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Inflammatory markers for the prognosis of acute ischemic stroke (AIS) with endovascular therapy remain unclear. The purpose of this study was to investigate the association between the systemic inflammatory response index (SIRI) and neutrophil-to-lymphocyte ratio (NLR) with unfavorable functional outcomes at 90-day in individuals of AIS who underwent endovascular therapy. A total of 128 AIS patients who had endovascular therapy were enrolled from the Nanjing Stroke Registry between September 2019 and November 2022. Peripheral venous blood was collected from patients within 24 h of admission for information on the following parameters: neutrophil count, lymphocyte count, and monocyte count. Then, the SIRI and NLR values were calculated and the association among SIRI, NLR, and modifled Rankin Scale scores 90 days after endovascular therapy was examined via univariate and multivariate logistic analyses. Receiver operating characteristic curves were utilized to determine the best threshold for SIRI and NLR in predicting negative neurological outcomes following endovascular treatment for patients with AIS. A total of 128 participants were evaluated, among which 50% had unfavorable outcomes. Linear regression analysis showed that the best threshold for SIRI was >1.407 (odds ratio = 1.265; 95% confidence interval, 1.071–1.493; P = 0.006), and for NLR it was >5.347 (odds ratio = 1.088; 95% confidence interval, 1.007–1.175; P = 0.033). These results revealed NLR and SIRI as significant predictors of unfavorable outcomes at 90 days. The area under the curve for SIRI and NLR in predicting 90-day adverse outcomes was 0.643 and 0.609, respectively. Higher SIRI and NLR levels at admission may lead to unfavorable outcomes at 90 days for AIS patients with endovascular therapy. [ABSTRACT FROM AUTHOR]

We aim to assess the incidence and impact of in-hospital medical complications (MCs) on clinical outcomes in acute ischemic stroke (AIS) patients after endovascular therapy (EVT). AIS patients who underwent EVT were consecutively recruited from January 2019 to July 2022. The primary outcome was a poor 3-month functional outcome, defined as a modified Rankin Scale score (mRS) of 3–6. The safety variables were symptomatic intracerebral hemorrhage and mortality at 7 and 30 days. A total of 306 (50.1%) patients experienced at least one of the MCs. The most common MC was pneumonia (42.6%). Multivariate analysis revealed that the setting of MCs was an independent predictor of a poor 3-month functional outcome (adjusted odds ratio [aOR] 4.40, 95% confidence interval [CI] 3.01–6.42; P < 0.001). In the subgroup analysis, this trend was significant, especially in the patients aged 60–75 years (aOR 5.87, 95% CI 3.45–9.97; P < 0.001) or with baseline NIHSS (≤16) (aOR 5.05, 95% CI 2.84–9.01; P < 0.001). For individuals, cardiac events (aOR 8.56, 95% CI 4.05–18.09; P < 0.001), pneumonia (aOR 5.08, 95% CI 3.42–7.55; P < 0.001), and gastrointestinal bleeding (GIB) (aOR 6.12, 95% CI 3.40–11.01; P < 0.001) were independently associated with the poor 3-month outcome. The setting of MCs was independently associated with symptomatic intracerebral hemorrhage (aOR 2.11, 95% CI 1.22–3.64; P = 0.007) and mortality at 30 days (aOR 2.11, 95% CI 1.22–3.64; P = 0.007) after adjustment, but not with mortality at 7 days. MCs in AIS patients after EVT have a high incidence, despite successful reperfusion, adversely affecting clinical outcomes and increasing short-term mortality. [ABSTRACT FROM AUTHOR]

Challenging arterial anatomy may prevent timely endovascular treatment (EVT) of acute ischemic stroke (AIS) through a transfemoral approach prompting the use of alternative access routes. We determined the crossover rate from femoral to radial access during EVT of AIS due to large vessel occlusion and identified its radiological predictors and clinical outcomes. Retrospective review of all AIS patients who underwent EVT at a single institution from January 2016 to March 2021 was performed. A primary and a secondary radial group depending on whether the radial approach was used primarily or secondary to failure of transfemoral approach were compared. A total of 358 consecutive AIS patients with large vessel occlusion underwent EVT. Radial approach was used primarily in 6 patients (primary radial [PR]) and secondarily in 16 patients (secondary radial [SR]). The rate of femoral to radial crossover was 4.7%. Type III arch and bovine arch configurations were the most common characteristic in the crossover group. Radial access was successful to secure intracranial access in all cases of PR and in 87% of crossover cases. There was no significant difference between the rates of successful reperfusion (53.3% SR, 83% PR, P = 0.20), National Institutes of Health Stroke Scale score on discharge (19 SR, 18 PR group, P = 0.90), or good outcome defined as modified Rankin Scale score 0–2 (13.3% SR, 33.3% PR, P = 0.29). A radial approach can be considered during EVT of AIS due to large vessel occlusion either primarily or secondarily with a lower threshold to switch from the femoral approach in cases of challenging anatomy. [ABSTRACT FROM AUTHOR]

Distal anterior cerebral aneurysm (DACA) represents 4% of intracranial aneurysms. Two treatment modalities are available: microsurgery and endovascular therapy (EVT). To compare the results between microsurgery and EVT in a modern French cohort. A multicenter retrospective cohort study of 3 French neurosurgical units was carried out from January 1, 2015, to December 31, 2020. All participants were adult patients who required treatment for a ruptured or unruptured DACA aneurysm. A total of 69 patients were included; 16 patients (23.2%) were treated by microsurgery and 53 (76.8%) were treated by EVT. Thirty-one patients (44.9%) had ruptured aneurysms. The complication rate was low, with 1 death and 1 symptomatic ischemia. There was no difference in complications between microsurgery and EVT (P = 0.22). The number of retreatments was higher in EVT (15% vs. 0%) but not significantly (P = 0.18). In the specific subgroup of DACA, both treatment modalities are effective in ruptured and unruptured aneurysms, with a low rate of complications. Retreatment may be more frequent in EVT but it does not lead to more complications. [ABSTRACT FROM AUTHOR]

Direct carotid cavernous fistulas (dCCF) involve pathologic shunting from the internal carotid artery into the cavernous sinus. We systematically reviewed the methods and outcomes of endovascular therapy for dCCF. PubMed, Scopus, and EMBASE were used to identify studies that reported outcomes for patients undergoing embolization of dCCF. Outcomes included rates of occlusion, complications, symptom improvement, and recurrence. Pooled rates for each outcome were obtained with random effects models. The influence of embolization method on outcomes was assessed with meta-regressions. There were 16 studies comprising 270 patients. The mean age was 39.6 years, there were 36.3% females, and the mean follow-up was 19.7 months. Coils were the most common method of embolization (69.3%), followed by Onyx (31.1%), covered stent (22.2%), N-butyl cyanoacrylate (6.7%), and flow diversion (4.8%). The pooled overall occlusion rate was 92.1% (95% confidence interval [CI], 86.3–95.6; I2 = 29.2%). The pooled complication rate was 10.9% (95% CI, 7.3–16; I2 = 0%). Use of coils were associated with a slightly lower odds of overall complications (odds ratio, 0.98; 95% CI, 0.97–0.99) and cranial nerve palsy (odds ratio, 0.98; 95% CI, 0.97–0.99). The pooled fistula recurrence rate was 8.3% (95% CI, 4.3–15.4; I2 = 30.9%). Endovascular therapy for dCCF is associated with high occlusion and low complication rates. Recurrence is not uncommon, highlighting the need for close follow-up. [ABSTRACT FROM AUTHOR]

We aimed to describe the initial experience of mechanical thrombectomy using tandem double stent retrievers combined with intermediate catheter aspiration to treat refractory severe hemorrhagic (SH)-cerebral venous sinus thrombosis (CVST). All refractory SH-CVST patients treated with mechanical thrombectomy using tandem double stent retriever (SR) combined with intermediate catheter aspiration (MT-TDSA) in our institution were retrospectively reviewed. MT-TDSA is a technique that fully engages the clot with double SRs and retrieves the clot using a double SR in combination with aspiration from an intermediate catheter. Demographics, clinical manifestation, medical history, the location of the occluded venous sinus, intraoperative details, procedure-related complications, and modified Rankin Scale (1, 6, 12 months postoperatively) were collected and analyzed. Fourteen patients (median age, 43 years) with refractory SH-CVST were treated with MT-TDSA between January 2016 and January 2020. Ten of 14 (71.4%) had a successful intraoperative recanalization rate (>90%) using MT-TDSA. No procedure-related complications occurred. Eleven patients had good clinical outcomes (modified Rankin Scale score 0–2 at 12 months postoperatively). MT-TDSA for refractory SH-CVST might improve clot-capturing ability and remove blood clots from cerebral venous sinuses effectively and safely, achieving good clinical outcomes. [ABSTRACT FROM AUTHOR]

This meta-analysis of published randomized controlled trials (RCTs) aimed to investigate the efficacy and safety of endovascular therapy (ET) for patients with acute ischemic stroke. The summary relative risks (RRs) with corresponding 95% confidence intervals were calculated to measure the effectiveness of ET using a random-effects model. Thirteen RCTs including 3408 patients were identified among 2851 initial electronic citations. Overall, the summary RR indicated that ET significantly increased the incidence of a modified Rankin Scale score of 0–2 (RR, 1.50; P < 0.001), asymptomatic intracerebral hemorrhage (IH) (RR, 1.42; P = 0.001), subarachnoid hemorrhage (RR, 2.36; P = 0.001), and major complications due to non-intracerebral bleeding (RR, 1.47; P = 0.014). However, ET had no significant effects on the risk of 7-day death (P = 0.827); death after 30 days (P = 0.085); symptomatic IH (P = 0.288); type 1 (P = 0.413), type 2 (P = 0.300), and total parenchymal hematoma (P = 0.160); intraventricular hemorrhage (P = 0.244); early neurologic deterioration (P = 0.570); recurrent stroke (P = 0.830); and symptomatic edema (P = 0.485). The findings of this meta-analysis suggest the incidence of a modified Rankin Scale score of 0–2 in patients who received ET was significantly increased. Moreover, the harmful effects of ET might exist due to greater risk of asymptomatic IH, subarachnoid hemorrhage, and non-intracerebral bleeding, and these results should be verified by further large-scale long-term RCT. [ABSTRACT FROM AUTHOR]

Contrast-induced neurotoxicity (CIN) is an infrequent complication of endovascular procedures, and its understanding remains poor. We aimed to study and characterize the clinical and imaging features of a case series of CIN after neurointerventional surgery. We reviewed all neuroendovascular consecutive procedures from September 2014 to November 2018. CIN was defined as new onset of neurologic deficits that occurred postoperatively after excluding other conditions. All demographic, clinical, procedural, and radiologic data were retrospectively analyzed and collected. Eleven cases of CIN in 1587 patients were identified out of 2510 procedures. The median age was 76 years (interquartile range [IQR], 65–81). The most common comorbidity was hypertension (82%). Median procedure time was 100 minutes (IQR, 80–130.5 minutes). All patients showed wide variability in intraprocedural blood pressure (BP) recordings with fluctuations from the baseline BP. Systolic BP ranged from 83 mm Hg below the patient baseline to 80 mm Hg above baseline. The median symptom onset was 4 hours (IQR, 0.8–9.5 hours). The CIN signs and symptoms presented gradually, initially with encephalopathy and later with focal signs. All patients had an initial computed tomography scan, which showed ipsilateral cerebral edema in 82% of patients. Two had contrast enhancement. Complete resolution of CIN symptoms was obtained in a median time of 3 days (IQR, 2.5–3 days). CIN should be considered in the context of the progressive onset of neurologic deficits after neuroendovascular procedures. A distinct imaging pattern of ipsilateral hemisphere edema in the absence of ischemia is usually identified. Variability in procedural BP might be a predisposing factor. [ABSTRACT FROM AUTHOR]

Despite the proven benefit of transradial access over transfemoral access in cardiac procedures, the transition for cerebrovascular procedures has only been slowly enforced. We present our experience with transradial access in cerebral diagnostic angiographies and neurointerventional procedures. We performed a retrospective analysis of patients who underwent transradial access for cerebrovascular procedures in 3 German centers between February 2017 and May 2019. Demographics, technical features, and complications were evaluated. Transradial access was successful in 40/45 endovascular procedures (89%). Selected catheterization of the intended vessels was obtained in 95% of cases (40/42). The rate of procedure-related vascular complications was 2% (1/45). In this small retrospective series, transradial access proved to be safe and efficient. In the future, it is planned to further promote it as a standard access alternative for more patients. [ABSTRACT FROM AUTHOR]

The integration of artificial intelligence (AI) with modern healthcare has become increasingly prominent. The purpose of this study is to explore the impact of the novel computer-aided triage system based on artificial intelligence (AI-CTS) on endovascular therapy (EVT) in patients with large vascular occlusions (LVO). This study marks the first comprehensive systematic review and meta-analysis on the subject. A comprehensive study was performed on PubMed, Medline, Embase, Cochrane Library, and Chinese databases from their establishment to September 2023, in accordance with PRISMA recommendations. RevMan 5.4 software was used for summative analysis. The outcomes included door-to-groin (DTG) time, time from CT scan initiation to EVT, time from CT scan to reperfusion, and 90-day modified Rankin Scale (mRS). A total of 7 studies involving 752 participants were included in the meta-analysis. The pooled results demonstrated that patients in the post-AI group had less time of DTG [SMD, 0.54; 95% CI, 0.40–0.69; P < 0.00001] and CT scan to EVT [SMD, 0.57; 95% CI, 0.42–0.73; P < 0.00001], as well as less time of CTA to recanalization [SMD, 0.63; 95% CI, 0.36–0.90; P < 0.00001]. There was no significant difference between the 2 groups in terms of the mRS at 90 days [OR, 0.66; 95% CI, 0.43–1.01; P = 0.06]. The combination of AI-CTS and EVT has improved the therapy process for LVO patients. However, the improvement in mRS at 90 days was not significant; further research is warranted. [ABSTRACT FROM AUTHOR]

Wide-necked bifurcation aneurysms (WNBAs) are challenging intracranial aneurysms. Several device and treatment approaches have been proposed for the treatment of WNBAs. The endovascular clip system (eCLIPs) is a newly developed endovascular device with flow diverter and flow disruptor features. This study aims to investigate the safety and efficacy of the eCLIPs for treatment of patients with WNBAs. This is a systematic review and meta-analysis study conducted in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. The electronic databases of PubMed, Embase, Scopus, and Web of Science were systematically reviewed from inception to June 19, 2023. The rate of complete and near-complete occlusion, successful device implantation, and serious adverse events were pooled using STATA, version 17. A total of 5 studies with 110 patients with WNBAs were systematically investigated. Our findings show that the immediate successful implantation rate of eCLIPs was 0.93 (95% confidence interval [CI], 0.88–0.97). Moreover, the immediate postoperative complete occlusion rate was 0.34 (95% CI, 0.10–0.58), and the immediate postoperative near-complete occlusion rate was 0.35 (95% CI, 0.24–0.45). Also, the near-complete occlusion rate at the latest follow-up was 0.3 (95% CI, 0.16–0.44). The serious adverse event rate was 0.14 (95% CI, 0.05–0.22). Stroke was also reported in 2 studies, with 1 study reporting 1 patient who experienced stroke within the first 24 hours and 1 study reporting no patients with stroke. Our findings document that the eCLIPs is a safe and effective device for treating patients with WNBAs and associated with favorable outcomes. [ABSTRACT FROM AUTHOR]

Postinterventional sedation is commonly used in clinical practice to ensure patient safety and comfort. Although sedation or anesthesia during thrombectomy has been well studied, the association between postinterventional sedation and functional outcomes in endovascularly treated patients with acute ischemic stroke (AIS) has yet to be investigated. We describe the association between postinterventional sedation and functional outcomes in patients with AIS treated with endovascular therapy (EVT). This observational study was based on a prospective registry. Patients with AIS treated with EVT from January 2013 to August 2017 at Xuanwu Hospital, Capital Medical University were included. Patients receiving postinterventional sedation were compared with patients not receiving sedation. The primary outcome was the 3 months modified Rankin Scale score. A total of 268 patients were eligible for study: 112 patients (41.8%) receiving postinterventional sedation and 156 patients (58.2%) without sedation. At 3 months follow-up, the median modified Rankin Scale score was 4 (interquartile range, 3–6) in the sedation group and 2 (interquartile range, 1–4) in the nonsedation group (P < 0.001). Multivariable regression analysis suggested that the need for postinterventional sedation was associated with unfavorable outcomes, with an odds ratio of 0.20 for functional independence (95% confidence interval [CI], 0.078–0.487; P < 0.001), 0.06 for freedom from disability (95% CI, 0.017–0.228; P < 0.001), and 8.37 for death (95% CI, 2.196–31.889; P = 0.002). Postinterventional sedation worsens functional outcomes in patients with AIS with large-vessel occlusions treated with EVT. Whether the sedation is a causative factor or a surrogate for poor functional outcomes remains to be determined. [ABSTRACT FROM AUTHOR]

Most cases of vertebral artery stenosis are treated either conservatively or surgically. When non-conservative treatment is chosen, whether to treat it with open surgery or endovascular intervention remains a topic of divergence. In the setting of endovascular therapy failure, the vertebral to common carotid artery transposition certainly is an appropriate choice to recover the posterior circulation. Like any other open surgery, it is not devoid of soft-tissue–related complications. A pseudoaneurysm following this procedure and at this particular location is a rare but lethal complication and, to the best of our knowledge, has not yet been reported. We present the case of an 80-year-old man with previous ischemic stroke who presented to the emergency department with aphasia, right-sided weakness, and dysarthria. Invasive imaging revealed right vertebral stenosis and hypoplastic left vertebral artery that failed endovascular therapy. The patient was then treated with a right vertebral to common carotid artery transposition. During follow-up, a pseudoaneurysm was found and treated with a stent-assisted coiling. Pseudoaneurysms at the extracranial carotid and vertebral circulation are rare and have potential for deadly outcomes. Despite several treatments available, this anatomical location requires endovascular therapy due to efficacy and promptitude of this treatment. This is an interesting case where the patient's management required open and endovascular procedures. The pseudoaneurysm was a rare complication that, to the best of our knowledge, has not previously been reported. This case is an illustration of complementary work between open surgery and endovascular intervention. [ABSTRACT FROM AUTHOR]

To explore the predictors of periprocedural complications and angiographic outcomes in large and giant intracranial posterior circulation aneurysms after endovascular treatment. Data from 99 patients with 103 large (≥10 mm; n = 94) and giant (>25 mm; n = 9) posterior circulation aneurysms treated with endovascular therapy at a single center were retrospectively analyzed. The treatment procedures included endovascular trapping (n = 15), coiling (n = 6), stent only (n = 10), stent-assisted coiling (n = 48), and pipeline embolization device (PED; n = 24). The outcome endpoints were the number of periprocedural complications and number of complete occlusions without any complication. Multivariate analysis revealed that intradural vertebral aneurysms (P = 0.041) and aneurysms ≤25 mm (P = 0.042) were associated with low periprocedural complication rates after endovascular therapy. Aneurysms not involving side branches (P = 0.024) and intradural vertebral aneurysms (P = 0.032) were predictors of complete aneurysm obliteration. No statistically significant differences were found in aneurysmal complete obliteration (P = 0.119) or periprocedural complications (P = 0.248) between a PED and traditional stent and coiling. Additionally, aneurysms not involving side branches (P = 0.030), intradural vertebral artery aneurysms (P = 0.003), and aneurysms treated with a PED (P = 0.020) were more likely to achieve complete occlusion over time. Aneurysm location, aneurysm size, and side branch involvement were predictors of periprocedural complications and angiographic outcomes of endovascular therapy for large and giant intracranial posterior circulation aneurysms. PED use provided no advantages compared with traditional stent and coiling in aneurysmal occlusion rates and periprocedural complications. Large case-control and long-term follow-up studies are needed to further explore the predictors of complications and angiographic outcomes and optimal treatment options for these aneurysms. [ABSTRACT FROM AUTHOR]

Background and Objective The prognosis of progressive ischemic stroke (PIS) caused by large proximal artery occlusion with hemodynamic was poor. Our study aimed to investigate the safety of endovascular therapy (ET) for patients with PIS who were selected based on ischemic penumbra detected on brain imaging. Methods A cohort of consecutive patients with PIS, who were treated with ET, were identified. Patients were selected for ET based on the presence of ischemic penumbra using magnetic resonance imaging. Clinical outcome includes 90-day modified Rankin scale, mortality, and symptomatic intracerebral hemorrhage (sICH) rate. Multivariate analysis was performed to compare treatment time of ≤6 hours (early) with >6 hours (late) after stroke. Results One hundred forty-eight patients were treated (100 early and 48 late). Compared with the early group, more successful recanalization rate in the late group (100% vs. 89%, P = 0.017), lower mortality (2.1% vs. 12%, P = 0.046), better clinical outcome (modified Rankin scale score ≤2, 81.3% vs. 65%, P = 0.046), and sICH rate was similar between the 2 groups (7.0% vs. 9.5%, P = 1.00). Only pretreatment National Institutes of Health Stroke Scale score (odds ratio [OR] = 0.836, P = 0.025), successful recanalization (OR = 7.077, P = 0.038), collateral status (OR = 3.121, P = 0.016), and sICH (OR = 0.053, P = 0.013) were predictors of a good prognosis. Conclusions In appropriately selected patients with PIS, ET can be performed safely. Furthermore, randomized clinical trials are needed to assess its effectiveness. [ABSTRACT FROM AUTHOR]

Objective Embolic occlusions of the common carotid artery (CCA)/internal carotid artery (ICA) and intracranial artery occlusions in acute ischemic stroke are associated with high morbidity and can benefit from endovascular therapy. However, the optimal endovascular strategy for these conditions is unclear. This study aimed to evaluate the feasibility of the pass-thrombectomy-protective thrombectomy (double PT) technique and the clinical outcome of treated patients. Methods We collected data on embolic occlusion of the CCA/ICA and intracranial artery occlusion in our prospective stroke registry database between January 2015 and February 2017. Clinical and angiographic data were retrospectively analyzed. Clinical outcome was evaluated at 3 months (modified Rankin scale [mRS] score), and an mRS score of 2 or lower was defined as a good clinical outcome. Results A total of 7 patients with tandem occlusion were included, with a mean age of 66 years. The median admission National Institutes of Health Stroke Scale score was 20, and 6 of 7 patients (85.7%) underwent successful recanalization. The median reperfusion time of the affected intracranial artery was 61 minutes. The rate of good clinical outcome was 42.9% (3/7), the mortality rate was 14.3% (1/7), and the embolic event rate was 14.3% (1/7) when the proximal clot was retrieved. Conclusions The double PT technique is feasible and safe in treating initial embolic tandem occlusion of the CCA/ICA. Highlights • Morphology of the occlusion site can be used to differentiate CCA embolic lesions from atherosclerotic lesions. • The double PT technique is feasible in treating embolic tandem occlusion. • Embolic events to the intracranial artery when the proximal clot was retrieved were low in the double PT technique. [ABSTRACT FROM AUTHOR]

We reviewed recent studies on ischemic penumbra, including the evolution of the definitions of ischemic penumbra and observations on the characteristics of blood flow and the molecular evolutionary mechanism of ischemic tissues; at the same time, a brief summary of current clinical treatment methods were included. From the perspective of neuroimaging and clinical treatment, the characteristics of cerebral blood flow, oxygen consumption, cell water content, and metabolites were analyzed, to evaluate the diagnosis and evolution of ischemic penumbra. The analysis of the evolutionary characteristics of multiple gene molecules and metabolites may provide ideas for clinical imaging diagnosis and clinical treatment, also allow the combination of multiparameter imaging indexes to be more accurate and effective for the assessment of ischemic penumbra. The research hotspot of imaging on the ischemic penumbra region in the future may be more focused on reflecting the evolutionary characteristics of local metabolites in the ischemic area. Using multimodality imaging to evaluate IP zones and guide the formulation of clinical treatment protocols. [ABSTRACT FROM AUTHOR]

Background Ruptured dissecting aneurysms located at the middle cerebral artery (MCA) are rare, and their standard treatment has not been defined. Furthermore, lenticulostriate artery involvement in the dissecting segment makes treatment extremely difficult, and no previous reports have described successful treatment for such conditions. Case Description We herein report the case of a 74-year-old woman who presented with sudden severe headache from subarachnoid hemorrhage due to dissection in the proximal M1 segment of left MCA involving lenticulostriate arteries. Digital subtraction angiography on day 6 showed that the dissecting aneurysm had enlarged despite strict blood pressure control. On day 8, the patient was treated successfully with a self-expanding closed cell stent and coil embolization, preserving blood flow in the lenticulostriate arteries as well as the MCA. Conclusions Follow-up digital subtraction angiography performed 5 weeks after endovascular therapy showed healing of the dissecting lesion, and the patient was discharged neurologically intact. [ABSTRACT FROM AUTHOR]

Background Nontraumatic carotid artery injury with active extravasation, or carotid blowout syndrome (CBS), is relatively rare and highly difficult to treat because it is difficult to approach the lesions owing to anatomic factors. It also involves quick progression and a risk of cerebral embolization caused by thrombi and carotid artery occlusion. Recently, covered stents were revealed to be effective for CBS. However, they have several disadvantages, such as their costs, rebleeding complications, or cerebral embolic risks. A firm selection method of CBS types that are appropriate for covered-stent therapy is expected. Case Description A 38-year-old man with esophageal cancer presented with massive hematemesis. Computed tomography revealed active extravasation from the left common carotid artery with medial projection. Initially, the open direct approach failed, which resulted in further bleeding and transient cardiopulmonary arrest. With tentative hemostasis using manual finger compression, emergency angiography was performed, and a covered stent, Fluency 8 mm × 60 mm, was placed at the rupture point. He was transferred to the rehabilitation hospital 36 days after admission with a modified Rankin score of 2 without major complications. Conclusion CBS cases having rupture points around the clavicle and having medial projection extravasation should be treated by covered stent placement under tentative hemostasis using manual finger pressure rather than conventional open surgical treatment. [ABSTRACT FROM AUTHOR]

Objective: To report results of endovascular therapy for acute ischemic stroke (AIS) in patients who were not candidates for intravenous thrombolysis (IVT) or in whom IVT failed. Methods: Prospectively collected data for patients treated between January 2006 and June 2009 were analyzed retrospectively. After careful patient and therapy selection, 213 AIS patients with a mean NIHSS score of 14.2 at presentation underwent intervention. End points analyzed were Thrombolysis in Myocardial Infarction (TIMI) 2/3 reperfusion, symptomatic intracranial hemorrhage (SICH) rates, and 90-day outcomes (modified Rankin Scale [mRS] and mortality). Multivariate binary logistic regression analysis was used to assess independent predictors of end points. Results: Of 189 patients with anterior circulation occlusions, 135 were treated within 0–8 hours, 33 were treated after 8 or more hours, and 21 were treated after wake-up stroke (WUS). Among 24 patients treated with posterior circulation occlusions, 4 had WUS. After treatment, 72.3% patients had TIMI 2/3 reperfusion; SICH rate was 8.7%; at 90 days, 36.6% recovered to mRS 2 or less. SICH rate was higher in patients with anterior circulation strokes who received treatment 8 or more hours after symptom onset (odds ratio [OR] = 3.8) and patients with WUS (OR = 4.9). In patients treated within 8 hours of onset of symptoms of anterior circulation stroke, SICH rate was only 6.7%. There was no difference in outcomes in patients with WUS compared with patients treated less than 8 hours after stroke onset. Conclusions: This is the first and largest prospective study to the authors'' knowledge that shows endovascular therapy for AIS patients in a real-world setting. High recanalization rates with low SICH rates were achieved using careful patient and therapy selection. [Copyright &y& Elsevier]

M2 occlusions represent 16%–41% of all middle cerebral artery occlusions, with >50% of functional independence achieved. The American Heart Association/American Stroke Association 2018 guidelines suggest that, with a level of evidence B-R, thrombectomy with stent retrievers may be appropriate for selected patients with M2 or M3 occlusions. The purpose of this study is to illustrate a new technique of distal (M2-M3) thrombectomy. Eight patients from May 2018 to February 2019 underwent a thrombectomy procedure for a M2 or M3 occlusion with a 3MAX or 4MAX intermediate aspiration catheter, a Headway Duo 167 cm microcatheter, and a Catchview Mini stent retriever. All thrombectomies were technically successful, defined as thrombolysis in cerebral infarction score ≤2b. Five out of the 8 patients attained a good functional outcome at 3 months, defined as modified Rankin scale score ≤2. This technique allows a safe and effective distal thrombectomy for M2-M3 occlusions. [ABSTRACT FROM AUTHOR]

Cerebral dural arteriovenous fistulas (DAVFs) are vascular lesions consisting of a pathologic high-flow connection between dural arteries and veins or dural sinuses. Small DAVFs shunts have been demonstrated to exist physiologically, but as their estimated diameter is around 8–12 μm, they are not visible even on high-quality angiography studies. We report 2 cases of immediate development of a DAVF after embolization with microparticles of the middle meningeal artery for treatment of chronic subdural hematoma. This report represents the first description of sudden development of a DAVF after endovascular embolization of an intracranial artery and may shed light on the pathophysiology and development of DAVFs. [ABSTRACT FROM AUTHOR]

Dural arteriovenous fistulas (DAVFs) in the anterior cranial fossa constitute approximately 1%–1.5% of intracranial vascular malformations. Depending on the drainage patterns, the diagnosis of ethmoidal DAVFs should prompt treatment because of the high risk of bleeding. Available treatments strategies are surgical treatment and the endovascular approach. To compare the surgical treatment with the endovascular therapy in terms of complete obliteration and perioperative adverse events. This study was performed according to the PRISMA guidelines. Eligible studies were identified through a search of PubMed and Cochrane until February 2019. A random effects model meta-analysis of odds ratios (OR) was conducted and the I-square was used to assess heterogeneity. Good outcome was defined as no neurologic deterioration within 30 days after the procedure. Five studies comprising 81 patients were included in the meta-analysis. Surgical disconnection was superior to endovascular therapy in terms of postprocedural complete obliteration rate (surgery group, 100% [n = 65/65]; endovascular therapy, 47% [n = 15/32]; OR, 32.19; 95% confidence interval, 5.46–189.72; I2 = 9.9%) and 30-day good outcome (surgery group, 98% [n = 63/64]; endovascular therapy, 47% [n = 15/32]; OR, 21.90; 95% confidence interval, 1.94–247.27; I2 = 53.6%). No significant differences in terms of 30-day stroke, transient ischemic attack; visual deficit, new-onset seizure, and intracranial hemorrhage were identified. Surgical treatment was superior to endovascular therapy in terms of complete obliteration and overall good outcome. Adverse event rates were similar between the 2 groups. Future studies should be conducted to validate our results. [ABSTRACT FROM AUTHOR]

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Background Sixth nerve palsy is a common complication of endovascular treatment for carotid-cavernous fistulas (CCF). Two hypotheses are evoked: the spontaneous venous congestion into the cavernous sinus and the direct compression of the nerve by the embolic agent into the cavernous sinus. Nevertheless, the evidence is still uncertain. Knowing the vicinity of the sixth nerve with the inferior petrosal sinus (IPS) in the Dorello canal, we hypothesized that the recanalization of the IPS increased the risk of nerve damage. Methods We analyzed a prospective database of patients treated for CCFs from March 2009 to April 2016. We excluded patients who did not need treatment, cases of high-flow CCF, and patients lost to follow-up, obtaining a homogeneous population of 82 patients with indirect CCFs. This population was divided in 2 groups: patients without new-onset/worsening of sixth nerve palsy and patients with this postprocedural complication. Results Our main endpoints were the potential differences between patients with or without recanalization of IPS and between those who underwent or not an embolization with Onyx-18. We did not find any statistically meaningful difference between the 2 groups concerning the necessity of IPS recanalization ( P > 0.999, odds ratio 0.97, 95% confidence interval 0.32–2.96) or with the use of Onyx-18 as an embolic agent ( P = 0.56; odds ratio 1.41, 95% confidence interval 0.41–2.45). Conclusions The recanalization of a thrombosed IPS does not increase the risk of procedural sixth nerve damage. The initial injury seems to relate with development/worsening of a sixth nerve palsy. [ABSTRACT FROM AUTHOR]

Objective Initial stenotic occlusion of the internal carotid artery with intracranial artery occlusion in acute ischemic stroke is associated with high morbidity and can benefit from endovascular therapy. However, the optimal endovascular strategy is unclear. This study aimed to evaluate the feasibility of the “half” anterograde approach and clinical outcome of treated patients. Revascularization validity of the 2 “half” anterograde approach with (Protect-Expand-Aspiration-Revascularization-Stent [PEARS] technique) or without (plain technique) using an embolic prevention device and aspiration was also compared. Methods Data on initial stenotic occlusion of the internal carotid artery with intracranial artery occlusion in our prospective stroke registry database between January 2015 and February 2017 were collected. Clinical and angiographic data were retrospectively analyzed. Clinical outcome was evaluated at 3 months, defined as a modified Rankin scale ≤2 as a good clinical outcome. Results Overall, 26 patients with tandem occlusion were included; 96.3% of patients had successful recanalization. The rate of a good clinical outcome was 61.8%, symptomatic parenchymal hemorrhage was 7.7%, and mortality was 15.4%. The PEARS technique took less time (56 ± 14 vs. 97 ± 31 minutes; P = 0.002) and had less embolic events (0 vs. 30.8%; P = 0.012) compared with the plain technique. Use of the PEARS technique was an independent predictor for shortening revascularization time (β = −0.651, P = 0.001). Conclusions The half anterograde approach technique is feasible and safe for treating tandem occlusion. Furthermore, the PEARS technique is associated with a shorter reperfusion time and less embolic events than the plain technique, and should be recommended in tandem occlusion. [ABSTRACT FROM AUTHOR]

Background Traumatic injury of the posterior communicating artery or the basilar artery causing arteriovenous fistulae is rare. Case Description Here we report an unusual case of the coincidence of a posterior communicating artery-cavernous sinus fistula and a basilar artery-cavernous sinus fistula associated with traumatic pseudoaneurysms of the posterior communicating and basilar arteries. The fistulas and pseudoaneurysms were obliterated completely after staged endovascular surgery via a transarterial and transvenous route. Conclusions To our knowledge, this is the first such report worldwide. [ABSTRACT FROM AUTHOR]