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.

El código ictus de Asturias / Code stroke in Asturias

Introducción: La trombólisis intravenosa con alteplasa es un tratamiento efectivo para el ictus isquémico si se aplica dentro de las primeras 4,5 horas, pero al que acceden <15% de los pacientes. La trombectomía mecánica recanaliza más obstrucciones proximales en las grandes arterias, pero necesita una infraestructura que la hace menos disponible. Métodos: Se detalla la evolución del código ictus en el Principado de Asturias y la adaptación del mismo a los sucesivos recursos para la atención urgente al ictus en la región. Teniendo en cuenta dichos recursos, las circunstancias poblacionales y geográficas de nuestra región, se plantea la reorganización del código ictus buscando la optimización del tiempo y la adecuación a cada paciente. Resultados: Reparto de las ocho áreas sanitarias de Asturias para derivar los pacientes candidatos a tratamientos de reperfusión hacia los dos hospitales donde se dispone de Unidad de Ictus y guardia de Neurología, con posibilidad de aplicar la fibrinólisis IV. Este reparto se realizó en función de la proximidad y la gravedad de los mismos, derivando todos los casos más graves directamente al hospital que dispone de guardia de Neurorradiología Intervencionista. El cribado del paciente se realizó por los Servicios de Emergencias Extrahospitalarias según la escala NIHSS. Conclusiones: Las modificaciones en el código ictus de Asturias permiten ofrecer tratamientos recanalizadores con buenos resultados, buscando la equidad y optimizando el manejo del binomio gravedad-tiempo para ofrecer a cada paciente el tratamiento óptimo en el menor plazo de tiempo posible y en condiciones de seguridad

Background: Intravenous thrombolysis with alteplase is an effective treatment for ischaemic stroke when applied during the first 4.5 hours, but less than 15% of patients have access to this technique. Mechanical thrombectomy is more frequently able to recanalise proximal occlusions in large vessels, but the infrastructure it requires makes it even less available. Methods: We describe the implementation of code stroke in Asturias, as well as the process of adapting various existing resources for urgent stroke care in the region. By considering these resources, and the demographic and geographic circumstances of our region, we examine ways of reorganising the code stroke protocol that would optimise treatment times and provide the most appropriate treatment for each patient. Results: We distributed the 8 health districts in Asturias so as to permit referral of candidates for reperfusion therapies to either of the 2 hospitals with 24-hour stroke units and on-call neurologists and providing IV fibrinolysis. Hospitals were assigned according to proximity and stroke severity; the most severe cases were immediately referred to the hospital with on-call interventional neurology care. Patient triage was provided by pre-hospital emergency services according to the NIHSS score. Conclusions: Modifications to code stroke in Asturias have allowed us to apply reperfusion therapies with good results, while emphasising equitable care and managing the severity-time ratio to offer the best and safest treatment for each patient as soon as possible

Code stroke in Asturias.

BACKGROUND: Intravenous thrombolysis with alteplase is an effective treatment for ischaemic stroke when applied during the first 4.5 hours, but less than 15% of patients have access to this technique. Mechanical thrombectomy is more frequently able to recanalise proximal occlusions in large vessels, but the infrastructure it requires makes it even less available. METHODS: We describe the implementation of code stroke in Asturias, as well as the process of adapting various existing resources for urgent stroke care in the region. By considering these resources, and the demographic and geographic circumstances of our region, we examine ways of reorganising the code stroke protocol that would optimise treatment times and provide the most appropriate treatment for each patient. RESULTS: We distributed the 8 health districts in Asturias so as to permit referral of candidates for reperfusion therapies to either of the 2 hospitals with 24-hour stroke units and on-call neurologists and providing IV fibrinolysis. Hospitals were assigned according to proximity and stroke severity; the most severe cases were immediately referred to the hospital with on-call interventional neurology care. Patient triage was provided by pre-hospital emergency services according to the NIHSS score. CONCLUSIONS: Modifications to code stroke in Asturias have allowed us to apply reperfusion therapies with good results, while emphasising equitable care and managing the severity-time ratio to offer the best and safest treatment for each patient as soon as possible.

Endovascular treatment of intracranial aneurysms using the Pipeline Flex embolization device: a case series of 30 consecutive patients.

BACKGROUND: The Pipeline Flex embolization device has some peculiarities in comparison with the previous generation device. Despite recent reports of the modified delivery system, its safety is still unknown. OBJECTIVE: To illustrate the intraprocedural and periprocedural complication rate with this new device in 30 consecutive patients. MATERIAL AND METHODS: Clinical, procedural, and angiographic data, including aneurysm size and location, device or devices used, angiographic and clinical data were analyzed. RESULTS: 30 patients harboring 30 aneurysms were analyzed. 39 devices were placed properly. Multiple Pipeline embolization devices (PEDs) were used in 7 cases. In 28 devices the distal end opened fully from the beginning with a complete wall apposition. In the remaining 11 devices, distal-end opening of the devices was instant but partial, but fully opened easily after recapture. Among the 30 procedures, recapture and reposition of the Pipeline Flex was performed four times owing to proximal migration/malposition of the device during delivery. Four intraprocedural/periprocedural complications occurred, of which 2 resulted in major complications, with neurologic deficits persisting for longer than 7 days. The 30-day morbidity rate was 6.6%, with no deaths. No aneurysm rupture or parenchymal hemorrhage was seen. CONCLUSIONS: The Pipeline Flex embolization device allows more precise and controlled deployment than the first-generation device. The number of devices and the complication rate during the learning curve are lower than reported with the first-generation PED. The new delivery system and the resheathing maneuvers do not seem to increase the intraprocedural complication rate in comparison with the first-generation PED.

Seguimiento mediante técnicas de neuroimagen de los aneurismas cerebrales tratados por vía endovascular / Neuroimaging follow-up of cerebral aneurysms treated with endovascular techniques

No existen recomendaciones específicas en las guías de práctica clínica sobre el tiempo, prueba de imagen ni intervalo para controlar la evolución de los aneurismas intracraneales tratados por vía endovascular. Hemos revisado la bibliografía existente en las principales bases de datos médicas usando como palabras clave: aneurisma cerebral, espirales, procedimiento endovascular y seguimiento. Nuestro objetivo ha sido, dentro del Grupo de Enfermedades Cerebrovasculares de la Sociedad Española de Neurorradiología, proponer unas recomendaciones y un protocolo orientativo, basados en la evidencia científica, para monitorizar mediante neuroimagen los aneurismas intracraneales tratados por técnicas endovasculares, incluyendo las técnicas de neuroimagen más adecuadas, el intervalo, el tiempo de seguimiento y la mejor forma de definir los hallazgos radiológicos, con el objetivo de mejorar los resultados clínicos y optimizar y racionalizar los recursos disponibles (AU)

There are no specific recommendations in clinical guidelines about the best time, imaging tests, or intervals for following up patients with intracranial aneurysms treated with endovascular techniques. We reviewed the literature, using the following keywords to search in the main medical databases: cerebral aneurysm, coils, endovascular procedure, and follow-up. Within the Cerebrovascular Disease Group of the Spanish Society of Neuroradiology, we aimed to propose recommendations and an orientative protocol based on the scientific evidence for using neuroimaging to monitor intracranial aneurysms that have been treated with endovascular techniques. We aimed to specify the most appropriate neuroimaging techniques, the interval, the time of follow-up, and the best approach to defining the imaging findings, with the ultimate goal of improving clinical outcomes while optimizing and rationalizing the use of available resources (AU)

[Neuroimaging follow-up of cerebral aneurysms treated with endovascular techniques]. / Seguimiento mediante técnicas de neuroimagen de los aneurismas cerebrales tratados por vía endovascular.

There are no specific recommendations in clinical guidelines about the best time, imaging tests, or intervals for following up patients with intracranial aneurysms treated with endovascular techniques. We reviewed the literature, using the following keywords to search in the main medical databases: cerebral aneurysm, coils, endovascular procedure, and follow-up. Within the Cerebrovascular Disease Group of the Spanish Society of Neuroradiology, we aimed to propose recommendations and an orientative protocol based on the scientific evidence for using neuroimaging to monitor intracranial aneurysms that have been treated with endovascular techniques. We aimed to specify the most appropriate neuroimaging techniques, the interval, the time of follow-up, and the best approach to defining the imaging findings, with the ultimate goal of improving clinical outcomes while optimizing and rationalizing the use of available resources.

Tratamiento endovascular y trombólisis intraarterial en el ictus isquémico agudo / Endovascular treatment and intra-arterial thrombolysis in acute ischemic stroke

Objetivo: Analizar la eficacia y la seguridad de la trombólisis intraarterial y el tratamiento endovascular en pacientes con ictus isquémico agudo. Diseño y ámbito: Estudio prospectivo observacional en una unidad de cuidados intensivos. Pacientes: Dieciséis pacientes recibieron tratamiento endovascular. Se recogieron datos epidemiológicos, localización de la oclusión arterial, tiempo desde el ictus al tratamiento, indicación del tratamiento, National Institutes of Health Stroke Scale al ingreso y al alta hospitalaria, y complicaciones y evolución funcional por escala de Rankin modificada realizada mediante una encuesta telefónica. Resultados: Diez varones, con una edad media de 59 años (29-74) y una estancia media en la unidad de cuidados intensivos de 6 días (1-33). Siete pacientes requirieron ventilación mecánica. Indicación del tratamiento: 4 casos por fracaso de la trombólisis intravenosa, 5 por oclusión de gran vaso, 2 por estar fuera de la ventana terapéutica, 3 por oclusión de la circulación posterior, uno por estar fuera de la ventana terapéutica y tener, además, una oclusión de gran vaso y uno por contraindicación para la trombólisis intravenosa. Localización de la oclusión: 3 en la circulación posterior y 13 en el territorio carotídeo y sus ramas. El fibrinolítico utilizado fue uroquinasa en dosis de 100.000-600.000 UI. Cuatro pacientes requirieron embolectomía mecánica y 10, implantación de stent. Se obtuvo recanalización completa en 11 pacientes (69%) y parcial en 4 (25%). Tres pacientes evolucionaron a muerte encefálica. Seis pacientes (46%) tuvieron una buena recuperación (escala de Rankin modificada <2). Como complicación técnica destacó un seudoaneurisma de la arteria femoral. Conclusiones: El tratamiento intraarterial obtiene altas tasas de recanalización y buenos resultados funcionales con escasas complicaciones. Su uso estaría indicado en pacientes con afectación neurológica importante (National Institutes of Health Stroke Scale >10) -tiempo de evolución de 3-6h-, y contraindicacio'n para la trombólisis intravenosa y la oclusión arterial proximal (AU)

Objective: Analysis of the safety and efficacy of intra-arterial thrombolysis therapy and endovascular treatment in acute ischemic stroke. Design and area: An observational prospective study in the Intensive Care Unit. Patients and methods: 16 patients had endovascular treatment. Epidemiological data, arterial occlusion site, time between stroke onset and treatment, treatment indication, NIHSS scale at admission and discharge from hospital, complications and functional outcome measured by modified Rankin scale (obtained by telephone survey) were collected. Results: Ten male patients with a mean age of 59 years (29-74) were included. The mean stay in the ICU was 6 days (1-33). Seven patients required mechanical ventilation. Treatment indications were: intravenous thrombolysis failure in 4 patients, major vessel occlusion in 5, outside of the therapeutic window in 2, posterior circulation occlusion in 3, outside of the therapeutic window plus major vessel occlusion in 1 and intravenous thrombolysis contraindication in 1. The occlusion site was on posterior circulation in 3 and on carotid territories and branches in 13. Thrombolytic treatment used was Urokinase at a dose of 100,000-600,000IU. Four patients required mechanical embolectomy and 10 stent implantation. Complete recanalization was observed in 11 (69%) and partial in 4 (25%). Three evolved to brain death. Six patients (46%) had a favorable outcome (modified Rankin scale score <2). Technical complication was 1 femoral artery pseudoaneurysm. Conclusions: With the intra-arterial treatment, high rates of recanalization and favorable outcome are obtained with few complications. It could be indicated in patients with severe neurological injury (NIHSS >10), evolution time between 3-6h, intravenous thrombolysis contraindication and proximal arterial occlusion (AU)

Confirmación angiográfica de la resolución espontánea de dos fistulas carotidocavernosas de bajo flujo / Angioplasty confirmation of the spontaneous

No disponible

No disponible

[Endovascular treatment and intra-arterial thrombolysis in acute ischemic stroke]. / Tratamiento endovascular y trombólisis intraarterial en el ictus isquémico agudo.

OBJECTIVE: Analysis of the safety and efficacy of intra-arterial thrombolysis therapy and endovascular treatment in acute ischemic stroke. DESIGN AND AREA: An observational prospective study in the Intensive Care Unit. PATIENTS AND METHODS: 16 patients had endovascular treatment. Epidemiological data, arterial occlusion site, time between stroke onset and treatment, treatment indication, NIHSS scale at admission and discharge from hospital, complications and functional outcome measured by modified Rankin scale (obtained by telephone survey) were collected. RESULTS: Ten male patients with a mean age of 59 years (29-74) were included. The mean stay in the ICU was 6 days (1-33). Seven patients required mechanical ventilation. Treatment indications were: intravenous thrombolysis failure in 4 patients, major vessel occlusion in 5, outside of the therapeutic window in 2, posterior circulation occlusion in 3, outside of the therapeutic window plus major vessel occlusion in 1 and intravenous thrombolysis contraindication in 1. The occlusion site was on posterior circulation in 3 and on carotid territories and branches in 13. Thrombolytic treatment used was Urokinase at a dose of 100,000-600,000IU. Four patients required mechanical embolectomy and 10 stent implantation. Complete recanalization was observed in 11 (69%) and partial in 4 (25%). Three evolved to brain death. Six patients (46%) had a favorable outcome (modified Rankin scale score ≤ 2). Technical complication was 1 femoral artery pseudoaneurysm. CONCLUSIONS: With the intra-arterial treatment, high rates of recanalization and favorable outcome are obtained with few complications. It could be indicated in patients with severe neurological injury (NIHSS ≥ 10), evolution time between 3-6h, intravenous thrombolysis contraindication and proximal arterial occlusion.

Tratamiento intravascular de la oclusión aguda carotídea con lesión en tándem intracraneal / Intravascular treatment for acute carotid occlusion with an intracranial tandem lesion

Se presenta el caso clínico de un paciente con una obstrucción aguda en el origen de la arteria carótida interna, a la que se asocia oclusión del segmento 1 de la arteria cerebral media homolateral con deterioro neurológico grave. Se describen las pruebas de neuroimagen (tomografía computarizada [TC] craneal sin contraste, angiografía por TC, perfusión por TC y arteriografía cerebral) y el tratamiento intravascular (fibrinólisis mecánica y farmacológica intraarteriales) con buen resultado morfológico y clínico. Se analiza el seguimiento del paciente (AU)

We present the case of a patient with an acute obstruction in the origin of the internal carotid artery that was associated with occlusion of segment one of the ipsilateral medial cerebral artery and severe neurologic deterioration. We describe the neuroimaging findings (unenhanced cranial computed tomography [CT], CT angiography, CT perfusion studies, and cerebral angiography) and the intravascular treatment (mechanical and pharmacological intra-arterial fibrinolysis). Treatment yielded good morphological and clinical results; we also analyze the follow-up of the patient (AU)

[Intravascular treatment for acute carotid occlusion with an intracranial tandem lesion]. / Tratamiento intravascular de la oclusión aguda carotídea con lesión en tándem intracraneal.

We present the case of a patient with an acute obstruction in the origin of the internal carotid artery that was associated with occlusion of segment one of the ipsilateral medial cerebral artery and severe neurologic deterioration. We describe the neuroimaging findings (unenhanced cranial computed tomography [CT], CT angiography, CT perfusion studies, and cerebral angiography) and the intravascular treatment (mechanical and pharmacological intra-arterial fibrinolysis). Treatment yielded good morphological and clinical results; we also analyze the follow-up of the patient.

Sinus pericranii asociado a trombosis espontánea de la vena oftálmica: estudios de neuroimagen / Sinus pericranii associated to spontaneous thrombosis of the ophthalmic vein: neuroimaging studies

El sinus pericranii es una comunicación venosa anormal entre los senos durales intracraneales y dilataciones venosas epicraneales. La localización periorbitaria es infrecuente. Se han descrito trombosis parciales espontáneas de las varices subcutáneas asociadas a clínica local, pero no hay ningún caso recogido en la bibliografía asociado a trombosis en la vena oftálmica. Se relaciona con malformaciones arteriovenosas y linfaticovenosas. Se presenta un caso de un paciente con un trastorno generalizado y difuso del drenaje venoso que afectaba al hemisferio cerebral derecho, que acudió al servicio de urgencias con clínica oftalmológica secundaria a trombosis de la vena oftálmica superior y que presentaba 3 sinus pericranii de localización frontal, parietal y occipital derechos (AU)

Sinus pericranii is an abnormal venous communication between the intracranial dural sinuses and epicranial venous dilatations. The periorbital location is uncommon; spontaneous partial thromboses of the subcutaneous varices have been reported in association with local signs and symptoms; however, to our knowledge there are no reports of sinus pericranii associated to thrombosis in the ophthalmic vein. Sinus pericranii is related to arteriovenous and lymphatic-venous malformations. We present the case of a patient with a generalized and diffuse disorder of venous drainage that affected the right cerebral hemisphere who presented at the emergency department with ophthalmologic signs and symptoms after thrombosis of the superior ophthalmic vein and who had three sinus pericranii located in the frontal, parietal, and occipital areas (AU)

[Sinus pericranii associated to spontaneous thrombosis of the ophthalmic vein: neuroimaging studies]. / Sinus pericranii asociado a trombosis espontánea de la vena oftálmica: estudios de neuroimagen.

Sinus pericranii is an abnormal venous communication between the intracranial dural sinuses and epicranial venous dilatations. The periorbital location is uncommon; spontaneous partial thromboses of the subcutaneous varices have been reported in association with local signs and symptoms; however, to our knowledge there are no reports of sinus pericranii associated to thrombosis in the ophthalmic vein. Sinus pericranii is related to arteriovenous and lymphatic-venous malformations. We present the case of a patient with a generalized and diffuse disorder of venous drainage that affected the right cerebral hemisphere who presented at the emergency department with ophthalmologic signs and symptoms after thrombosis of the superior ophthalmic vein and who had three sinus pericranii located in the frontal, parietal, and occipital areas.