Endovascular treatment of ischemic stroke due to isolated internal carotid artery occlusion: ETIS registry data analysis.

BACKGROUND: The best treatment for acute ischemic stroke (AIS) due to isolated cervical internal carotid artery occlusion (CICAO) (i.e., without associated occlusion of the circle of Willis) is still unknown. In this study, we aimed to describe EVT safety and clinical outcome in patients with CICAO. METHODS: We analyzed data of all consecutive patients, included in the Endovascular Treatment in Ischemic Stroke (ETIS) Registry between 2013 and 2020, who presented AIS and proven CICAO on angiogram and underwent EVT. We assessed carotid recanalization, procedural complications, National Institutes of Health Stroke Scale (NIHSS) at 24 h post-EVT, and 3-month favorable outcome (modified Rankin Scale, mRS ≤ 2 or equal to the pre-stroke value). RESULTS: Forty-five patients were included (median age: 70 years; range: 62-82 years). The median NIHSS before EVT was 14 (9-21). Carotid stenting was performed in 23 (51%) patients. Carotid recanalization at procedure end and on control imaging was observed in 37 (82%) and 29 (70%) patients, respectively. At day 1 post-EVT, the NIHSS remained stable or decreased in 25 (60%) patients; 12 (29%) patients had early neurologic deterioration (NIHSS ≥ 4 points). The rate of procedural complications was 36%, including stent thrombosis (n = 7), intracranial embolism (n = 7), and symptomatic intracranial hemorrhage (n = 1). At 3 months, 18 (40%) patients had a favorable outcome, and 10 (22%) were dead. CONCLUSION: Our study suggests that EVT in AIS patients with moderate/severe initial deficit due to CICAO led to high rate of recanalization at day 1, and a 40% rate of favorable outcome at 3 months. There was a high rate of procedural complication which is of concern. Randomized controlled trials assessing the superiority of EVT in patients with CICAO and severe deficits are needed.

Clinical Outcome of Acute Ischemic Strokes in Patients with COVID-19.

INTRODUCTION: Acute ischemic stroke (AIS) and thrombotic events (TEs) were reported in patients with COVID-19. Clinical outcome of AIS in the course of COVID-19 remains unknown. We compared early clinical outcome and mortality of COVID-positive (+) patients admitted for AIS with COVID-negative (-) ones. We hypothesized that COVID+ patients would have poorer clinical outcomes and present a higher rate of TEs and mortality compared with COVID- ones. METHODS: In this multicentric observational retrospective study, we enrolled patients over 18 years old admitted for AIS in 3 stroke units of the Parisian region during lockdown from March 17, 2020, to May 2, 2020. COVID-19 status as well as demographic, clinical, biological, and imaging data was collected retrospectively from medical records. Poor outcome was defined as modified Rankin score (mRS) 3-6 (3-6) at discharge. We also compared TE frequency and mortality rate through a composite criterion in both groups. RESULTS: Two hundred and sixteen patients were enrolled; mean age was 68 years old, and 63% were male. Forty patients were CO-VID+ (18.5%) and 176 were COVID-. Obesity was statistically more frequent in the COVID+ group (36 vs. 13% p < 0.01). The percentage of patients with mRS (3-6) at discharge was higher in the COVID+ group compared with the COVID- group (60 vs. 41%, p = 0.034). The main predictor of presenting a mRS (3-6) at discharge was high NIHSS score at admission (OR, CI 95%: 1.325, 1.22-1.43). Mortality rate was higher in the COVID+ group (12 vs. 3.4%, p = 0.033) as well as TE frequency (15 vs. 2.8%, p < 0.01). CONCLUSION: In this study, patients with AIS infected by SARS-CoV-2 showed a poorer early outcome than COVID- ones. However, when compared to other factors, COVID-19 was not a significant predictor of poor outcome. Vascular morbidity and mortality rates were significantly higher in the COVID+ group compared with the COVID- group.

Brain Abscesses After Endovascular Embolization of a Brain Arteriovenous Malformation with Squid.

BACKGROUND: The use of nonadhesive liquid embolic agents (NALEAs) has gained great popularity in the treatment of brain vascular malformations, with a lower rate of local complications than surgery. However, we describe the formation of brain abscesses after endovascular treatment of a brain arteriovenous malformation (bAVM) and how important removal of the NALEAs was in the treatment of these abscesses. CASE DESCRIPTION: A 68-year-old man presented with seizures after being treated for an unruptured bAVM using Squid (Emboflu), an NALEA. Radiologic imaging revealed brain lesions suspicious of abscesses around the previously treated bAVM. A surgical excision of the bAVM and the embolized material was performed as was drainage of the brain abscesses. Bacterial cultures were positive for Enterococcus faecalis, and the patient left the hospital with an appropriate antibiotic regimen without new deficits. CONCLUSIONS: This is the first reported case of a bAVM treated with Squid complicated with brain abscesses, a rare but very serious complication. This complication should be treated not only using antibiotherapy but with complete safe removal of the embolic material.

Intracranial Extension of Extracranial Vertebral Dissection Is Associated With an Increased Risk of Ischemic Events.

Background and Purpose- Intracranial artery dissection can eventually lead to subarachnoid or intracerebral hemorrhage. Little is known about the clinical features and risks associated with extracranial vertebral artery dissection that extends intracranially. The clinical and imaging characteristics of extracranial vertebral artery dissection (eVAD) with (e+iVAD) or without (eVAD) intracranial extension were analyzed. Methods- The frequency of ischemic events, including ischemic strokes and transient ischemic attacks, was compared between e+iVAD and eVAD patients from a monocentric cohort study. Results- Among 328 patients with cervical artery dissection, vertebral artery dissection was diagnosed in 153 individuals. Twenty-nine patients had e+iVAD (19%) and 124 patients had only eVAD (81%). Cardiovascular risk factors did not differ between these 2 groups, but ischemic events were more frequent in patients with e+iVAD than in patients with eVAD (86% versus 48%, P=0.0002). Subarachnoid hemorrhage occurred in 1 patient with e+iVAD and in 9 with eVAD (6% versus 3%, P=0.53). Intracranial extension was an independent factor associated with ischemic stroke at admission (odds ratio, 6.43; 95% CI, -1.96 to 21.08; P=0.002) after adjustment for cardiovascular risk factors and imaging findings. Conclusions- In a large cohort of patients with vertebral artery dissection, intracranial extension of the vessel dissection appears associated with an increased risk of ischemic stroke.

Alterations of the cerebral cortex in sporadic small vessel disease: A systematic review of in vivo MRI data.

Cerebral small vessel diseases of the brain are a major determinant of cognitive impairment in the elderly. In small vessel diseases, the most easily identifiable lesions, both at post-mortem evaluation and magnetic resonance imaging, lie in subcortical areas. However, recent results obtained post-mortem, particularly in severe cases, have highlighted the burden of cortex lesions such as microinfarcts and diffuse neuronal loss. The recent development of image post-processing methods allows now assessing in vivo multiple aspects of the cerebral cortex. This systematic review aimed to analyze in vivo magnetic resonance imaging studies evaluating cortex alterations at different stages of small vessel diseases. Studies assessing the relationships between small vessel disease magnetic resonance imaging markers obtained at the subcortical level and cortex estimates were reviewed both in community-dwelling elderly and in patients with symptomatic small vessel diseases. Thereafter, studies analyzing cortex estimates in small vessel disease patients compared with healthy subjects were evaluated. The results support that important cortex alterations develop along the course of small vessel diseases independently of concomitant neurodegenerative processes. Easy detection and quantification of cortex changes in small vessel diseases as well as understanding their underlying mechanisms are challenging tasks for better understanding cognitive decline in small vessel diseases.