Hemorrhagic transformation in acute ischemic stroke: hemorrhagic subtypes and symptomatic intracranial hemorrhage.

BACKGROUND: Few clinical studies perform detailed analyses of subtypes of intracranial hemorrhage (ICH) after mechanical thrombectomy (MT) used to treat acute ischemic stroke. Symptomatic intracranial hemorrhage (sICH) is a formidable complication of MT and is widely used in clinical trials as a safety outcome. However, variable definitions of sICH are used across clinical studies. OBJECTIVE: To radiographically subcategorize post-MT ICH development within this large cohort and examine overlap with sICH. Second, to examine the agreement of this definition of sICH with local site-reported occurrences of sICH to see how sICH rates change with modifications of the definitions used. METHODS: A large cohort of patients treated with MT for acute ischemic stroke (n=1395) was analyzed to (1) radiographically characterize hemorrhagic subtypes of intracranial hemorrhage (ICH) occurring after MT; (2) examine associations of hemorrhagic subtypes with sICH; and (3) compare core laboratory-adjudicated occurrences of sICH with site-reported sICH. RESULTS: The overall rate of ICH was 552/1395 patients (39.6%), and the overall rate of sICH was 47/1395 (3.4%). The most common type of ICH was hemorrhagic infarction type 1 (HI1), which represented 45.3% of all ICH cases- followed by HI2 (31.5%) and subarachnoid hemorrhage (SAH, 29.2%). Parenchymal hematoma 2 (PH2) represented only 3.3% of all ICH cases. Of the PH2 hemorrhages, only 33.3% were determined to be symptomatic. Of sICH cases, the most common ICH subtypes were HI2 (48.9%) and SAH (38.3%). Comparison of sICH rates as determined by core laboratory adjudication versus local site-reported results showed that only 14 patients were identified as having sICH with both definitions, with 47 patients total with sICH according to one definition, but not the other. CONCLUSIONS: Results of this analysis demonstrate the radiographic subtypes of ICH and also highlight the limitations of variable criteria used to define sICH, suggesting that it might be appropriate to revisit how sICH is defined post-MT. TRIAL REGISTRATION NUMBER: Clinical trial NCT03845491.

Placing the balloon-guide catheter in the high cervical segment of the internal carotid artery is associated with improved recanalization.

BACKGROUND: Mechanical thrombectomy (MT) is part of the standard of care for stroke treatment, and improving its efficacy is one of the main objectives of clinical investigation. Of importance is placement of the distal end of balloon-guided catheters (BGC). We aim to determine if this influences outcomes. METHODS: We analyzed data from the ASSIST Registry, an international, multicenter prospective study of 1492 patients. We divided patients treated with BGC according to the placement of the BGC: low cervical (LCG (the lower 2/3 of cervical internal carotid artery (ICA)) or high cervical (HCG (upper 1/3 of cervical ICA, petro-lacerum or higher)). We analyzed characteristics and outcomes overall and stratified on the primary MT technique: Stent-Retriever only (SR Classic), Combined use of aspiration catheter and SR (Combined), and Direct Aspiration (ADAPT). RESULTS: Our study included 704 subjects -323 in the low cervical and 381 in the high cervical groups. Statistical differences were seen in the proportion of females and tandem lesions (both higher for LCG). Placing the BGC in the high cervical segment is associated with better recanalization rates (expanded treatment in cerebral infarction (eTICI) score of 2c-3) at the end of the procedure (P<0.0001) and shorter procedures (P=0.0005). After stratifying on the three primary techniques (SR Classic, Combined, and ADAPT), placing the BGC in the high segment is associated with a better first-pass effect (FPE), less distal emboli, and better clinical outcomes in the SR Classic technique. CONCLUSIONS: Placing the distal end of the BGC at the high cervical segment or higher is associated with better recanalization.

Technique and impact on first pass effect primary results of the ASSIST global registry.

BACKGROUND: Patients treated with mechanical thrombectomy (MT) for acute ischemic strokes from large vessel occlusion (LVO) have better outcomes with effective reperfusion. However, it is unknown which technique leads to better technical and clinical success. We aimed to determine which technique yields the most effective first pass reperfusion during MT. METHODS: In a prospective, multicenter global registry we enrolled patients treated with operator preferred MT technique at 71 hospitals from January 2019 to January 2022. Three techniques were assessed: SR Classic with stent retriever (SR) and balloon guide catheter (BGC); SR Combination which employed SR with contact aspiration with or without BGC; and direct aspiration (DA) with or without BGC. The primary outcome was achieving an expanded Thrombolysis In Cerebral Infarction (eTICI) score of 2c or 3 on the first pass, with the primary technique as adjudicated by core lab. The primary clinical outcome measure was a 90-day modified Rankin Scale (mRS) score of 0-2. RESULTS: A total of 1492 patients were enrolled. Patients treated with SR Classic or SR Combination were more likely to achieve first pass eTICI 2c or 3 reperfusion (P=0.01). There was no significant difference in mRS 0-2 (P=0.46) or safety endpoints. CONCLUSIONS: The use of SR Classic or SR Combination was more likely to achieve first pass eTICI 2c or 3 reperfusion. There were no significant differences in clinical outcomes and safety endpoints.

Treatment of Intracranial Aneurysms With the SILK Embolization Device in a Multicenter Study. A Retrospective Data Analysis.

BACKGROUND: Flow-diverter technology has become an important stent-based embolization tool in the treatment of complex cerebrovascular pathology. We report here the experience of 4 Spanish centers with using the SILK flow-diverter (SFD) device. OBJECTIVE: To evaluate the safety and efficacy of using the SFD in the endovascular treatment of intracranial aneurysms with complex morphology. METHODS: We retrospectively examined a prospectively maintained database of patients treated with SFD devices between July 2008 and December 2013 at 1 of 4 institutions in Spain. Data regarding patient demographics, aneurysm characteristics, and technical procedure were analyzed. Angiographic and clinical findings were recorded during the procedure and at 12 months postoperatively. RESULTS: A total of 175 SFD devices were implanted in 157 patients (women/men: 119/38; mean, median, and range of age: 56.2, 56.7, and 19-80 years, respectively), who were treated in a delayed manner (3-6 months from the event) for 180 aneurysms (165 unruptured and 15 ruptured). Adverse events (acute and delayed) were observed in 28.7% of cases (45/157), and most were resolved (19.1%; 30/157). Six months after the procedure, total morbidity and mortality were 9.6% (15/157) and 3.2% (5/157), respectively. Long-term imaging follow-up showed complete occlusion, neck remnants, and residual aneurysm in 78.1% (100/128), 14.0% (18/128), and 7.8% (10/128) of cases, respectively. CONCLUSIONS: The SFD device is an effective tool for the treatment of challenging aneurysms, and allows complete occlusion within a year of the procedure in most patients, with morbidity and mortality comparable to those previously reported for similar devices.

Endovascular treatment of a pial arteriovenous fistula of a posteroinferior cerebellar artery with a double origin.

Pial arteriovenous fistulas (pAVF) of the posterior fossa are rare and may present with symptoms secondary to mass effect, venous hypertension or hemorrhage, among others. A case is presented of a previously healthy 2-year-old boy with neurological deficit arising from pAVF of the posteroinferior cerebellar artery. The pAVF was successfully treated with endovascular occlusion.

[Clivus metastasis from hepatocarcinoma associated with transarterial hepatic chemoembolization]. / Metástasis en clivus de hepatocarcinoma asociado a quimiembolización transarterial hepática.

Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world, and its incidence has increasing in the latest years. Recent advances in both, diagnosis and treatment, have improved the prognosis. Transarterial chemoembolization (TACE) is a therapeutic option, valid for patients who are not candidates for curative treatments, which has demonstrate to improve survival. Complications of TACE are very frequent and often severe. Postembolization syndrome is extremely frequent. Liver abscess, acute pancreatitis, acute cholecistitis, biloma, intestinal ischemia, gastroduodenal ulcerations and liver failure, are less frequent complications. Recently, it has been described an increasing risk of distant metastasis after transarterial chemoembolization. Most frequent metastasis are in the lung, abdominal lymph nodes, bone, and suprarenal glands. Metastases in nervous system, especially in clivus, are rarely. We report the case of a patient with hepatocellular carcinoma treated with transarterial chemoembolization who was diagnosed with metastasis in clivus.

Metástasis en clivus de hepatocarcinoma asociado a quimiembolización transarterial hepática / Clivus metastasis from hepatocarcinoma associated with transarterial hepatic chemoembolization

El carcinoma hepatocelular (CHC) es la quinta causa de cáncer en el mundo, con una incidencia creciente. Los avances en el diagnóstico y el tratamiento han mejorado su pronóstico. La quimioembolización transarterial (QET) es una opción terapéutica válida para pacientes no candidatos a tratamientos curativos, que ha demostrado mejorar la supervivencia. Las complicaciones asociadas a la QET son frecuentes y, en ocasiones, graves. El síndrome postembolización es la complicación más frecuente. El absceso hepático, la pancreatitis, la colecistitis, la formación de biloma, la isquemia intestinal, la úlcera gastroduodenal y el fallo hepático son complicaciones menos frecuentes. Recientemente, se ha descrito un aumento en la incidencia de metástasis a distancia en pacientes que previamente recibieron QET. Las metástasis extrahepáticas más frecuentes del CHC se dan en pulmón, ganglios abdominales, sistema óseo y glándulas suprarrenales. Las metástasis cerebrales y, concretamente en clivus, son excepcionales. El caso que presentamos es el de un paciente afectado de CHC al que, tras recibir varias sesiones de QET, se le diagnostica metástasis en clivus

Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world, and its incidence has increasing in the latest years. Recent advances in both, diagnosis and treatment, have improved the prognosis. Transarterial chemoembolization (TACE) is a therapeutic option, valid for patients who are not candidates for curative treatments, which has demonstrate to improve survival. Complications of TACE are very frequent and often severe. Postembolization syndrome is extremely frequent. Liver abscess, acute pancreatitis, acute cholecistitis, biloma, intestinal ischemia, gastroduodenal ulcerations and liver failure, are less frequent complications. Recently, it has been described an increasing risk of distant metastasis after transarterial chemoembolization. Most frequent metastasis are in the lung, abdominal lymph nodes, bone, and suprarenal glands. Metastases in nervous system, especially in clivus, are rarely. We report the case of a patient with hepatocellular carcinoma treated with transarterial chemoembolization who was diagnosed with metastasis in clivus

Metástasis en clivus de hepatocarcinoma asociado a quimiembolización transarterial hepática / Clivus metastasis from hepatocarcinoma associated with transarterial hepatic chemoembolization

El carcinoma hepatocelular (CHC) es la quinta causa de cáncer en el mundo, con una incidencia creciente. Los avances en el diagnóstico y el tratamiento han mejorado su pronóstico. La quimioembolización transarterial (QET) es una opción terapéutica válida para pacientes no candidatos a tratamientos curativos, que ha demostrado mejorar la supervivencia. Las complicaciones asociadas a la QET son frecuentes y, en ocasiones, graves. El síndrome postembolización es la complicación más frecuente. El absceso hepático, la pancreatitis, la colecistitis, la formación de biloma, la isquemia intestinal, la úlcera gastroduodenal y el fallo hepático son complicaciones menos frecuentes. Recientemente, se ha descrito un aumento en la incidencia de metástasis a distancia en pacientes que previamente recibieron QET. Las metástasis extrahepáticas más frecuentes del CHC se dan en pulmón, ganglios abdominales, sistema óseo y glándulas suprarrenales. Las metástasis cerebrales y, concretamente en clivus, son excepcionales. El caso que presentamos es el de un paciente afectado de CHC al que, tras recibir varias sesiones de QET, se le diagnostica metástasis en clivus

Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world, and its incidence has increasing in the latest years. Recent advances in both, diagnosis and treatment, have improved the prognosis. Transarterial chemoembolization (TACE) is a therapeutic option, valid for patients who are not candidates for curative treatments, which has demonstrate to improve survival. Complications of TACE are very frequent and often severe. Postembolization syndrome is extremely frequent. Liver abscess, acute pancreatitis, acute cholecistitis, biloma, intestinal ischemia, gastroduodenal ulcerations and liver failure, are less frequent complications. Recently, it has been described an increasing risk of distant metastasis after transarterial chemoembolization. Most frequent metastasis are in the lung, abdominal lymph nodes, bone, and suprarenal glands. Metastases in nervous system, especially in clivus, are rarely. We report the case of a patient with hepatocellular carcinoma treated with transarterial chemoembolization who was diagnosed with metastasis in clivus