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BACKGROUND Bilateral and simultaneous occlusion of the anterior circulation is a rare event in patients with acute ischemic stroke. Although endovascular treatment is feasible and safe, the endovascular strategy to be used remains a subject of debate. OBJECTIVE To assess the different endovascular strategies proposed for the treatment of a bilateral, simultaneous anterior circulation occlusion following acute ischemic stroke. METHODS We present a retrospective study of the clinical and radiological records of all patients with a bilateral, simultaneous anterior circulation occlusion treated at our center between January 2019 and December 2022. Following the PRISMA guidelines, we also conducted a systematic review of the literature. RESULTS Two patients with a bilateral and simultaneous middle cerebral artery occlusion were treated at our center during the study period. A TICI score ≥2b was obtained in 4 out of 4 occlusions. Modified Rankin Scale (mRS) at 90 days was 0 and 4, respectively. The literature review retrieved reports on 22 patients. The most frequent bilateral occlusion sites were internal carotid artery-middle cerebral artery. The clinical presentation was severe in most patients. A combined thrombectomy technique proved to have the highest number of first-pass recanalization. A TICI ≥2b was obtained in 95% of patients and an mRS ≤2 was found in 31.8% of patients. CONCLUSIONS In patients with bilateral and simultaneous occlusion of the anterior circulation, endovascular treatment using a combined technique appears to be rapid and effective. The clinical evolution of this patient population strongly depends on the severity of the onset symptoms.

BACKGROUND Focal vasospasm (FV) of the occluded vessel can occur during the endovascular treatment of acute ischemic stroke (AIS). Nimodipine is commonly used to treat vasospasm and can play a role in distinguishing it from artery narrowing due to iatrogenic dissection or residual clot. However, nimodipine administration can result in arterial hypotension and subsequent enlargement of the ischemic core. OBJECTIVE To assess the efficacy of preventive and continuous vasoactive amine infusion to counterbalance nimodipine-induced hypotension. METHODS We reviewed data from a prospective registry of patients treated for AIS between January 2019 and January 2022 who were administered nimodipine. All patients were equipped with an arterial cannula for invasive blood pressure measurement and given vasoactive amines preemptively before general anesthesia and throughout the procedure. Data obtained from invasive monitoring of mean arterial blood pressure (MABP) in a time-lapse of 25 min before and after nimodipine administration were analyzed. RESULTS MABP significantly decreased after nimodipine administration but remained within the recommended range (81.79 ± 0.49 mmHg). Nimodipine was effective in reducing FV caused by stent retriever passage in 76.3% of cases. Furthermore, it proved valuable in diagnosing iatrogenic dissection (9.2%), residual clot (10.5%), or intracranial stenosis (4%). CONCLUSIONS Infusion of vasoactive amines effectively counteracted the intraarterial nimodipine effect, thus avoiding frank arterial hypotension during endovascular treatment. Nimodipine has been useful in differentiating the diagnosis of FV resulting from mechanical thrombectomy and other potential causes, such as iatrogenic dissection or residual clot.

BACKGROUND Several variations of the combined thrombectomy technique for acute ischemic stroke using a stent retriever and aspiration catheter have been described. The aim of our study was to assess how the presence of the microcatheter and stent retriever affect the basic aspiration parameters, namely, flow rate and aspiration force, depending on their position within the aspiration catheter. METHODS Two experimental set-ups were designed to assess changes in flow rate and aspiration force according to the position of the stent retriever and microcatheter within the aspiration catheter. RESULTS The transition of the stent retriever and microcatheter from the distal to proximal position resulted in a progressive increase in the flow rate, but with no impact on aspiration force. Additionally, the size of the stent retriever had no significant effect on flow rate changes and the reduction in flow rate was related to the microcatheter diameter. Negative pressure generated inside the aspiration catheter impacted on its distal segment located beyond the radiopaque marker, thus leading to its partial collapse. As a consequence, the measured aspiration force was lower than the theoretical aspiration force level for all tested aspiration catheters. CONCLUSIONS In our experimental model, the position of the stent retriever and microcatheter within the aspirator catheter affected the flow rate, but not the aspiration force. Negative pressure generated within the aspiration catheter appeared to determine a partial collapse of the distal segment that resulted in a less effective aspiration force than the theoretical aspiration force level.