Intracranial stents in the endovascular treatment of acute ischemic stroke. / Uso del stent intracraneal en el tratamiento endovascular en agudo del ictus.

OBJECTIVE: To evaluate the efficacy and safety of intracranial stenting as a rescue therapy after failed mechanical thrombectomy in patients with acute ischemic stroke. MATERIAL AND METHODS: We retrospectively studied 42 patients treated with intracranial stenting after failed mechanical thrombectomy between December 2008 and January 2016. We compared outcomes before and after the incorporation of stentrievers. We assessed the degree of recanalization in the carotid and basilar territories (modified TIMI score), prognostic factors, and outcome (modified Rankin Score at 3 months). Safety was evaluated in function of the appearance of symptomatic intracranial hemorrhage (SICH). RESULTS: Median NIHSS was 17 in patients with carotid territory strokes and 26 in those with vertebrobasilar territory strokes. Median time from onset of symptoms to treatment was 225minutes in carotid territory strokes and 390minutes in vertebrobasilar territory strokes. A total of 10 patients underwent intravenous fibrinolytic therapy before treatment with stentrievers. Two patients developed SICH; both had undergone intravenous fibrinolytic therapy (p=0.0523). Recanalization was effective in 30 (71.4%) in the entire series: in 7 (50%) of 14 patients treated before the incorporation of stentrievers and in 23 (82.1%) of 28 treated after the incorporation of stentrievers (p=0.0666). Outcome at 3 months was good in 2 (14.3%) patients in the earlier group and in 14 (50%) patients in the later group (p=0.042). We found significant associations between recanalization and outcome (p=0.0415) and between shorter time to treatment and outcome (p=0.002). Outcome was good in 14 (48.3%) of the 29 patients with carotid territory strokes and in 2 (15.4%) of the 13 patients with vertebrobasilar territory strokes (p=0.078). CONCLUSIONS: Intracranial stenting is the rescue treatment when the usual treatment fails. Stentrievers must be used to eliminate the clot burden before stenting. In our study, antiplatelet treatment did not seem to increase the risk of SICH except in patients with prior intravenous fibrinolytic treatment.

[Vertebrobasilar recanalization techniques before the placement of stent-retrievers: reopening is not synonymous with good outcome]. / Técnicas de recanalización vertebrobasilar antes de la introducción de las endoprótesis recuperadoras: la reapertura no es sinónimo de buena evolución.

OBJECTIVES: To evaluate the recanalization rate and clinical outcome three months after endovascular treatment for vertebrobasilar occlusion before the placement of stentrievers. MATERIAL AND METHODS: We reviewed all cases of basilar thrombosis treated with endovascular techniques at our center. We reviewed the clinical outcomes with the main objective of determining the recanalization rate and the secondary objective of evaluating the outcome using the modified Rankin scale (mRS) three months after treatment. We assessed clinical and angiographic variables and correlated them with outcome and complications. RESULTS: We reviewed a total of 27 consecutive patients (mean age, 58.1±15.5 y; median National Institutes of Health Stroke Scale (NIHSS), 21, interquartile range, 18-29; median Glasgow coma score (GCS) 7, interquartile range, 4-9.5). The mean time between the onset of symptoms and endovascular treatment was 26.3±41.7hours. Complete or partial recanalization was achieved in 23 (85.1%) patients. Three months after treatment, 16 (59.2%) had died and 6 (22.2%) had good outcome (mRS ≤ 2). CONCLUSION: Endovascular treatment achieved a high rate of recanalization of occlusions of the basilar artery. Nevertheless, a high percentage of the patients did not have a good outcome. New materials might improve the prognosis in these patients.

[Transient ischemic attacks as the only manifestation of a dural arteriovenous fistula]. / Accidentes isquémicos transitorios como única manifestación de una fístula arteriovenosa dural.

INTRODUCTION: Transient ischemic attacks (TIA), as the only clinical manifestation of a dural arteriovenous malformation, are very seldom seen in clinical practice. CASE REPORT: We describe the case of a 68 year old male with recurring bouts of right hemiparesis, due to haemodynamic alterations stemming from a dural arteriovenous malformation located in the right middle fossa, with cortical venous drainage towards the superior longitudinal sinus, which hampers the drainage of the left parietal cortical veins. Computerized tomography and magnetic resonance scans performed on admission to hospital revealed blood in the left parietal sulcus, with no parenchymatous lesions. This dural arteriovenous fistula was initially treated by the endovascular administration of polyvinyl alcohol in 150 250 mm particles, but after 11 days the patient again presented symptoms of right hemiparesis which became increasingly frequent and intense. This led to the search for a definitive treatment for the dural arteriovenous fistula with cyanoacrylates. No similar symptoms have been observed in the five years follow up carried out after the embolization. CONCLUSIONS: In cases of dural arteriovenous fistulas the arterialized cortical vein can impede the drainage of other veins towards the common venous sinus. On very rare occasions this can lead to the appearance of symptoms of transient ischemic attacks in territories that are a long way from the location of the abovementioned arteriovenous malformation.

[Paralysis of cranial nerves as a form of presentation of dissection of the internal carotid artery]. / Parálisis de pares craneales bajos como forma de presentación de la disección de la arteria carótida interna.

INTRODUCTION: Dissection of the internal carotid artery (DIC) is a known cause of cerebral infarct, especially in young patients. The classical clinical syndrome consists of unilateral pain of the head or neck, homolateral oculo-sympathetic paresis and ischaemic symptoms of the cerebral hemisphere involved. Presentation as paralysis of cranial nerves is rare and occurs in less than 12% of cases. The neurological involvement seems to be due to compression caused by the increased diameter of the artery involved. CASE REPORTS: Two patients are reported with paralysis of the lower cranial nerves secondary to DIC. In the first case there was paralysis of the left cranial nerves IX, X, and XII which was diagnosed on angiography using computerized tomography with spiral acquisition. The second patient had clinical involvement of cranial nerves IX, X, XI and XII and magnetic resonance angiography showed the dissection. Both cases were confirmed after digital subtraction angiography. CONCLUSION: Diagnosis of DIC requires a high level of suspicion in cases with atypical onset. The use of new techniques of non invasive imaging diagnosis such as computerized tomography and magnetic resonance angiography permit effective diagnosis of this disorder.