First-Pass Effect in M1-Occlusion Stroke Patients Treated with Combined Stent-Retriever/Large-Bore Distal Aspiration Catheter Thrombectomy.

INTRODUCTION: Combined stent-retriever/large-bore distal aspiration catheter (LB-DAC) thrombectomy was recently introduced to treat large-vessel occlusion; however, it is unclear whether larger inner diameters improve outcomes. We compared angiographic and clinical outcomes in patients with occlusions of the M1 segment of the middle cerebral artery treated with mechanical thrombectomy using extra-LB-DAC versus LB-DAC in combination with stent-retrievers. METHODS: We analyzed consecutive patients with M1 occlusion included in the ROSSETTI registry treated with non-balloon guide catheter combined LB-DAC/stent-retriever thrombectomy between June 2019 and April 2022. We compared demographics, baseline clinical variables, procedural variables, angiographic outcomes, and clinical outcomes [National Institute of Health Stroke Scale score at 24 h (24h-NIHSS) and modified Rankin scale score at 3 months] between patients treated with extra-LB-DAC (Sofia Plus, MIVI Q6, Catalyst7; inner diameter, 0.068″-0.070″) versus LB-DAC (Sofia 5F, MIVI Q5, Catalyst 6; inner diameter, 0.055″-0.064″). Primary outcome was the first-pass effect (FPE) rate, defined as near-complete/complete reperfusion (mTICI 2c-3) after a single pass of the device. RESULTS: We included 324 patients (extra-LB-DAC, 185, 57.1% patients). Demographics, clinical data, and clinical outcomes were similar between the two groups; however, there was a trend towards improvement in National Institute of Health Stroke Scale score at 24 h (24h-NIHSS) in the cohort treated with extra-LB-DAC 9 points (IQR 4;16 points) vs. 12 points (IQR 4;18 points, P = 0.083). Patients treated with extra-LB-DAC had higher FPE rate (47% vs. 30.9%; P = 0.003) and higher modified FPE (mTICI ≥ 2b after a single pass) rate (65.9% vs 46.8%; P = 0.001). The use of extra-LB-DAC was an independent factor in predicting FPE (odds ratio 1.982, 95% confidence interval 1.250-3.143, P = 0.004). CONCLUSION: Our results suggest that in combined LB-DAC/stent-retriever thrombectomy, a larger aspiration catheter inner diameter is associated with higher rates of FPE and mFPE.

Embolia cerebral cálcica: presentación de una serie de 9 casos y revisión de la literatura / Calcified cerebral embolism: a 9 case series and review of the literature

Objetivo: Las embolias cerebrales cálcicas (ECC) representan una causa de ictus poco descrita e infradiagnosticada, que puede ser la primera manifestación de una enfermedad vascular o cardíaca. El objetivo del presente trabajo es describir las características de las ECC en una serie de casos y revisar la literatura. Pacientes y métodos: Tres centros hospitalarios aportaron casos al trabajo. Se evaluaron los métodos diagnósticos, las características de neuroimagen, la fuente embólica, el tratamiento y el pronóstico de los pacientes con ECC. Resultados: Se recogieron un total de 9 casos con ECC espontánea como causa de ictus isquémico agudo. Todos afectaron a la arteria cerebral media y se estudiaron mediante TC. Se encontró una posible fuente cálcica en 6 pacientes (66,6%): carotídea en 3 (33,3%) y cardíaca en otros 3 (33,3%) pacientes. Solo un paciente se trató en la fase aguda mediante trombectomía y solo un 11% tuvieron un mRS ≤ 2 a los 3 meses. Conclusiones: Las ECC son más frecuentes de lo que se creía en el pasado y, aunque siguen siendo comúnmente infradiagnosticadas, tienen una gran relevancia pronóstica a la hora de dirigir el estudio etiológico del ictus. (AU)

Objective: Calcified cerebral embolism (CCE), a rarely reported and underdiagnosed cause of stroke, may be the first manifestation of a vascular or cardiac disease. Our purpose is to describe the characteristics of CCE in a series of 9 cases and review the literature on the subject. Patients and methods: We included patients with CCE from 3 different hospitals. We described the diagnostic approach, neuroimaging findings, origin of the embolism, treatment, and prognosis of these patients. Results: We identified a total of 9 patients presenting spontaneous CCE as the cause of acute ischaemic stroke. In all cases, the middle cerebral artery was affected; all patients underwent CT. A possible calcific source was found in 6 patients (66.6%), originated in the carotid arteries in 3 (33.3%) and in the heart in the other 3 patients (33.3%). Only one patient was treated in the acute phase (trombectomy) and only 11% of patients had modified ranking scale scores ≤ 2 at 3 months. Conclusions: CCE is more frequent than previously thought and, although the condition continues to be underdiagnosed, it is of considerable prognostic relevance in the aetiological study of stroke. (AU)

Calcified cerebral embolism: a 9-case series and review of the literature.

OBJECTIVE: Calcified cerebral embolus (CCE), a rarely reported and underdiagnosed cause of stroke, may be the first manifestation of a vascular or cardiac disease. We describe the characteristics of CCE in a series of 9 cases and review the literature on the subject. PATIENTS AND METHODS: We included patients with CCE from 3 different hospitals. We describe the diagnostic approach, neuroimaging findings, origin of the embolism, treatment, and prognosis of these patients. RESULTS: We identified a total of 9 patients presenting spontaneous CCE as the cause of acute ischaemic stroke. In all cases, the middle cerebral artery was affected; all patients underwent CT. A possible calcific source was found in 6 patients (66.6%), originating in the carotid arteries in 3 (33.3%) and in the heart in the other 3 patients (33.3%). Only one patient was treated in the acute phase (trombectomy) and only 11% of patients had modified Ranking Scale scores ≤ 2 at 3 months. CONCLUSIONS: CCE is more frequent than previously thought and, although the condition continues to be underdiagnosed, it is of considerable prognostic relevance in the aetiological study of stroke.

False ischaemic penumbras in CT perfusion in patients with carotid artery stenosis and changes following angioplasty and stenting. / Falsas penumbras isquémicas en la TC de perfusión en pacientes con estenosis carotídea y cambios después de la angioplastia y stenting.

INTRODUCTION: Carotid artery stenosis influences CT perfusion (CTP) studies, sometimes manifesting as a false ischaemic penumbra (FIP). This study aims to estimate the incidence of FIP in patients with carotid artery stenosis, establish their relationship with the degree of stenosis, and measure quantitative and qualitative changes in CTP after carotid angioplasty and stenting (CAS). METHODS: Between October 2013 and June 2015, we prospectively selected 26 patients with carotid stenosis who underwent CAS, with CTP being performed 2-10 days before and after CAS. RESULTS: Sixteen patients had unilateral stenosis (11 in the subgroup displaying < 90% stenosis and 5 in the subgroup with ≥ 90% stenosis) and 10 patients had bilateral stenosis. The incidence of FIP in patients with carotid artery stenosis was 38.5%. Risk of FIP increased in direct relation to degree of stenosis, with a relative risk of 11 in the subgroup with ≥ 90% stenosis with respect to the subgroup displaying < 90% stenosis (95% CI, 1.7-71.3; P=.0005). There were statistically significant changes in the parameters CBF, TTP, MTT, and Tmax CTP, which reverted after angioplasty. No significant changes were found in CBV. CONCLUSIONS: Carotid artery stenosis involves changes in CTP parameters. Patients with ≥ 90% stenosis carry a high risk of FIP; CTP studies may therefore be misinterpreted in these cases. Changes in CTP parameters are reverted after CAS.

Calcified cerebral embolism: a 9 case series and review of the literature. / Embolia cerebral cálcica: presentación de una serie de 9 casos y revisión de la literatura.

OBJECTIVE: Calcified cerebral embolism (CCE), a rarely reported and underdiagnosed cause of stroke, may be the first manifestation of a vascular or cardiac disease. Our purpose is to describe the characteristics of CCE in a series of 9 cases and review the literature on the subject. PATIENTS AND METHODS: We included patients with CCE from 3 different hospitals. We described the diagnostic approach, neuroimaging findings, origin of the embolism, treatment, and prognosis of these patients. RESULTS: We identified a total of 9 patients presenting spontaneous CCE as the cause of acute ischaemic stroke. In all cases, the middle cerebral artery was affected; all patients underwent CT. A possible calcific source was found in 6 patients (66.6%), originated in the carotid arteries in 3 (33.3%) and in the heart in the other 3 patients (33.3%). Only one patient was treated in the acute phase (trombectomy) and only 11% of patients had modified ranking scale scores ≤ 2 at 3 months. CONCLUSIONS: CCE is more frequent than previously thought and, although the condition continues to be underdiagnosed, it is of considerable prognostic relevance in the aetiological study of stroke.

Silk flow-diverter stent for the treatment of complex intracranial aneurysms: A one-year follow-up multicenter study.

Background Flow-diverter stents have been successfully used in the treatment of complex aneurysms with limited therapeutic alternatives. We report our experience using the Silk flow diverter (SFD; Balt Extrusion, Montmorency, France) for the treatment of complex aneurysms in four Argentine centers. Methods We conducted a retrospective review of 246 consecutive patients who were treated with the SFD at four Argentine centers between January 2009 and January 2017. The patient and aneurysm characteristics, as well as the details of the procedure, were analyzed. The angiographic and clinical findings were recorded during and immediately after the procedure and at 12-month follow-up. Results Angiography follow-up at 12 months was possible in 235 patients (95.5%) with 282 aneurysms. A total of 265 aneurysms (93.9%) presented with complete occlusion of the aneurysmal sac (class 1) and 17 aneurysms (6.1%) presented with partial occlusion (class 2). The 12-month clinical follow-up showed 11 patients with major events (seven, scale 2; five, scale 3; and two, scale 4). The morbidity and mortality rates were 4.2% (11/289) and 2.1% (5/289), respectively. Conclusions The treatment of aneurysms with the SFD was associated with a low rate of complications and a high percentage of aneurysmal occlusion. These findings suggest that SFD is an effective and safe alternative in the endovascular treatment of complex aneurysms.

Expanding the use of flow diverters beyond their initial indication: treatment of small unruptured aneurysms.

BACKGROUND: Experience with the endovascular treatment of unruptured small intracranial aneurysms by flow diverter devices is still limited. OBJECTIVE: To assess the safety and efficacy of the SILK flow diverter (SFD) in the treatment of small unruptured cerebral aneurysms (<10 mm). METHODS: We performed a retrospective review of a prospectively maintained database of patients treated with a SFD between July 2008 and December 2013 at 4 institutions in Spain to identify all patients with small unruptured aneurysms (<10 mm). Data for patient demographics, aneurysm characteristics, and technical procedures were analyzed. Angiographic and clinical findings were recorded during the procedure and at 6- and 12-month follow-ups. RESULTS: A total of 109 small aneurysms were treated with a SFD in 104 patients (78 women; 26 men; mean, median, and range of age: 55.2, 57.1, and 19-80 years, respectively). A total of 60 patients were asymptomatic (57.7%). All except 7 aneurysms (6.4%) arose from the anterior circulation. The mean size of the aneurysms was 4.7±1.9 mm. At 6 months, the neuromorbidity and neuromortality rates were 2.9% and 0.9%, respectively. Imaging at the 12-month follow-up showed complete occlusion, neck remnants, and residual aneurysm in 88.5% (69/78), 7.7% (6/78), and 3.3% (3/78) of cases, respectively. No delayed hemorrhage occurred. CONCLUSIONS: The findings suggest that the indications for SFD can be safely extended to small intracranial aneurysms.

Vascular reconstruction of a fusiform basilar aneurysm with the Silk embolization system.

We present the case of a 47-year-old man with a fusiform aneurysm of the basilar cerebral artery, who was successfully treated with the placement of a novel flow diverter system (Silk stent).

High plasma glutamate concentrations are associated with infarct growth in acute ischemic stroke.

BACKGROUND: Excitotoxic and inflammatory mechanisms have been demonstrated as mediating early neurologic deterioration (END) in patients with cerebral infarction. Here we investigate whether molecular markers associated with END are related to the volume and outcome of the diffusion weighted image (DWI) lesion in acute ischemic stroke. METHODS: MRI was performed on admission and at 72 hours in 197 patients with acute hemispheric infarction of <12 hours' duration. DWI lesion enlargement was calculated as the absolute difference between volumes on admission and day 3 of evolution. NIH Stroke Scale was scored at the same intervals. END was defined as an increase >/=4 points within the 3 days. Glutamate, l-arginine, interleukin-6 (IL-6), and tumor necrosis factor-alpha levels were analyzed in blood samples obtained on admission. RESULTS: DWI lesion growth was found in 144 (73%) patients (median increase 38 [6.5, 83.4] cm(3)) and END occurred in 58 (29.4%) patients. Baseline glutamate (r = 0.71), l-arginine (r = -0.35), and IL-6 levels (r = 0.50) showed a high and significant correlation with the DWI lesion enlargement (all p < 0.001). After adjustment for potential confounders, glutamate levels were the only molecular marker associated with DWI lesion enlargement at 72 hours (beta = 0.21; SD = 0.07; p = 0.004). CONCLUSIONS: Molecular markers of early neurologic deterioration may play a role as mediators of lesion growth in cerebral ischemia. Plasma glutamate concentration is the most powerful and independent predictor biomarker of lesion enlargement in the acute phase of ischemic stroke, and so may well be useful as a signature of tissue at risk of infarction.

LEO stent monotherapy for the endovascular reconstruction of fusiform aneurysms of the middle cerebral artery.

We present the case of a patient with a fusiform aneurysm of the M1 segment of the middle cerebral artery (MCA) in which endovascular stent placement without coiling was performed. A 3.5-mm x 25-mm LEO self-expanding stent was deployed along the fusiform aneurysm of the horizontal MCA M1 segment. Digital subtraction angiography showed progressive thrombosis at 6 months and complete thrombosis of the fusiform MCA aneurysm at 12 months.

Microwire strategy for the endovascular treatment of an aneurysm at the origin of the posterior inferior cerebellar artery.

The ultimate goal of endovascular treatment of intracranial aneurysms is complete occlusion of the aneurysm without compromising the parent artery. Several techniques have been described for the treatment of wide-necked aneurysms. An innovative method is proposed for the treatment of wide-necked aneurysms with the neck incorporated in the parent artery.

Medium-term results using the leo self-expanding stent in the treatment of complex intracranial aneurysms.

The preliminary experience with the Leo microstent in combination with detachable coils for the treatment of patients with wide-necked cerebral aneurysms is reported, and the technical complications and recommendations for optimum placement and deployment are discussed. Thirty.two patients identified as harboring wide-necked aneurysm were selected for stent-assisted coiling. Aneurysms were paraophthalmic-cavernous in 13 cases, eight were located at the posterior communicating artery, four at the basilar artery, three at the vertebral arteries, two at the posterior cerebral arteries, one at the right middle artery, and one at the right posterior inferior cerebellar artery. After appropriate antiplatelet therapy, the Leo stent was delivered to the aneurysm site and positioned without difficulty, except in four cases requiring the use of steam to shape the tip of the Vasco microcatheter. Angiographic follow-up was undertaken at six months in 32 patients, at one year in 27 patients, and at two years in 20 patients. Stent placement in the desired position with complete or near complete occlusion of the aneurysm was feasible in all patients. In one patient, the stent was slightly displaced during microwire manipulation for aneurysm microcatheterization. Two-year angiography in 20 patients showed 18 complete occlusions and two aneurysms with a minimal residual neck. The Leo stent represents a significant advancement in the vascular treatment of intracranial aneurysms providing high radial force and an easy delivery system i.e., it is a feasible, secure and effective system.

Long-term Follow-up Angiography of Intracranial Aneurysms Treated with Cook Detachable Coil System.

The long-term outcome of detachable coil embolization of cerebral aneurysms is still unknown. The purpose of this study was to evaluate the stability of the anatomic occlusion of aneurysms treated with the Cook detachable coil system and assess the rate of recanalization and recurrence. A study involving 250 patients with 271 ruptured aneurysms treated with the Cook detachable system between January 1997 and September 2003 who subsequently underwent six month, one year and two year follow-up angiography were enrolled in the study. Angiographic findings were reviewed to determine the percentage of aneurysm occlusion. Long-term follow-up angiograms (at two years) demonstrated complete occlusion in 75% of cases, and subtotal occlusion in 25% of cases. Overall morbidity was 7.3%, aneurysm recurrence 3.2%, and aneurysm re-treatment 3.2%. Recurrent subarachnoid hemorrhage occurred in only one patient. Angiographic follow-up demonstrated the stability and durability of treatment with the Cook detachable coil system.

Spontaneous regression of intracranial arteriovenous malformations. A report of two cases.

Spontaneous and complete regression of cerebral arteriovenous malformations has rarely been reported in the literature. We describe two new cases with a literature review.

CT and MR imaging findings in methanol intoxication.

We present the CT and MR imaging findings in acute methanol intoxication in a 35-year-old man who was admitted to the emergency department with weakness, blurred vision, mild bilateral areactive mydriasis, and a progressive decrease in the level of consciousness. CT and MR imaging showed bilateral putaminal hemorrhagic necrosis and subcortical white matter lesions with peripheral contrast enhancement. There was only partial improvement in patient's Glasgow Coma Scale score during follow-up.

Exclusion of a cavernous aneurysm by leo stent.

SUMMARY: The Leo stent is a cranial self-expanding stent recently developed for the treatment of wideneck aneurysms.We report the first case with total occlusion of a cavernous aneurysm nine months after stent placement without complementary coiling.

The clinical-DWI mismatch: a new diagnostic approach to the brain tissue at risk of infarction.

OBJECTIVE: To evaluate the usefulness of a mismatch between the severity of acute clinical manifestations and the diffusion-weighted imaging (DWI) lesion in predicting early stroke outcome and infarct volume. METHODS: One hundred sixty-six patients with a hemispheric ischemic stroke of <12 hours' duration were studied. The NIH Stroke Scale (NIHSS) score and the volume of DWI lesion were measured on admission and at 72 +/- 12 hours. Infarct volume was measured on T2-weighted or fluid-attenuated inversion recovery images at day 30. Early neurologic deterioration (END) was defined as an increase of > or =4 points between the two NIHSS evaluations. Thirty-eight patients received IV thrombolysis or abciximab. Clinical-DWI mismatch (CDM) was defined as NIHSS score of > or =8 and ischemic volume on DWI of < or =25 mL on admission. The adjusted influence of CDM on END, DWI lesion enlargement at 72 hours, and infarct growth at day 30 was evaluated by logistic regression analysis and generalized linear models. RESULTS: CDM was found in 87 patients (52.4%). Patients with CDM had a higher risk of END than patients without CDM because NIHSS < 8 (odds ratio [OR], 9.0; 95% CI,1.9 to 42) or DWI lesion > 25 mL (OR, 2.0; 95% CI, 0.8 to 4.9). CDM was associated with an increase of 46 to 68 mL in the mean volume of DWI lesion enlargement and infarct growth in comparison with non-CDM. All the effects were even greater and significant in patients not treated with reperfusion therapies. CONCLUSIONS: Acute stroke patients with an NIHSS score of > or =8 and DWI volume of < or =25 mL have a higher probability of infarct growth and early neurologic deterioration. The new concept of CDM may identify patients with tissue at risk of infarction for thrombolytic or neuroprotective drugs.

[Cerebral atrophy in multiple sclerosis patients treated periodically with boluses of methylprednisolone]. / Atrofia cerebral en pacientes con esclerosis múltiple tratados con bolos periódicos de metilprednisolona.

INTRODUCTION: In the last years advances in the treatment of the remittant and secondary progressive forms of the multiple sclerosis (MS) have taken place. In the primary progressive forms (PP) the side effects of potentially useful drugs prevent their use; in some studies an improvement of the evolution with the intravenous administration of periodic pulses of methylprednisolone (MP) has been observed. OBJECTIVE: To evaluate if periodic pulses of intravenous MP injected every 4-6 weeks increase the degree of cerebral atrophy of the patients with PP MS. PATIENTS AND METHODS: We studied 11 patients with PP MS treated during 33 months with periodic pulses of intravenous MP. The degree of cerebral atrophy was evaluated in axial cuts of 10 mm of studies of magnetic resonance with the indices of Evans, bicaudate, bifrontal, frontal spears and bithalamic. The statistical evaluation of the results was made applying the test of Wilcoxon-Mann-Whitney. RESULTS: There are not statistically significant differences in the degree of cerebral atrophy with any of the used indices. CONCLUSIONS: Periodic pulses of intravenous MP do not accelerate the cerebral atrophy in patients with progressive forms of multiple sclerosis.

Headache as a surrogate marker of the molecular mechanisms implicated in progressing stroke.

The mechanism for headache in patients with acute ischaemic stroke are not completely understood. We analysed the relationship between headache and the early worsening of neurological symptoms in patients with acute ischaemic stroke, and we studied the possible biochemical mechanisms implicated. Headache at the onset of ischaemic stroke predicted progression with a sensitivity, specificity, and positive predictive value of 56%, 99%, and 98%, respectively. CSF concentrations of glutamate, Interleukin-6, and NO-m were significantly greater in patients with progressing stroke than in patients with nonprogressing stroke, and these biochemical markers were also significantly higher in patients with headache than in those without headache. Results of this study suggest that headache at the onset of ischaemic stroke is an independent predictor of neurological worsening and we hypothesize that headache might be a surrogate marker of the molecular mechanisms involved in neurological worsening after acute stroke.