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Background and Purpose: Acute ischemic stroke and large vessel occlusion can be concurrent with the coronavirus disease 2019 (COVID-19) infection. Outcomes after mechanical thrombectomy (MT) for large vessel occlusion in patients with COVID-19 are substantially unknown. Our aim was to study early outcomes after MT in patients with COVID-19., Methods: Multicenter, European, cohort study involving 34 stroke centers in France, Italy, Spain, and Belgium. Data were collected between March 1, 2020 and May 5, 2020. Consecutive laboratory-confirmed COVID-19 cases with large vessel occlusion, who were treated with MT, were included. Primary investigated outcome: 30-day mortality., Secondary Outcomes: early neurological improvement (National Institutes of Health Stroke Scale improvement ≥8 points or 24 hours National Institutes of Health Stroke Scale 0-1), successful reperfusion (modified Thrombolysis in Cerebral Infarction grade ≥2b), and symptomatic intracranial hemorrhage., Results: We evaluated 93 patients with COVID-19 with large vessel occlusion who underwent MT (median age, 71 years [interquartile range, 59-79]; 63 men [67.7%]). Median pretreatment National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score were 17 (interquartile range, 11-21) and 8 (interquartile range, 7-9), respectively. Anterior circulation acute ischemic stroke represented 93.5% of cases. The rate modified Thrombolysis in Cerebral Infarction 2b to 3 was 79.6% (74 patients [95% CI, 71.3-87.8]). Thirty-day mortality was 29% (27 patients [95% CI, 20-39.4]). Early neurological improvement was 19.5% (17 patients [95% CI, 11.8-29.5]), and symptomatic intracranial hemorrhage was 5.4% (5 patients [95% CI, 1.7-12.1]). Patients who died at 30 days exhibited significantly lower lymphocyte count, higher levels of aspartate, and LDH (lactate dehydrogenase). After adjustment for age, initial National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, and successful reperfusion, these biological markers remained associated with increased odds of 30-day mortality (adjusted odds ratio of 2.70 [95% CI, 1.21-5.98] per SD-log decrease in lymphocyte count, 2.66 [95% CI, 1.22-5.77] per SD-log increase in aspartate, and 4.30 [95% CI, 1.43-12.91] per SD-log increase in LDH)., Conclusions: The 29% rate of 30-day mortality after MT among patients with COVID-19 is not negligible. Abnormalities of lymphocyte count, LDH and aspartate may depict a patient's profiles with poorer outcomes after MT. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT04406090.

Background: Circumferential wrapping of the aneurysm wall with a variety of materials is a well-known therapeutic approach for the repair of unclippable intracranial aneurysms (IAs). Wrapping materials can stimulate foreign-body inflammatory reactions and parent artery narrowing with resultant ischemic stroke. In this study, a single-center retrospective review of the outcome with wrapping of IAs is presented beside an analysis of existing literature., Methods: For the institutional analysis, all patients who underwent wrapping of IAs in the last five years were analyzed. For the analysis of the literature, a MEDLINE search between 1990 and the present was performed for clinical series reporting wrapping of IAs. Specifically, the risk of rebleeding, cerebrovascular complications, and the incidence of granuloma formation were evaluated., Results: Two hundred and ninety patients with IA were surgically treated in our department. Fifteen patients (5.2%) underwent wrapping of IA. Early parent artery narrowing occurred in one patient (6.7%) and was associated with ischemic stroke. Delayed cerebrovascular complications, including parent artery narrowing (one case), granuloma formation (one case), and fatal bleeding from an unruptured aneurysm, occurred in three patients (20%). For the review of the literature, 197 cases of wrapped aneurysms were collected. Bleeding after wrapping occurred in 16 (12%) of the patients with ruptured aneurysms. Acute ischemic complications were reported in 7 cases (3.5%) and granuloma formation was observed in 3 patients (1.5%)., Conclusions: These data suggest that the microsurgical wrapping of IAs present a risk of ischemic complications and granuloma formation. Additionally, the rebleeding rate of ruptured aneurysms remains high, although still lower than the natural history of untreated ruptured aneurysms.

Purpose. The long-term efficacy of carotid artery stenting is debated. Predictors of stent restenosis are not fully investigated. Our aim was to assess the incidence of long term restenosis after CAS and to identify some predictors of restenosis. Methods. We retrospectively selected 189 treated patients and we obtained the survival Kaplan-Meier curves for overall survival, for freedom from stroke or death and from restenosis. To correlate clinical, radiological, and procedural variables to stent restenosis, an univariate analysis was performed while to determine independent predictors of restenosis, a multivariate analysis was applied. Results. At 1, 3, and 5 years, the cumulative overall survival rate was 98%, 94%, and 92% with a cumulative primary patency rate of 87%, 82.5%, and 82.5%. The percentage residual stenosis after CAS and multiple stents deployment were independent predictors of restenosis, while diabetes and tumors are suggestive but not significant predictors of restenosis. Conclusions. In our CAS experience, encouraging long-term results seem to derive from both neurological event free rate and restenosis incidence. Adequate recanalization of the treated vessel is important to limit the development of stent restenosis. Multiple stents deployment, and with less evidence, diabetes, or neoplasms has to be considered to facilitate restenosis.

The rotational variance dependence of diffusion tensor imaging (DTI) derived parameters on the number of diffusion weighting directions (N) has been investigated by several Monte Carlo simulation studies. However, the dependence of fractional anisotropy (FA) and mean diffusivity (MD) maps on N, in terms of accuracy and contrast between different anatomical structures, has not been assessed in detail. This experimental study further investigated in vivo the effect of the number of diffusion weighting directions on DTI maps of FA and MD. Human brain FA and MD maps of six healthy subjects were acquired at 1.5T with varying N (6, 11, 19, 27, 55). Then, FA and MD mean values in high (FAH, MDH) and low (FAL, MDL) anisotropy segmented brain regions were measured. Moreover, the contrast-to-signal variance ratio (CVRFA, CVRMD) between the main white matter and the surrounding regions was calculated. Analysis of variance showed that FAL, FAH and CVRFA significantly (p < 0.05) depend on N. In particular, FAL decreased (6%-11%) with N, whereas FAH (1.6%-2.5%) and CVRFA (4%-6.5%) increased with N. MDL, MDH and CVRMD did not significantly (p>0.05) depend on N. Unlike MD values, FA values significantly vary with N. It is noteworthy that the observed variation is opposite in low and high anisotropic regions. In clinical studies, the effect of N may represent a confounding variable for anisotropy measurements and the employment of DTI acquisition schemes with high N (> 20) allows an increased CVR and a better visualization of white matter structures in FA maps.

Objectives: To assess midbrain atrophy through morphometric (linear, surface and volumetric) measurements in patients with clinically diagnosed progressive supranuclear palsy (PSP) and to establish the most accurate measure to be implemented in routine magnetic resonance (MR) protocol in distinguishing PSP from healthy subjects and MSA-p (multiple system atrophy, parkinsonian form) patients., Materials and Methods: We studied 15 patients with the diagnosis of probable PSP, seven patients with the diagnosis of probable MSA-p and 14 age-matched healthy volunteers. MR protocol includes a sagittal SE T1-weighted sequence for cross-sectional area and linear brainstem measurements and a 3D-FSPGR sequence for brainstem volume measurements., Results: A highly significant difference in the antero-posterior midbrain diameter, area and volume in PSP compared with control subjects was found. Only a measurement of the midbrain area and pons area enabled one to distinguish between PSP and MSA-p. Receiver operating characteristic analysis revealed that the midbrain area has the highest diagnostic accuracy in distinguishing between PSP and other conditions, with a sensitivity of 100% and specificity of 90.5%. The addition of the midbrain area/pons area ratio (A(ms)/A(pn) ratio) measurement improves the specificity in distinguishing between PSP and MSA., Conclusions: Morphological indexes indicate midbrain atrophy in PSP patients The combination of the A(ms) and A(ms)/A(pn) ratio measurements allows to discriminate between PSP and other conditions.

Objective: To report our recent experience in transarterial embolisation of dural arteriovenous malformations (DAVM) using a new liquid embolic agent, Onyx18., Patients and Methods: 6 patients were enrolled in this series. Clinical presentation was separated into 2 groups: aggressive (n=2), non aggressive (n=4). The DAVM was located at the superior sagittal sinus (n=1), at the transverse sinus (n=2), at the condylian canal (n=1), in the lesser sphenoid wing region (n=1), and in the tentorium region (n=1). The DAVM drained directly into a condylian or a cortical vein for three patients and into a venous sinus with cortical venous reflux for the three others. In this latter situation, the sinus was anatomically excluded from the normal brain venous drainage., Results: A full brain angiogram including both internal carotid arteries, both external carotid arteries and ipsilateral vertebral artery, was performed before and after each treatment. The feeder chosen after a selective catheterisation for Onyx18 injection was always meningeal. Each treatment consisted of a single Onyx injection after one unique feeder catheterisation. Complete anatomical exclusion of the DAVM was achieved and demonstrated by the post treatment angiogram in all cases. There was no clinical complication after the treatment., Conclusion: Onyx18 used is a safe treatment for DAVMs. When its injection is performed in optimal conditions, it fills the total DAVM and its drainage vein or sinus after a single arterial feeder catheterisation.

Background and Purpose: Percutaneous transluminal angioplasty with stent (CAS) is an alternative method to endarterectomy in the revascularization of carotid artery stenosis. Protected CAS is currently used to prevent distal embolization. Diffusion-weighted MRI (DWI) is the most sensitive tool to evaluate silent cerebral ischemia. The purpose of this research was to assess the incidence of cerebral embolic lesions during CAS and to evaluate whether cerebral protection devices can reduce the number of silent cerebral ischemia with respect to unprotected CAS., Methods: Fifty-two patients with high-grade internal stenosis underwent CAS; 30 patients (group a) were treated with a cerebral protection device, and 22 (group b) were treated without it. All of the patients were evaluated preoperatively and postoperatively with fluid-attenuated inversion recovery and DWI sequences to depict the number of new embolic silent cerebral lesions., Results: Embolic silent cerebral lesions occurred in 30% of CAS. Cerebral protection devices reduce the number of new lesions significantly reducing the consistent lesions ipsilateral to the treated vessel. Inconsistent lesions do not differ in both groups of patients. Clinical, radiological, and procedural variables do not correlate with the appearance of new cerebral lesions., Conclusions: Embolic cerebral lesions detected with DWI are more frequent with unprotected CAS, although they are present also with the use of cerebral protection devices. Probably a part of silent cerebral lesions arise from the procedural maneuver in the aortic arch.

Purpose: To prospectively evaluate several diffusion-tensor magnetic resonance (MR) imaging indexes (mean diffusivity [MD], fractional anisotropy [FA], and eigenvalues) of corticospinal tract impairment in patients with progressive muscular atrophy (PMA) and patients with amyotrophic lateral sclerosis (ALS)., Materials and Methods: This study had institutional review board approval, and written informed consent was obtained from all subjects. Eight male patients with PMA (mean age, 63 years +/- 13 [standard deviation]), eighteen patients with ALS (14 men and four women; mean age, 64 years +/- 7), and twelve control subjects (four men and eight women; mean age, 65 years +/- 6) underwent diffusion-tensor MR imaging at which 25 spin-echo echo-planar imaging diffusion-weighted images (b = 1000 sec/mm2) were acquired along noncollinear directions. MD and FA were measured along the corticospinal tracts in each patient and subject. Changes in diffusion along and orthogonal to fiber bundles in patients were evaluated by using diffusion-tensor eigenvalues. Differences in diffusion-tensor imaging indexes between patients with PMA and those with ALS, as compared with these indexes in control subjects, were evaluated with Mann-Whitney testing. Correlations between diffusion-tensor imaging indexes and clinical variables were estimated with Pearson and Spearman rank correlation testing., Results: As compared with MD (697.1 x 10(-6) mm2/sec +/- 28.1) and FA (0.585 +/- 0.032) in control subjects, MD was typically significantly increased (734.7 x 10(-6) mm2/sec +/- 41.2, P = .035) and FA significantly decreased (0.534 +/- 0.053, P = .037) along the corticospinal tracts in patients with ALS, while these parameters showed no significant change in patients with PMA (MD, 707.0 x 10(-6) mm2/sec +/- 44.2; FA, 0.559 +/- 0.028). Estimation of diffusion-tensor eigenvalues revealed normal diffusion along fiber tracts in all patients, while diffusion was increased orthogonal to fiber tracts only in patients with typical ALS. In patients with ALS, MD correlated with disease duration while FA correlated with disease severity., Conclusion: Diffusion-tensor MR imaging reveals corticospinal tract impairment in ALS but not in PMA., (RSNA, 2005)

The purpose was to evaluate the blood flow redistribution in the neck vessels of patients with internal carotid artery (ICA) stenosis. Eighty-six patients with ICA stenosis underwent contrast-enhanced magnetic resonance angiography (CEMRA) and fast 2D phase contrast (2D-PC) sequence to measure the mean blood flow (MBF) of ICA, basilar artery (BA) and middle cerebral artery (MCA). CEMRA revealed 53 severe stenoses, 45 moderate stenoses and 3 occluded vessels. Patients with a unilateral severe ICA stenosis had a significantly reduced MBF of the ICA compared to the control group; the MBF reduction of the severely stenosed ICA was less conspicuous if associated with a controlateral severe stenosis. The MBF of the BA increased significantly in the presence of the bilateral severe ICA stenosis and in the ICA occlusion. The MBF of the MCA was unchanged in the presence of various degrees of ICA stenosis. Measurement of MBF with fast PC MRA permits cerebropethal blood flow assessment and gives additional information in grading ICA stenosis. The reduced MBF of a severe ICA stenosis has to be considered with caution since it depends also on the status of the controlateral ICA and may be considered a confident parameter only in case of unilateral carotid stenosis.