examinations. The future is bright and promises lower radiation and intravenous contrast agent doses and higher spatial resolution, and will further incorporate deep learning to improve the effectiveness of CT.

Ischaemic strokes disrupt brain networks, leading to remote effects in key regions like the thalamus, a critical hub for brain functions. However, non-invasive methods to quantify these remote consequences still need to be explored. This study aimed to demonstrate that MRI-derived R2* changes can capture iron accumulation linked with inflammation secondary to stroke-induced disconnection. To link remote R2* changes to stroke-induced disconnection, we first conducted a secondary analysis of 156 prospectively included stroke patients who underwent MRI at baseline and 1-year follow-up. We mapped fibres disconnected by baseline infarcts to compare the R2* changes over 1 year according to the disconnectivity status in specific thalamic nuclei groups. We also identified the variables associated with elevated R2* at 1 year in a multivariate context through linear regressions. In parallel, to understand the biological underpinning of the remote R2* changes, we set up a translational mouse model through photothrombotic induction of focal cortical infarcts or sham procedures in 110 C57BL/6J mice. We explored the mice through combinations of in vivo MRI at 72 h, 2-, 4- and 8-weeks, histology, qPCR for gene expression, mass spectrometry for iron concentration quantification and additional ex vivo high-resolution diffusion tensor imaging. In stroke patients, we found a significant increase of R2* within severely disconnected medial and lateral thalamic nuclei groups from baseline to 1 year. At the same time, no change occurred if these structures were not disconnected. We also showed that the disconnectivity status at baseline was significantly associated with R2* at follow-up, independently from confounders, establishing a direct and independent relationship between baseline disconnection and the subsequent R2* increase within the associated locations. In mice, we recapitulated the patients' conditions by observing increased R2* in the stroke groups, specifically within the disconnected thalamic nuclei. Such remote and focal R2* changes peaked at 2 weeks, preceding and correlating with longer-term atrophy at 8 weeks. We established that the remote R2* increase was spatially and temporally correlated with a significant increase of chemically determined iron load bound to ferritin within activated microglial cells. This study provides critical evidence that R2* is a sensitive marker of inflammation secondary to network disconnection, potentially informing future neuroprotective strategies targeting remote brain regions after stroke.

Background A target mismatch profile can identify good clinical response to recanalization after acute ischemic stroke, but does not consider region specificities. Purpose To test whether location-weighted infarction core and mismatch, determined from diffusion and perfusion MRI performed in patients with acute stroke, could improve prediction of good clinical response to mechanical thrombectomy compared with a target mismatch profile. Materials and Methods In this secondary analysis, two prospectively collected independent stroke data sets (2012-2015 and 2017-2019) were analyzed. From the brain before stroke (BBS) study data (data set 1), an eloquent map was computed through voxel-wise associations between the infarction core (based on diffusion MRI on days 1-3 following stroke) and National Institutes of Health Stroke Scale (NIHSS) score. The French acute multimodal imaging to select patients for mechanical thrombectomy (FRAME) data (data set 2) consisted of large vessel occlusion-related acute ischemic stroke successfully recanalized. From acute MRI studies (performed on arrival, prior to thrombectomy) in data set 2, target mismatch and eloquent (vs noneloquent) infarction core and mismatch were computed from the intersection of diffusion- and perfusion-detected lesions with the coregistered eloquent map. Associations of these imaging metrics with early neurologic improvement were tested in multivariable regression models, and areas under the receiver operating characteristic curve (AUCs) were compared. Results Data sets 1 and 2 included 321 (median age, 69 years [IQR, 58-80 years]; 207 men) and 173 (median age, 74 years [IQR, 65-82 years]; 90 women) patients, respectively. Eloquent mismatch was positively and independently associated with good clinical response (odds ratio [OR], 1.14; 95% CI: 1.02, 1.27; P = .02) and eloquent infarction core was negatively associated with good response (OR, 0.85; 95% CI: 0.77, 0.95; P = .004), while noneloquent mismatch was not associated with good response (OR, 1.03; 95% CI: 0.98, 1.07; P = .20). Moreover, adding eloquent metrics improved the prediction accuracy (AUC, 0.73; 95% CI: 0.65, 0.81) compared with clinical variables alone (AUC, 0.65; 95% CI: 0.56, 0.73; P = .01) or a target mismatch profile (AUC, 0.67; 95% CI: 0.59, 0.76; P = .03). Conclusion Location-weighted infarction core and mismatch on diffusion and perfusion MRI scans improved the identification of patients with acute stroke who would benefit from mechanical thrombectomy compared with the volume-based target mismatch profile. Clinical trial registration no. NCT03045146 © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Nael in this issue.

Normal-appearing white matter (NAWM) is a hub of plasticity, but data relating to its influence on post-ischemic stroke (IS) outcome remain scarce. The aim of this study was to evaluate the relationship between NAWM integrity and cognitive outcome after an IS. A longitudinal study was conducted including supra-tentorial IS patients. A 3-Tesla brain MRI was performed at baseline and 1 year, allowing the analyses of mean fractional anisotropy (FA) and mean diffusivity (MD) in NAWM masks, along with the volume of white matter hyperintensities (WMH) and IS. A Montreal Cognitive Assessment (MoCA), an Isaacs set test, and a Zazzo's cancellation task were performed at baseline, 3 months and 1 year. Mixed models were built, followed by Tract-based Spatial Statistics (TBSS) analyses. Ninety-five patients were included in the analyses (38% women, median age 69 ± 20). FA significantly decreased, and MD significantly increased between baseline and 1 year, while cognitive scores improved. Patients who decreased their NAWM FA more over the year had a slower cognitive improvement on MoCA (β = − 0.11, p = 0.05). The TBSS analyses showed that patients who presented the highest decrease of FA in various tracts of white matter less improved their MoCA performances, regardless of WMH and IS volumes, demographic confounders, and clinical severity. NAWM integrity deteriorates over the year after an IS, and is associated with a cognitive recovery slowdown. The diffusion changes recorded here in patients starting with an early preserved white matter structure could have long term impact on cognition.

Une identification rapide du mécanisme étiologique dans le cadre d'un AVC ischémique pourrait permettre d'améliorer la prise en charge des patients présentant une occlusion proximale traitée par thrombectomie mécanique (TM). (1–4) Nous avons étudié la relation entre la détection d'un thrombus dans le territoire carotidien externe lors de la TM et l’étiologie de l'AVC ainsi que son pronostic clinique. Nous avons examiné de manière rétrospective notre base de données monocentrique incluant tous les patients traités par TM dans le cadre d'un AVC ischémique en rapport avec une occlusion proximale de la circulation antérieure entre janvier 2015 et août 2020. Parmi les 1298 patients inclus, un embole dans l'artère carotide externe (ACE) a été détecté chez 68 d'entre eux (5,2 %). La présence d'un embole dans l'ACE était significativement associée aux occlusions de la terminaison de l'artère carotide interne (p < 0,001), à l’étiologie cardioembolique (p < 0,001) et à un plus faible clot burden score (CBS) (p < 0,001). Le NIHSS (aOR = -2,7; 95 % CI -4,9 à 0,3; p = 0,021) et l'ASPECTS à 24h (aOR = 0,9; 95% CI 0,2 à 1,5; p = 0,004) étaient plus mauvais chez les patients présentant un thrombus de l'ACE. Il n'a pas été mis en évidence de différence significative entre les groupes concernant l’évolution neurologique à 3 mois (aOR = 0,8; 95 % IC, 0,42 à 1,52; p = 0,50). Chez les patients présentant un AVC ischémique dû à une occlusion proximale de la circulation antérieure traitée par TM, la présence d'un thrombus dans l'ACE était significativement associée à l’étiologie cardioembolique et une charge de thrombus élevée. Ce signe angiographique peu rapporté pourrait être un indice étiologique d'importance dans un tel contexte (tableaux 1 – 2)

Microstructural changes after an ischemic stroke (IS) have mainly been described in white matter. Data evaluating microstructural changes in gray matter (GM) remain scarce. The aim of the present study was to evaluate the integrity of GM on longitudinal data using mean diffusivity (MD), and its influence on post-IS cognitive performances. A prospective study was conducted, including supra-tentorial IS patients without pre-stroke disability. A cognitive assessment was performed at baseline and 1 year, including a Montreal Cognitive Assessment, an Isaacs set test, and a Zazzo cancelation task (ZCT): completion time and number of errors. A 3-T brain MRI was performed at the same two time-points, including diffusion tensor imaging for the assessment of GM MD. GM volume was also computed, and changes in GM volume and GM MD were evaluated, followed by the assessment of the relationship between these structural changes and changes in cognitive performances. One hundred and four patients were included (age 68.5 ± 21.5, 38.5% female). While no GM volume loss was observed, GM MD increased between baseline and 1 year. The increase of GM MD in left fronto-temporal regions (dorsolateral prefrontal cortex, superior and medial temporal gyrus, p < 0.05, Threshold-Free Cluster Enhancement, 5000 permutations) was associated with an increase time to complete ZCT, regardless of demographic confounders, IS volume and location, GM, and white matter hyperintensity volume. GM integrity deterioration was thus associated with processing speed slowdown, and appears to be a biomarker of cognitive frailty. This broadens the knowledge of post-IS cognitive impairment mechanisms.

BACKGROUND AND PURPOSE:An early understanding of stroke mechanism may improve treatment and outcome in patients presenting with large vessel occlusion stroke (LVOS) treated with mechanical thrombectomy (MT). We aimed to investigate whether spontaneous external carotid artery (ECA) embolism detection during MT is associated with stroke etiology and clinical outcome.METHODS:We retrospectively reviewed our prospectively maintained institutional database including consecutive patients with anterior circulation LVOS treated with MT between January 2015 and August 2020.RESULTS:An ECA embolus was detected in 68 of 1298 patients (5.2%). The kappa coefficient for interobserver agreement was 0.89 (95% confidence interval [CI] 0.82-0.95). ECA embolism was significantly associated with intracranial internal carotid artery (ICA) occlusion (p < 0.001), cardioembolic etiology (p < 0.001) and a lower clot burden score (p < 0.001). Day-1 variation of National Institutes of Health Stroke Scale score (adjusted odds ratio [OR] -2.7, 95% CI -4.9 to 0.3; p = 0.021) and delta Alberta Stroke Program Early Computed Tomography Score (adjusted OR 0.9, 95% CI 0.2 to 1.5; p = 0.004) were worse among patients with ECA emboli. There was no significant difference in 90-day functional outcome between groups (adjusted OR 0.8, 95% CI 0.42 to 1.52; p = 0.50).CONCLUSION:In patients with anterior circulation LVOS treated with MT, ECA embolism was significantly associated with cardioembolic etiology, high thrombus burden and proximal intracranial ICA occlusions. This underexplored angiographic pattern might provide a valuable etiologic clue to the underlying cause of anterior circulation LVOS and may also help determine the appropriate revascularization strategy.

Objective: The objective of this study was to evaluate the impact of radiological biomarkers suggestive of cerebral small vessel disease (SVD) on the evolution of cognitive performances after an ischemic stroke (IS). Methods: We studied patients with a supratentorial IS recruited consecutively to a prospective monocentric longitudinal study. A cognitive assessment was performed at baseline, 3 months, and 1 year and was based on a Montreal Cognitive Assessment, an Isaacs set test of verbal fluency (IST), and a Zazzo’s cancellation task (ZCT) for the evaluation of attentional functions and processing speed. The following cerebral SVD biomarkers were detected on a 3-T brain MRI performed at baseline: white matter hyperintensities (WMHs), deep and lobar microbleeds, enlarged perivascular spaces in basal ganglia and centrum semiovale, previous small deep infarcts, and cortical superficial siderosis (cSS). Generalized linear mixed models were used to evaluate the relationship between these biomarkers and changes in cognitive performances. Results: A total of 199 patients (65 ± 13 years, 68% male) were analyzed. Overall, the cognitive performances improved, more significantly in the first 3 months. Severe WMH was identified in 34% of the patients, and focal cSS in 3.5%. Patients with severe WMH and focal cSS had overall worse cognitive performances. Those with severe WMH had less improvement over time for IST (β = −0.16, p = 0.02) and the number of errors to ZCT (β = 0.19, p = 0.02), while those with focal cSS had less improvement over time for ZCT completion time (β = 0.14, p = 0.01) and number of errors (β = 0.17, p = 0.008), regardless of IS volume and location, gray matter volume, demographic confounders, and clinical and cardiovascular risk factors. Conclusion: The severity of SVD biomarkers, encompassing WMH and cSS, seems to reduce the magnitude of cognitive recovery after an IS. The detection of such SVD biomarkers early after stroke might help to identify patients with a cognitive vulnerability and a higher risk of poststroke cognitive impairment.

Objective To determine whether the total small vessel disease (SVD) score adds information to the prediction of stroke outcome compared to validated predictors, we tested different predictive models of outcome in patients with stroke. Methods White matter hyperintensity, lacunes, perivascular spaces, microbleeds, and atrophy were quantified in 2 prospective datasets of 428 and 197 patients with first-ever stroke, using MRI collected 24 to 72 hours after stroke onset. Functional, cognitive, and psychological status were assessed at the 3- to 6-month follow-up. The predictive accuracy (in terms of calibration and discrimination) of age, baseline NIH Stroke Scale score (NIHSS), and infarct volume was quantified (model 1) on dataset 1, the total SVD score was added (model 2), and the improvement in predictive accuracy was evaluated. These 2 models were also developed in dataset 2 for replication. Finally, in model 3, the MRI features of cerebral SVD were included rather than the total SVD score. Results Model 1 showed excellent performance for discriminating poor vs good functional outcomes (area under the curve [AUC] 0.915), and fair performance for identifying cognitively impaired and depressed patients (AUCs 0.750 and 0.688, respectively). A higher SVD score was associated with a poorer outcome (odds ratio 1.30 [1.07–1.58], p = 0.0090 at best for functional outcome). However, adding the total SVD score (model 2) or individual MRI features (model 3) did not improve the prediction over model 1. Results for dataset 2 were similar. Conclusions Cerebral SVD was independently associated with functional, cognitive, and psychological outcomes, but had no clinically relevant added value to predict the individual outcomes of patients when compared to the usual predictors, such as age and baseline NIHSS.

Background Gadolinium leakage in ocular structures (GLOS) was recently observed in fluid-attenuated inversion recovery (FLAIR) images obtained the day after an initial gadolinium injection in stroke patients. The specificity of GLOS to stroke and its mechanisms remain unclear. Objective We investigated the factors associated with GLOS in a cohort of patients presenting with acute neurological deficits. Materials and Methods This retrospective study included consecutive patients admitted to our stroke unit for acute neurological deficit between July 2017 and August 2018 who underwent baseline brain magnetic resonance imaging with the injection of a macrocyclic gadolinium agent and another scan without injection within 72 hours. The patients were separated into a stroke group and a stroke mimic group based on diffusion-weighted images. Gadolinium leakage in ocular structures was defined as a bright signal in the vitreous in follow-up FLAIR compared with baseline FLAIR (pregadolinium). Clinical data were collected together with imaging features from the baseline scans, including the volume of the infarct and of hypoperfusion if applicable, white matter hyperintensities, the number of lacunes, and the number of microbleeds, which were combined to yield a small vessel disease (SVD) score. We compared the prevalence of GLOS in both groups using the chi(2) test. In the entire cohort, univariate and multivariate regression models were used to test the associations between GLOS and the collected data. Results Among the 467 patients included in the study, GLOS was observed in similar proportions in the stroke group (32.2%, 136/422) and the stroke mimic group (28.9%, 13/45; mean difference, 3.3%; 95% confidence interval, -10.9 to 17.6; P = 0.65). In univariate analysis, GLOS was associated with older age, increased prevalence of vascular risk factors, brain imaging features of SVD (white matter hyperintensities, lacunes, microbleeds), as well as with impairment of renal function and increased dose of gadolinium. No associations were found with factors related to stroke, such as its volume, acute treatment, or rate of recanalization. Multivariate analyses showed that aging (P < 0.001), diabetes (P = 0.010), severe renal failure (P = 0.004), and increased dose of gadolinium (P < 0.001) were independent contributors to GLOS. Conclusions Gadolinium leakage in ocular structures, which occurs more commonly at higher concentrations of gadolinium, is not specific to stroke and may represent increased permeability of the blood-retinal barrier associated with age- and vascular risk factor-related SVD.

En IRM de diffusion, les hautes valeurs de b semblent refléter des variations de cellularité. Cependant l’intérêt d’augmenter jusqu’à de très hautes des valeurs de b reste incertain. Nous avons testé les performances de la diffusivité moyenne (MD) calculée avec des valeurs de b standard (1000s/mm2), haute (3000s/mm2) et très haute pour cartographier la myéloarchitecture corticale. Nous avons d’abord optimisé la résolution spatiale, le nombre de directions et le nombre d’acquisitions minimales pour obtenir une diffusion avec un rapport signal sur bruit suffisant dans le cortex cérébral à b1000, b3000 et b5000 s/mm2. Ensuite, nous avons scanné 9 volontaires sains avec ces diffusion ajoutées à un T1wi et un T2wi. Nous avons comparé les cartes surfaciques corticales de myéline (T1wi/T2wi) aux cartes de MD calculées pour chaque valeur de b (appelées MD1000, MD3000 et MD5000) dans 360 aires corticales avec des corrélations de Spearman et des modèles de régression linéaire multiple. La carte surfacique de MD1000 variait très peu entre les aires corticales alors que les cartes de MD3000 et de MD5000 reflétaient inversement la carte de myéline ; des valeurs plus basses de MD étaient observées dans les régions corticales les plus myélinisées (Figure 1). Quantitativement, les corrélations de Spearman entre la myéline et la MD devenaient de plus en plus négatives en augmentant les valeurs de b. Les modèles de régression linéaire multiple confirmaient une association négative entre MD et myéline et étaient significativement meilleurs de MD1000 à MD3000 et MD5000 (R2 = 0.33, p < 0,001 ; R2 = 0,43, p < 0,001 ; et R2 = 0,50, p < 0,001) (Figure 2). La comparaison des 3 modèles de régression montrait de meilleures performances pour le modèle avec la MD5000. La MD calculée avec de plus hautes valeurs de b est sensible à de subtiles variations cellulaires comme la myéloarchitecture corticale.

Background and Purpose— The aim of the present study was to evaluate the relationship between normal-appearing white matter (NAWM) integrity and postischemic stroke recovery in 4 main domains including cognition, mood, gait, and dependency. Methods— A prospective study was conducted, including patients diagnosed for an ischemic supratentorial stroke on a 3T brain MRI performed 24 to 72 hours after symptom onset. Clinical assessment 1 year after stroke included a Montreal Cognitive Assessment, an Isaacs set test, a Zazzo cancelation task, a Hospital Anxiety and Depression scale, a 10-meter walking test, and a modified Rankin Scale (mRS). Diffusion tensor imaging parameters in the NAWM were computed using FMRIB (Functional Magnetic Resonance Imaging of the Brain) Diffusion Toolbox. The relationships between mean NAWM diffusion tensor imaging parameters and the clinical scores were assessed using linear and ordinal regression analyses, including the volumes of white matter hyperintensities, gray matter, and ischemic stroke as radiological covariates. Results— Two hundred seven subjects were included (66±13 years old; 67% men; median National Institutes of Health Stroke Scale score, 3; interquartile range, 2–6). In the models including only radiological variables, NAWM fractional anisotropy was associated with the mRS and the cognitive scores. After adjusting for demographic confounders, NAWM fractional anisotropy remained a significant predictor of mRS (β=−0.24; P =0.04). Additional path analysis showed that NAWM fractional anisotropy had a direct effect on mRS (β=−0.241; P =0.001) and a less important indirect effect mediating white matter hyperintensity burden. Similar results were found with mean diffusivity, axial diffusivity, and radial diffusivity. In further subgroup analyses, a relationship between NAWM integrity in widespread white matter tracts, mRS, and Isaacs set test was found in right hemispheric strokes. Conclusions— NAWM diffusion tensor imaging parameters measured early after an ischemic stroke are independent predictors of functional outcome and may be additional markers to include in studies evaluating poststroke recovery.

Background The substantia nigra (SN) is suspected to be affected after remote infarction, in view of its large array of connections with the supratentorial brain. Whether secondary involvement of SN worsens overall clinical outcome after a supratentorial stroke has not previously been studied. Purpose To assess longitudinal changes in SN R2* by using MRI in the setting of ipsilesional supratentorial infarct and the relationship of SN signal change to clinical outcome. Materials and Methods Participants prospectively included from 2012 to 2015 were evaluated at 24-72 hours (baseline visit) and at 1 year with MRI to quantify R2*. The SN was segmented bilaterally to calculate an R2* asymmetry index (SN-AI); greater SN-AI indicated greater relative R2* in the ipsilateral compared with contralateral SN. The 95th percentile of R2* (hereafter, SN-AI95) was compared according to infarct location with mixed linear regression models. We also conducted voxel-based comparisons of R2* and identified individual infarcted voxels associated with high SN-AI95 through voxel-based lesion-symptom mapping. Multivariable regression models tested the association between SN-AI95 and clinical scores. Results A total of 181 participants were evaluated (127 men, 54 women; mean age ± standard deviation, 64.2 years ± 13.1; 75 striatum infarcts, 106 other locations). Visual inspection, SN-AI95, and average maps consistently showed higher SN R2* at 1 year if ipsilateral striatum was infarcted than if it was not (SN-AI95, 4.25 vs -0.88; P < .001), but this was not observed at baseline. The striatal location of the infarct was associated with higher SN-AI95 at 1 year independently from infarct volume, SN-AI95 at baseline, microbleeds, age, and sex (β = 4.99; P < .001). Voxel-based lesion-symptom mapping confirmed that striatum but also insula, internal capsule, and external capsule were associated with higher SN-AI95 at 1 year. SN-AI95 was an independent contributor of poor motor outcome (Box and Block Test, β = -.62 points; P = .01). Conclusion In patients with stroke, greater substantia nigra R2*, likely reflective of greater iron content, can be observed at 1 year ipsilateral from remote infarcts of specific location, which is associated with worse motor function. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Vernooij in this issue.

BACKGROUND AND PURPOSE:The role of stroke location as a determinant of mood and cognitive symptoms is still a matter of debate. The aim of this study was to identify the predictive value of ischemic stroke location, on a voxel basis, for mood and cognitive outcome.MATERIALS AND METHODS:A prospective monocentric study including patients with a supratentorial ischemic stroke was conducted. A 3 Tesla brain MRI was performed at baseline. Mood and cognition were assessed using Hospital Anxiety and Depression scale (HAD), apathy inventory (AI), and Montreal Cognitive Assessment scale subscores, performed at 3 months poststroke. Statistical maps of ischemic stroke location associated with 3 months mood and cognitive scores were obtained using a voxel-based lesion-symptom mapping approach (Brunner and Munzel test). Significant voxels (false discovery rate [FDR] corrected-P < .01) were identified using the standard Montreal Neurological Institute-152 space template.RESULTS:Two hundred and sixty-five nonsevere stroke patients were included (64% men, mean age 66 ± 14, median National Institute of Health Stroke Score 3, interquartile range 2-6). Ischemic stroke location was not associated with HAD or AI scores. Language, abstraction, and delayed recall performances were mainly associated with left-side hemispheric lesions. Lesions in both hemispheres were associated with lower performances in visuospatial and executive functions, naming, attention, and orientation.CONCLUSION:Ischemic stroke location does not predict mood outcome at 3 months but is a determinant of cognitive outcome in specific domains.

INTRODUCTION:Few studies described strategies to improve the use of diagnostic tests in intensive care units (ICU). No study assessed whether their impact was sustained or not. In this study, we assessed whether a multi-faceted intervention for more appropriate use of laboratory testing can decrease the number of tests, is sustainable, is not associated with additional morbidity and represents a potential cost saving.MATERIAL AND METHODS:An open-label prospective cohort study in two separated units of the same medical intensive care unit (ICU) including respectively 3315 and 2392 consecutive patients. After the observation period (2010), a reduction in ICU A of unnecessary diagnostics tests as part of a program including senior supervisory of juniors' orders, encouragements for orders containment at each everyday round discussions (period 2; 2011). Period 3 (2012) consisted in the prolongation of the protocol as a routine care without supervision; Period 4 (2013) was a new period of observation without intervention. No modification was implemented in ICU B in periods 2-4.RESULTS:After the intervention, a decrease in the overall number of tests per ICU-patient-days (37.3±5.5 (baseline) to 15.2±3.2 (- 59%); p<0.0001) was observed. The total cost of the tests decreased from 239±41 to 104±28 euros per ICU-patient days; p<0.0001. The effect on laboratory test orders was sustainable in period 3 (-49%) and 4 (-30%). No significant secondary effect of the intervention was observed in period 2. In ICU B, there was no significant change in the overall laboratory test orders in between the periods.CONCLUSIONS:Laboratory test containment is effective, likely safe and sustainable provided that an educational program is repeatedly promoted, that it makes sense for the whole team, that senior and junior physicians are both committed in the program, and that encouragements for laboratory orders containment at each everyday round discussions.

Introduction: Initial motor impairment assessed in the acute stroke phase (as measured by the Fugl-Meyer (FM) Assessment) is a strong predictor of lower extremity (LE) motor impairment at 3 months (Smith et al., 2017). The predictive value of measures of motor tract integrity, lesion size and location is not known. For our analysis we combined two motor tracts that might be particularly important in the control of proximal leg muscles to create a canonical tract of the corticospinal tract proper (CST) and the corticorubrospinal tract (CRST)(Lindenberg et al., 2010; Rueber et al., 2012). In previous work (Feng et al., 2015) we have shown that weighted CST-Lesion Load (a combined variable of lesion size and location) is a significant predictor of 3 months outcome for the UE. Hypothesis: Weighted CST-CRST Lesion-Load (wCST/CRST-LL) can improve the FM-based predictions of lower limb motor recovery. Methods: Ischemic stroke patients with a upper limb paresis (UE-FM<66) and lower limb paresis (LE-FM<34) were assessed between 48-72h and 3 months poststroke with the FM scale. Lesion maps drawn on diffusion-weighted images were used to calculate lesion loads of a combined CST-CRST probabilistic tract derived from matched elderly healthy control subjects. Then, several variables that have been shown to predict outcome (e.g., FM, lesion load, age, hemisphere) were subjected to individual regression analyses. Significant variables (at p<0.05) were entered into a multiple regression model to assess predictors of lower limb motor recovery (i.e., actual difference in LE-FM between 3 months and initial stroke phase assessment). Results: Both baseline and 3-months follow-up were available for 134 patients. Initial motor impairment (FM-LE) and wCST/CRST-LL were independent strong predictors of lower limb motor recovery (respectively p<0.0001 and p=0.0005). Combining initial motor impairment and wCST/CRST lesion load was a much better model than FM-LE by itself (respectively R2=0.43 and R2=0.46, p=0.003) which was confirmed by the Akaike Information Criterion (AIC). Conclusion: wCST/CRST-LL, a combined measure of lesion size/location, adds significant power to a combined model with FM, but is also a strong predictor of lower limb motor recovery by itself.

Intracranial aneurysm formation, growth and rupture are incompletely understood. Inflammation plays a key role in the formation and rupture of intracranial aneurysms. Inflammation is mediated through several factors such as cytokines, chemokines and growth factors. The purpose of this study was to determine if these inflammatory proteins were increased in the lumen of human intracranial aneurysm and correlate these data with gene expression regulation (transcriptomic) at tissue level. The concentration of 27 inflammatory proteins in blood samples drawn from the lumen of human intracranial unruptured aneurysms of 21 patients were compared with blood samples from the femoral arteries of the same patients. We compared these proteomic data from intra-aneurysmal blood with transcriptomic data obtained by RNA sequencing of 7 human unruptured aneurysm walls and 6 human controls cortical arteries. The mean serum concentration of Il-1ra, IL-2, IL-5, IL-6 FGF-basic, GM-CSF, MCP-1, TNF-α and MIP-1α was significantly higher in samples taken from cerebral aneurysms compared to femoral arteries. In our transcriptomic analysis, we found a significant upregulation of IL-2 gene and IL-5 gene (coding for IL-2 and IL-5) in aneurysm walls compared with controls cortical arteries. Higher concentration of inflammatory proteins was found in intra-aneurysmal sampling compared with femoral sampling. Transcriptomic data showed an upregulation of IL-2 gene and IL-5 gene in aneurysm walls compared with controls cortical arteries. Our findings suggest that we may detect intra-aneurysmal blood marker of aneurysm wall inflammation.

Adverse events in endovascular treatment for ruptured and unruptured cerebral aneurysms are feared particularly thromboembolic complications when stent device is used. Dual antiplatelet therapy is a standard of care but choice of appropriate association doesn’t reach any consensus in neurovascular context. Objective is to match efficiency of aspirin-clopidogrel and aspirin-ticagrelor associations in the prevention of thromboembolic complications after cerebral aneurysms stenting treatment. This is a monocentric, retrospective, cohort comparison study design. We compared both groups treated with either clopidogrel or ticagrelor in association with aspirin in consecutive aneurysms protected with flow diverter embolization device or stent-assisted coiling. Data were collected on patient demographics and thromboembolic risk factors, procedural details, antiplatelet treatment regime, complications, angiographic and functional outcomes. One hundred and sixteen patients were treated by cerebral stenting between January 2013 and September 2017 and benefited from dual anti-agregation. Sex, age, smoking status and procedural details did not differ between the two groups. We show no difference about onset of thromboembolic complications and functional outcomes. Aspirin and ticagrelor association in the field of interventional neuroradiology is not accepted in routine. Questions are to be solved about treatment resistance (absence of prerequisite agregability test) and hemorrhagic complications.