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Background: Evidence from randomized controlled trials has shown a benefit for endovascular treatment in basilar artery occlusion. We aimed to show the effect of the recanalization result on outcome and determine the role of underlying basilar stenosis in a real-world setting., Methods: A retrospective, single-center study of patients who received endovascular treatment for basilar artery occlusion from March 2008 to June 2022 was conducted. Clinical and outcome characteristics were gathered. Multivariate logistic regression analysis was performed to predict poor outcomes (post-treatment mRS 5 or 6). MRS shift analysis was performed., Results: This study includes 210 patients (mean age, 71.4 years +/- 13.3 [standard deviation]; 124 men). The variables age (OR, 1.04; 95% CI: 1.01-1.08; p = 0.014), underlying basilar stenosis (OR: 4.86; 95% CI: 2.15-10.98; p < 0.001), admission NHISS (OR: 1.09; 95% CI: 1.04-1.13; p < 0.001), and TICI (OR: 1.89; 95% CI: 1.09-3.25; p = 0.022) independently predicted a poor outcome. Patients with occlusions due to underlying stenosis had significantly worse recanalization rates. Median post-treatment mRS in all patients with embolic occlusion was 4; IQR, 2-5 (only patients with embolic occlusion: mTICI 0-2a, median: 5 [IQR, 4-5.5]; mTICI 2b, median: 4 [IQR, 2.5-6]; mTICI 3, median: 3 [IQR, 1-5]; p = 0.037). Median post-treatment mRS in all patients with occlusions due to underlying stenosis was 5; IQR, 4-6 (only patients with embolic occlusions: mTICI 0-2a, median: 6 [IQR, 4.5-6]; mTICI 2b, median: 6 [IQR, 4.25-6]; mTICI 3, median: 5 [IQR, 3.5-5.25]; p = 0.059)., Conclusions: Successful recanalization is essential for preventing poor outcomes in basilar artery occlusion. Underlying basilar stenosis diminishes the effect of successful recanalization on the overall outcome.

Introduction: While incident ischemic lesions (IILs) are not unusual on follow-up magnetic resonance imaging (MRI) following stroke, their risk factors and prognostic significance remain unknown., Methods: In a prospective multicenter study of 503 acute stroke patients, we assessed IILs on registered MRI images at baseline and 6 months, analyzing risk factors and clinical outcomes across 36 months., Results: At 6 months, 78 patients (15.5%) had IILs, mostly diffusion-weighted imaging-positive (72%) and clinically covert (91%). Older age and small vessel disease (SVD) lesions were baseline risk factors for IILs. IILs were associated with worse cognitive (beta for global cognition: -0.31, 95% confidence interval [CI]: -0.48 to -0.14) and functional outcomes (beta for modified Rankin scale [mRS]: 0.36, 95% CI: 0.14 to 0.58), and higher recurrent stroke risk (hazard ratio: 3.81, 95% CI: 1.35 to 10.69). IILs partially explained the relationship between SVD and poor cognition., Discussion: IILs are common and are associated with worse cognitive and functional outcomes and stroke recurrence risk. Assessing IILs following stroke might aid prognostication., Highlights: Incident ischemic lesions (IILs) were assessed with registered baseline and 6-month magnetic resonance imaging (MRI) scans in a stroke cohort. IILs 6 months after stroke are present in one-sixth of patients and are mostly clinically silent. Small vessel disease burden is the main baseline risk factor for IILs. IILs are associated with cognitive and functional impairment and stroke recurrence. Assessing IILs by follow-up MRI aids long-term prognostication for stroke patients., (© 2024 The Author(s). Alzheimer's & Dementia published by Wiley Periodicals LLC on behalf of Alzheimer's Association.)

Objectives: Basilar artery occlusion (BAO) may be etiologically attributed to embolism or in situ thrombosis due to basilar stenosis (BS). Patients with BAO due to BS (BAOS) are known to have worse outcomes than patients with embolic occlusions (BAOE). BAOS occurs more proximally in the basilar artery (BA) than BAOE. We hypothesize that differing brain stem infarct patterns contribute to outcome differences between these stroke etiologies., Methods: This retrospective study includes 199 consecutive patients with BAO who received endovascular treatment at a single center. Final infarction in brain parenchyma dependent on the posterior circulation was graded semiquantitatively on magnetic resonance imaging (MRI). Associations to underlying stenosis and angiographic and clinical outcome variables were tested. The primary endpoint was early good clinical outcome (EGCO, mRS score ≤ 3 at discharge)., Results: Infarct extension of the medulla oblongata (OR = 0.25; 95% CI = 0.07-0.86; p = 0.03), the inferior pons (OR = 0.328; 95% CI = 0.17-0.63; p = 0.001), the superior pons (OR = 0.57; 95% CI = 0.33-0.99; p = 0.046), and the occipital lobes (OR = 0.46; 95% CI = 0.26-0.80; p = 0.006) negatively predicted EGCO. Infarct extension for other posterior-circulation-dependent brain regions was not independently associated with unfavorable early outcomes. Patients with BAOS had more proximal occlusions and greater infarct volumes in the inferior brain stem. Successful reperfusion (mTICI 2b-3) occurred more often in patients with BAOE than in BAOS (BAOE: 131 (96.3%); BAOS: 47 (83.9%), p = 0.005)., Conclusion: Unfavorable early outcomes in patients with BAOS may be explained by a higher likelihood of inferior brain stem infarcts and lower rates of reperfusion success., Clinical Relevance Statement: Basilar artery occlusion due to underlying stenosis is associated with a poorer prognosis than that caused by embolism; these results suggest that aggressive endovascular therapy, usually involving the placement of a permanent stent, may be warranted in these patients., Key Points: Inferior brain stem and occipital infarcts are prognostically unfavorable in basilar artery occlusion. Basilar artery occlusion due to stenosis occurs more proximally and is associated with worse outcomes. Differentiating etiologies of basilar artery occlusion may influence how aggressively treated the occlusion is., (© 2024. The Author(s).)

Background: Nowadays, there is no method to quantitatively characterize the material composition of acute ischemic stroke thrombi prior to intervention, but dual-energy CT (DE-CT) offers imaging-based multimaterial decomposition. We retrospectively investigated the material composition of thrombi ex vivo using DE-CT with histological analysis as a reference., Methods: Clots of 70 patients with acute ischemic stroke were extracted by mechanical thrombectomy and scanned ex vivo in formalin-filled tubes with DE-CT. Multimaterial decomposition in the three components, i.e., red blood cells (RBC), white blood cells (WBC), and fibrin/platelets (F/P), was performed and compared to histology (hematoxylin/eosin staining) as reference. Attenuation and effective Z values were assessed, and histological composition was compared to stroke etiology according to the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria., Results: Histological and imaging analysis showed the following correlation coefficients for RBC (r = 0.527, p < 0.001), WBC (r = 0.305, p = 0.020), and F/P (r = 0.525, p < 0.001). RBC-rich thrombi presented higher clot attenuation in Hounsfield units than F/P-rich thrombi (51 HU versus 42 HU, p < 0.01). In histological analysis, cardioembolic clots showed less RBC (40% versus 56%, p = 0.053) and more F/P (53% versus 36%, p = 0.024), similar to cryptogenic clots containing less RBC (34% versus 56%, p = 0.006) and more F/P (58% versus 36%, p = 0.003) than non-cardioembolic strokes. No difference was assessed for the mean WBC portions in all TOAST groups., Conclusions: DE-CT has the potential to quantitatively characterize the material composition of ischemic stroke thrombi., Relevance Statement: Using DE-CT, the composition of ischemic stroke thrombi can be determined. Knowledge of histological composition prior to intervention offers the opportunity to define personalized treatment strategies for each patient to accomplish faster recanalization and better clinical outcomes., Key Points: • Acute ischemic stroke clots present different recanalization success according to histological composition. • Currently, no method can determine clot composition prior to intervention. • DE-CT allows quantitative material decomposition of thrombi ex vivo in red blood cells, white blood cells, and fibrin/platelets. • Histological clot composition differs between stroke etiology. • Insights into the histological composition in situ offer personalized treatment strategies., (© 2024. The Author(s).)

Background: Post-stroke diffusion weighted imaging (DWI) signal transformation of the infarct core, which results in high apparent diffusion coefficient (ADC) values and variable DWI signal intensity, is completed no later than 1 month after onset of ischemia. We observed frequent exceptions to this timeline of change in DWI signal, which led to uncertainties in further clinical patient management., Methods: A prospective single-center study of patients treated with mechanical thrombectomy of a large vessel occlusion in the anterior circulation was conducted. Patients received high-resolution MRI at 3T, including DWI, in the acute post-stroke phase and in the follow-up after 3-12 months., Results: Overall, 78 patients (45 men) of mean age 63.6 years were evaluated. We identified persisting or new diffusion restriction in 29 of the 78 patients (37.2%) on follow-up imaging. Diffusion restrictions in a different location from the infarct core, representing new (sub-)acute ischemia, were observed in four patients (5.1%). Smaller areas of persisting diffusion restriction (pDWI lesions with high DWI signal and reduced ADC values) within the former infarct core were observed in 25 patients (32.1%) without clinical evidence of recurrent stroke, but with worse outcome scores at follow-up compared with patients without pDWI lesions. The presence of pDWI lesions is associated with a large primary infarct core (multivariate regression OR 1.03 (95% CI 1.01 to 1.05); p<0.01), mediating the relationship between pDWI lesions and clinical outcome., Conclusion: Smaller foci of persisting diffusion restriction (pDWI lesions) in the follow-up after endovascular treatment for stroke are frequent and likely represent a slowed ADC signal progression within a formerly large infarct core., Competing Interests: Competing interests: Outside the submitted work, CZ has received speaker honoraria from Bayer-Schering. He serves as a co-editor on the advisory board of Clinical Neuroradiology and is president of the German Society of Neuroradiology (DGNR). All the other authors declare no conflict of interest., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Mechanical thrombectomy (MT) is frequently performed for distal medium vessel occlusions (DMVO) of the anterior circulation in acute stroke patients. However, evidence for its clinical benefit remains scarce. In this study, we aim to investigate clinical course and safety outcomes of MT in comparison to standard medical therapy (SMT) in DMVO. This single-center retrospective observational study included 138 consecutive patients treated for DMVO of the anterior circulation between 2015 and 2021. To reduce the risk of selection bias, propensity score matching (PSM) of patients with MT versus SMT was performed for the covariates NIHSS and mRS at admission. Out of all 138 patients, 48 (34.8%) received MT and 90 (65.2%) received SMT only. Overall, patients treated with MT showed significantly higher NIHSS and mRS scores at admission. Post 1:1 PSM, there was a trend toward a better NIHSS improvement in patients with MT (median 4 vs. 1, P = 0.1). No significant differences were observed in the occurrence of symptomatic intracranial hemorrhage or mortality between the groups before and after PSM. A subgroup analysis showed significantly higher NIHSS improvement (median 5 versus 1, P = 0.01) for patients with successful MT (≥ mTICI 2b). Mechanical thrombectomy for distal medium vessel occlusions (DMVO) in the anterior circulation appeared safe and feasible. Successful recanalization was associated with clinical improvement. Larger, multi-center, randomized-controlled trials are required to corroborate these findings., (© 2023. The Author(s).)

Introduction: It remains unknown whether the global small vessel disease (SVD) burden predicts post-stroke outcomes., Methods: In a prospective multicenter study of 666 ischemic and hemorrhagic stroke patients, we quantified magnetic resonance imaging (MRI)-based SVD markers (lacunes, white matter hyperintensities, microbleeds, perivascular spaces) and explored associations with 6- and 12-month cognitive (battery of 15 neuropsychological tests) and functional (modified Rankin scale) outcomes., Results: A global SVD score (range 0-4) was associated with cognitive impairment; worse performance in executive function, attention, language, and visuospatial ability; and worse functional outcome across a 12-month follow-up. Although the global SVD score did not improve prediction, individual SVD markers, assessed across their severity range, improved the calibration, discrimination, and reclassification of predictive models including demographic, clinical, and other imaging factors., Discussion: SVD presence and severity are associated with worse cognitive and functional outcomes 12 months after stroke. Assessing SVD severity may aid prognostication for stroke patients., Highlights: In a multi-center cohort, we explored associations of small vessel disease (SVD) burden with stroke outcomes. SVD burden associates with post-stroke cognitive and functional outcomes. A currently used score of SVD burden does not improve the prediction of poor outcomes. Assessing the severity of SVD lesions adds predictive value beyond known predictors. To add predictive value in assessing SVD in stroke patients, SVD burden scores should integrate lesion severity., (© 2022 The Authors. Alzheimer's & Dementia published by Wiley Periodicals LLC on behalf of Alzheimer's Association.)

Objectives: Endovascular treatment of acute stroke patients with large vessel occlusions is well established. But tandem lesions of the internal carotid artery and the intracranial anterior circulation remain a challenge regarding the technical conditions and the putative higher risk of hemorrhage due to often required antiplatelet therapy.This study aims to evaluate the clinical outcome and the risk of hemorrhage after endovascular treatment of tandem lesions, with special regard to the periprocedural antiplatelet regimen., Materials and Methods: In this retrospective study, we included 63 consecutive stroke patients with endovascular treated tandem lesions. One hundred eleven patients with a solitary intracranial occlusion were matched using a "propensity score-matched analysis" with the covariates sex, age, wake-up stroke, iv-thrombolysis and NIHSS., Results: Rates of successful recanalization (mTICI 2b/3) and periprocedural complications were equal in both groups (P = 0.19; P = 0.35). The rate of good clinical outcome (mRS≤2) was similar, and the incidence of symptomatic hemorrhages was not significantly different (7.9% tandem lesions vs. 5.4% isolated intracranial occlusion, P = 0.51). Even intensified antiplatelet therapy in patients with tandem lesions did not increase the rate of symptomatic intracranial hemorrhages (P = 0.87)., Conclusions: Clinical outcome and symptomatic intracranial hemorrhages did not differ significantly between endovascular treated patients with tandem lesions and matched patients with solitary intracranial occlusions, regardless of the antiplatelet regimen. Therefore, the complex technical requirements for recanalization of a tandem lesion and the putative higher risk should not result in reluctant treatment that would decrease the chance of a good clinical outcome., Competing Interests: The authors declare no conflict of interest., (© 2023 The Authors. Published by Elsevier Ltd.)

Importance: International guidelines recommend avoiding intravenous thrombolysis (IVT) in patients with ischemic stroke who have a recent intake of a direct oral anticoagulant (DOAC)., Objective: To determine the risk of symptomatic intracranial hemorrhage (sICH) associated with use of IVT in patients with recent DOAC ingestion., Design, Setting, and Participants: This international, multicenter, retrospective cohort study included 64 primary and comprehensive stroke centers across Europe, Asia, Australia, and New Zealand. Consecutive adult patients with ischemic stroke who received IVT (both with and without thrombectomy) were included. Patients whose last known DOAC ingestion was more than 48 hours before stroke onset were excluded. A total of 832 patients with recent DOAC use were compared with 32 375 controls without recent DOAC use. Data were collected from January 2008 to December 2021., Exposures: Prior DOAC therapy (confirmed last ingestion within 48 hours prior to IVT) compared with no prior oral anticoagulation., Main Outcomes and Measures: The main outcome was sICH within 36 hours after IVT, defined as worsening of at least 4 points on the National Institutes of Health Stroke Scale and attributed to radiologically evident intracranial hemorrhage. Outcomes were compared according to different selection strategies (DOAC-level measurements, DOAC reversal treatment, IVT with neither DOAC-level measurement nor idarucizumab). The association of sICH with DOAC plasma levels and very recent ingestions was explored in sensitivity analyses., Results: Of 33 207 included patients, 14 458 (43.5%) were female, and the median (IQR) age was 73 (62-80) years. The median (IQR) National Institutes of Health Stroke Scale score was 9 (5-16). Of the 832 patients taking DOAC, 252 (30.3%) received DOAC reversal before IVT (all idarucizumab), 225 (27.0%) had DOAC-level measurements, and 355 (42.7%) received IVT without measuring DOAC plasma levels or reversal treatment. The unadjusted rate of sICH was 2.5% (95% CI, 1.6-3.8) in patients taking DOACs compared with 4.1% (95% CI, 3.9-4.4) in control patients using no anticoagulants. Recent DOAC ingestion was associated with lower odds of sICH after IVT compared with no anticoagulation (adjusted odds ratio, 0.57; 95% CI, 0.36-0.92). This finding was consistent among the different selection strategies and in sensitivity analyses of patients with detectable plasma levels or very recent ingestion., Conclusions and Relevance: In this study, there was insufficient evidence of excess harm associated with off-label IVT in selected patients after ischemic stroke with recent DOAC ingestion.

Magnetic resonance imaging (MRI) is an important imaging modality in stroke. Computer based automated medical image processing is increasingly finding its way into clinical routine. The Ischemic Stroke Lesion Segmentation (ISLES) challenge is a continuous effort to develop and identify benchmark methods for acute and sub-acute ischemic stroke lesion segmentation. Here we introduce an expert-annotated, multicenter MRI dataset for segmentation of acute to subacute stroke lesions ( https://doi.org/10.5281/zenodo.7153326 ). This dataset comprises 400 multi-vendor MRI cases with high variability in stroke lesion size, quantity and location. It is split into a training dataset of n = 250 and a test dataset of n = 150. All training data is publicly available. The test dataset will be used for model validation only and will not be released to the public. This dataset serves as the foundation of the ISLES 2022 challenge ( https://www.isles-challenge.org/ ) with the goal of finding algorithmic methods to enable the development and benchmarking of automatic, robust and accurate segmentation methods for ischemic stroke., (© 2022. The Author(s).)

The separation of mixtures of substances into their individual components plays an important role in many areas of science. In medical imaging, one method is the established analysis using dual-energy computed tomography. However, when analyzing mixtures consisting of more than three individual basis materials, a physical limit is reached that no longer allows this standard analysis. In addition, the X-ray attenuation coefficients of chemically complicated basis materials may not be known and also cannot be determined by other or previous analyses. To address these issues, we developed a novel theoretical approach and algorithm and tested it on samples prepared in the laboratory as well as on ex-vivo medical samples. This method allowed both five-material decomposition and determination or optimization of the X-ray attenuation coefficients of the sample base materials via optimizations of objective functions. After implementation, this new multimodal method was successfully tested on self-mixed samples consisting of the aqueous base solutions iomeprol, eosin Y disodiumsalt, sodium chloride, and pure water. As a first proof of concept of this technique for detailed material decomposition in medicine we analyzed exact percentage composition of ex vivo clots from patients with acute ischemic stroke, using histological analysis as a reference standard., (© 2022. The Author(s).)

Although a pathophysiological impact remains difficult to prove in individual patient care, a patent foramen ovale (PFO) is currently considered of high relevance for secondary prophylaxis in selected patients with cryptogenic ischemic stroke. By quantification of histological clot composition, we aimed to enhance pathophysiological understanding of PFO attributable ischemic strokes. Retrospectively, we evaluated all cerebral clots retrieved by mechanical thrombectomy for acute ischemic stroke treatment between 2011 and 2021 at our comprehensive stroke care center. Inclusion criteria applied were cryptogenic stroke, age (≤60 years), and PFO status according to transesophageal echocardiography, resulting in a study population of 58 patients. Relative clot composition was calculated using orbit image analysis to define the ratio of main histologic components (fibrin/platelets (F/P), red blood cell count (RBC), leukocytes). Cryptogenic stroke patients with PFO (PFO+, n = 20) displayed a significantly higher percentage of RBC (0.57 ± 0.17; p = 0.002) and lower percentage of F/P (0.38 ± 0.15; p = 0.003) compared to patients without PFO (PFO-, n = 38) (RBC: 0.41 ± 0.21; F/P: 0.52 ± 0.20). In conclusion, histologic clot composition in cryptogenic stroke varies depending on the presence of a PFO. Our findings histologically support the concept that a PFO may be of pathophysiological relevance in cryptogenic ischemic stroke.

Purpose: Acute basilar artery occlusion, a neurovascular emergency leading to high rates of morbidity and mortality, is usually diagnosed by CT imaging. The outcome is partly dependent on etiology, with a worse outcome in occlusions with underlying basilar artery stenosis. As this occlusion type requires a more complex angiographic therapy, this study aimed to develop new CT markers in emergency admission imaging to rapidly identify underlying stenosis. Methods: A total of 213 consecutive patients (female n = 91, age in years (mean/SD/range): 72/13/28−97), who received endovascular treatment at a single comprehensive stroke center for acute basilar artery occlusion, were included in this study. After applying strict inclusion criteria for imaging analyses, novel CT imaging markers, such as ‘absolute density loss’ (ADL) and relative thrombus attenuation (CTA-index), that measure perviousness, were assessed for n = 109 patients by use of CT-angiography and correlated to different occlusion patterns (thrombotic vs. embolic). Inter-observer agreement was assessed using an intraclass correlation coefficient for independent measures of a radiologist and a neuroradiologist. Associations between the imaging markers and clinical and interventional parameters were tested. Results: CT markers differ between the subgroups of basilar artery occlusions with and without underlying stenosis (for ADL: 169 vs. 227 HU (p = 0.03), for CTA-index: 0.55 vs. 0.70 (p < 0.001)), indicating a higher perviousness in the case of stenosis. A good inter-rater agreement was observed for ADL and CTA-index measures (ICC 0.92/0.88). For the case of embolic occlusions, a more pervious thrombus correlates to shorter time intervals, longer procedure times, and worse reperfusion success (p-values < 0.05, respectively). Conclusions: ADL and CTA-index are easy to assess in the emergency setting of acute basilar artery occlusion with the use of routinely acquired CT-angiography. They show a high potential to differentiate thrombotic from embolic occlusions, with an impact on therapeutic decisions and angiographic procedures. Measurements can be quickly performed with good reliability, facilitating implementation in clinical practice.

Long-term management after stroke has not been standardized in contrast to acute and rehabilitative stroke care. The fragmented outpatient sector of healthcare allows a high degree of flexibility but also variability in the quality of care provided. The commission on long-term stroke care of the German Stroke Society developed a concept on how to provide standardized multiprofessional long-term stroke care with a focus on patient-centered comprehensive care. We propose a diagnostic work-up in stages, with an initial patient-reported screening, followed by an adapted in-depth assessment of affected domains. This includes internistic domains (management of risk factors) and also genuine neurological domains (spasticity, cognitive deficits etc.) that must be considered. This information is then merged with patient expectations and prioritization to a standardized treatment plan. Special challenges for the implementation of such a comprehensive care system are the intersectoral and intrasectoral communication between healthcare providers, patients and relatives, the need to create a compensation system for providers and the establishment of appropriate quality management services. Digital health applications are helpful tools to provide aspects of diagnostics, treatment and communication in long-term stroke care., (© 2021. The Author(s).)

Introduction: Despite sufficient oral anticoagulation (OAC) to prevent cardioembolism, some patients suffer from cerebral ischemic strokes of suspected cardioembolic origin. Reasons for that are not clarified yet. In certain cases, the suspected cardioembolic origin of stroke is questioned. This study aimed to understand the thrombi origin and pathophysiology in patients suffering from stroke despite OAC by the analysis of histologic thrombus composition and imaging characteristics., Materials and Methods: On two distinct cohorts, we retrospectively analyzed histologic ( n = 92) and imaging features ( n = 64), i.e., thrombus perviousness in admission CT imaging, of cerebral thrombi retrieved by the endovascular treatment for a large vessel occlusion of the anterior circulation. In each group, patients with non-cardioembolic strokes and suspected cardioembolic strokes with or without anticoagulation were compared., Results: Fibrin/platelet content of suspected cardioembolic thrombi (mean/SD 57.2% ± 13) is higher than in non-cardioembolic thrombi (48.9% ± 17; p = 0.01). In suspected cardioembolic thrombi, the fibrin/platelet content does not differ in the subgroups of patients with (57.3% ± 13) and without prior OAC treatment (56.6% ±13; p = 0.8), both with higher values than non-cardioembolic thrombi. Thrombus perviousness (ε) of suspected cardioembolic OAC thrombi (mean/SD: 0.09 ± 0.06) differs significantly from non-cardioembolic thrombi (0.02 ± 0.02; p < 0.001). Further, ε is higher in suspected cardioembolic thrombi with OAC than in cardioembolic thrombi without OAC (0.06 ± 0.03; p = 0.04) and with insufficient OAC (0.04 ± 0.02; p = 0.07)., Conclusion: Thrombi of the suspected cardioembolic origin of patients with prior OAC do not differ in their histologic composition from those without prior OAC, but both differ from non-cardioembolic thrombi. These histologic results make a non-cardioembolic etiology for strokes despite prior OAC rather unlikely but favor other reasons for these ischemic events. Perviousness assessment reinforces the histologic findings, with additional information about the OAC thrombi, which present with higher perviousness. This suggests that OAC would not affect the relative histologic thrombus composition but may alter the microstructure, as reflected by perviousness., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Ikenberg, Boeckh-Behrens, Maegerlein, Härtl, Hernandez Petzsche, Zimmer, Wunderlich and Berndt.)

Background and Purpose: Mechanical thrombectomy (MT) is standard care for patients suffering from an ischemic stroke due to a large vessel occlusion. Immediate and follow-up transcranial ultrasound examinations after MT were shown to have a diagnostic benefit. However, it is unclear whether repeated extracranial ultrasound after MT has an additional diagnostic yield, that is, depicts new findings., Methods: Retrospectively, from our prospective database we identified all patients after MT who presented for a follow-up examination between January 2017 and March 2020 and who had received an ultrasound examination after MT and at follow-up. Clinical data were extracted from our database. Ultrasound images of all patients were revisited to identify new findings at follow-up compared to examination after MT., Results: Ninety-one patients were identified appropriate for further analysis, with a mean age of 67.8 ± 16 years. Median National Institute of Health Stroke Scale at admission was 11 ± 8.5 points. At baseline ultrasound, 18 patients (19.8%) had no atherosclerotic alterations and 73 patients (82.2%) had a plaque burden of ≥1 plaque. During follow-up, in 5 patients (5.5%) a pathological finding presented in first examination evolved dynamically, that is, normalized. Vessel status of all other patients was stable, especially, in no patient a new relevant pathological finding occurred., Conclusions: Although sonographic normalization of pathologic findings was observed, pathologic new findings were not detected during follow-up. This study provides first data for a discussion of the role of ultrasound in a structured stroke care after MT. However, larger studies are required to improve the understanding., (© 2021 The Authors. Journal of Neuroimaging published by Wiley Periodicals LLC on behalf of American Society of Neuroimaging.)

Vaccine-induced immune thrombotic thrombocytopenia (VITT) and cerebral venous sinus thrombosis (CVST) have been recently described as rare complications following vaccination against SARS-CoV-2 with vector vaccines. We report a case of a young woman who presented with VITT and cerebral CVST 7 days following vaccination with ChAdOx1 nCov-19 (AstraZeneca). While the initial MRI was considered void of pathological findings, MRI 3 days later revealed extensive CVST of the transversal and sigmoidal sinus with intracerebral haemorrhage. Diagnostic tests including a platelet-factor-4-induced platelet activation assay confirmed the diagnosis of VITT. Treatment with intravenous immunoglobulins and argatroban resulted in a normalisation of platelet counts and remission of CVST., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)