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Intravenous (IV) periprocedural antiplatelet therapy (APT) for patients undergoing acute carotid stenting during mechanical thrombectomy (MT) is not fully investigated. We aimed to compare the safety profile of IV low dose cangrelor versus IV glycoprotein IIb/IIIa (GP-IIb/IIIa) inhibitors in patients with acute tandem lesions (TLs). We retrospectively identified all cases of periprocedural administration of IV cangrelor or GP-IIb/IIIa inhibitors during acute TLs intervention from a multicenter collaboration. Patients were divided in two groups according to the IV APT regimen at the time of MT procedure: 1) cangrelor and 2) GP-IIb/IIIa inhibitors (tirofiban and eptifibatide). Safety outcomes included rates of symptomatic intracranial hemorrhage (sICH), parenchymal hematoma type 1 and 2 (PH1-PH2), and hemorrhagic infarction type 1 and 2 (HI1-HI2). Sixty-three patients received IV APT during MT, 30 were in the cangrelor group, and 33 were in the GP-IIb/IIIa inhibitors group. There were no significant differences in the rates of sICH (3.3% vs. 12.1%, aOR=0.21, 95%CI 0.02–2.18, p= 0.229), HI1-HI2 (21.4% vs 42.4%, aOR=0.21, 95%CI 0.02–2.18, p= 0.229), and PH1-PH2 (17.9% vs. 12.1%, aOR=1.63, 95%CI 0.29–9.83, p= 0.577) between both treatment groups. However, there was a trend toward reduced hemorrhage rates with cangrelor. Cangrelor was associated with increased odds of complete reperfusion (aOR=5.86; 95%CI 1.57–26.62; p =0.013). In this retrospective non-randomized cohort study, our findings suggest that low dose cangrelor has similar safety and increased rate of complete reperfusion compared to IV GP-IIb/IIIa inhibitors. Further prospective studies are warranted to confirm this association. [ABSTRACT FROM AUTHOR]

Background: Stroke may be the first symptom of prosthetic valve thrombosis (PVT); therefore, rapid diagnosis and therapy are crucial. We aimed to evaluate the prevalence, main predictors, and long-term clinical evolution of patients with PVT in the acute phase of stroke.Methods: We studied consecutive acute ischemic stroke patients with prosthetic heart valves who underwent emergent transesophageal echocardiography (TEE) during a 5-year period. Two groups were defined depending on the presence of PVT (PVT or non-PVT groups). Baseline characteristics, TEE findings, and international normalized ratios (INRs) at the stroke event were registered. Follow-up visits and TEE control examinations were performed.Results: Sixty-seven patients were registered. TEE was performed within the first week in 85% of patients (n = 57). PVT was diagnosed in 41.8% of cases (n = 28). Clinical severity and baseline INR level showed no differences when the PVT and non-PVT groups were compared. The presence of PVT was associated with the mitral valve location as compared with the aortic valve location (75% versus 25%, P = .003), the presence of spontaneous echocontrast (64.3% versus 35.9%, P = .022), and low ejection fraction (66.7% versus 32.7%, P = .019). The PVT group showed a trend toward higher percentage of recurrence (10.7% versus 2.5%, P = .102) in the follow up period (mean follow-up 25 months).Conclusions: The detection of PVT in the acute stroke phase was relevant, as the stroke recurrence rate was considerable. Therefore, all patients with prosthetic heart valve should undergo emergent TEE. [ABSTRACT FROM AUTHOR]

Background: This phase 1/2a, open-label, multicenter, dose-escalation, safety study describes the first evaluation of plasmin as an intracranial thrombolytic treatment for acute ischemic stroke in the middle cerebral artery. The rationale for intrathrombus administration is that plasmin would bind fibrin inside the targeted clot, protecting it from circulating inhibitors.Methods: Plasmin was given in escalating doses within 9 hours of stroke onset, and treatment efficacy was determined in 5 patient cohorts (N = 40): cohort 1 (20 mg, .5 mL/min), cohort 2a (40 mg, .05 mL/min), cohort 2b (40 mg, .33 mL/min), cohort 3a (80 mg, .67 mL/min), and cohort 3b (80 mg, .33 mL/min).Results: Plasmin was generally safe at doses as high as 80 mg. No symptomatic intracranial hemorrhage was observed, and the rate of asymptomatic intracranial hemorrhage (12.5%) was consistent with that expected under supportive care. No relationship was observed between the plasmin dose and the incidence or severity of bleeding events, any particular serious adverse events, nor death. Changes in clinical chemistry, hematology, and coagulation parameters following plasmin treatment were unremarkable and unrelated to the dose. Plasmin administration resulted in successful reperfusion of the occluded vessel in 25% of patients across all cohorts, with no relationship between successful perfusion and total plasmin dose but a potential increase in reperfusion with slower infusion rates.Conclusions: Plasmin treatment of the occluded middle cerebral artery within 9 hours of stroke onset was well tolerated and did notincrease adverse outcomes; however, successful recanalization was achieved in only a limited number of patients. [ABSTRACT FROM AUTHOR]

Background: Recent evidence regarding carotid revascularization advises against carotid angioplasty and stenting (CAS) in patients aged >70 years with conventional risk for carotid endarterectomy (CEA). The poor outcome of transfemoral CAS in this age group may be explained by the anatomic characteristics of the aortic trunk and supra-aortic vessels in elderly patients, as well as by a high prevalence of aortic arch atheromatosis. Transcervical CAS with flow reversal for cerebral protection avoids these unfavorable characteristics. This study analyzed the short-term and middle-term results of transcervical CAS with flow reversal in patients aged >70 years at high risk for CEA. Methods: Between January 2006 and January 2011, 219 cases of >70% carotid artery stenosis in high-risk patients aged >70 years (55.7% asymptomatic and 44.3% symptomatic) were treated by transcervical CAS. All patients underwent complete neurologic examination by a stroke neurologist before and after the procedure. Primary end points were stroke, death, or myocardial infarction (MI), technical success, and complications at 30 days. During follow-up, we analyzed the rate of restenosis ≥50% and ipsilateral stroke. Data were collected prospectively and outcome was analyzed in all cases, including technical failures. Results: The 30-day combined stroke/death/MI rate was 2.2% (stroke, 1.8%; stroke/death, 2.2%; and MI, 0.45%). In symptomatic patients, stroke/death/MI was 5.1% (stroke, 4.1%; stroke/death, 5.1%). None of the asymptomatic patients suffered stroke, MI, or death postoperatively. Technical success was 96.3% (four inability to cross lesion, two major common carotid dissections, one failed preangioplasty, one stent thrombosis). One cervical hematoma required surgical drainage. At follow-up (18.8 ± 16.9 months), cumulative (standard error) incidence of >70% restenosis was 3% (1%) at 1 year and 8% (3%) at 2 and 3 years. Only one patient experienced ipsilateral stroke during follow-up. Overall survival (standard error) was 94% (2%) at 1 year and 90% (3%) at 2 and 3 years. Conclusions: In our experience, transcervical CAS with flow reversal is a safe technique for treating carotid stenosis in patients aged >70 years. We believe that avoiding the aortic arch and tortuous supra-aortic vessels is responsible for the favorable results in this study. [ABSTRACT FROM AUTHOR]

Background: Randomized controlled trials have shown that periprocedural rates of stroke and death are higher with carotid artery stenting (CAS) than with carotid endarterectomy (CEA) in the treatment of carotid artery stenosis. Diffusion-weighted magnetic resonance imaging (DW-MRI) has shown higher rates of clinically silent new ischemic brain lesions when CAS is performed as compared with CEA. The Silk Road Medical Embolic PROtectiOn System: First-In-Man (PROOF) Study is a single-arm first-in-man study using the MICHI Neuroprotection System (Silk Road Medical Inc, Sunnyvale, Calif), a novel transcervical access and cerebral embolic protection system. This system enables stent implantation under controlled blood flow reversal of the carotid artery, also known as Flow Altered Short Transcervical Carotid Artery Stenting (FAST-CAS). Methods: Between March 2009 and February 2010, a total of 44 subjects were enrolled into the study. The primary composite endpoint was major stroke, myocardial infarction, or death within 30 days. Forty-three patients (97.7%) completed the study through the 30-day endpoint. One patient was lost to follow-up. In a subgroup of consecutive subjects, DW-MRI examinations were performed preprocedure and within 24 to 48 hours after the stent implantation. Blinded independent neuroradiologists reviewed all DW-MRI studies and confirmed the absence or presence of new ischemic brain lesions. Results: All enrolled patients were successfully treated, and no major adverse events were seen through the follow-up period. Thirty-one subjects had DW-MRI examinations. Of these, five patients (16%) had evidence of new ischemic brain lesions but no clinical sequelae. Transient intolerance to reverse flow was reported in 9% of cases, but in all cases, a stent was successfully placed, and the intolerance was managed by minimizing the duration of reverse flow during the procedure. Conclusion: In this first-in-man experience, FAST-CAS using the MICHI Neuroprotection System was shown to be a safe and feasible method for carotid revascularization. DW-MRI findings suggest controlled reverse flow provides cerebral embolic protection similar to that seen with CEA. [ABSTRACT FROM AUTHOR]

Objective: We sought to evaluate the success rates in achieving preventive therapeutic goals in patients who experienced an ischemic stroke (IS) and compare them with those achieved in patients with coronary artery disease (CAD). Methods: This was an observational multicenter case-control study (3 patients with IS and one control subject with CAD) performed in 1444 primary health centers in Spain. Preventive therapeutic objectives according to American Heart Association guidelines were predefined. Demographic data, vascular risk factors, and success/failure in achievement of objectives were recorded and compared between patients with IS and CAD. Results: A total of 5458 patients were included, 4098 (75.1%) had IS and 1360 (24.9%) had CAD. Although more than 90% of patients with hypertension, diabetes, or dyslipidemia were under specific drug regimens, only about 25% achieved the recommended therapeutic objective for each risk factor. Success rate was especially low among patients with IS compared with CAD: hypertension (23.8% v 27.2%; P = .028); dyslipidemia (13.6% v 20.3%; P < .001); and abdominal obesity (49.1% v 54.6%; P = .002). The only objective widely achieved in both groups was the use of antithrombotic drugs in atrial fibrillation (97.2% v 94.7%; P = .125). Only 3.3% of patients with IS had all risk factors under control, compared with 5.6% of those with CAD (P = .006). For all patients, multivariate logistic regression model showed that independent predictors of full risk factor control were: presence of CAD as compared with IS (odds ratio [OR] 2.11; 95% confidence interval [CI] 1.35-3.29; P = .001), older age (OR 1.02; 95% CI 1.00-1.04; P = .028), and having less than 3 risk factors (OR 16.98; 95% CI 9.02-31.97; P < .001). Conclusions: Success in achieving preventive therapeutic objectives for secondary prevention of vascular events is low, especially among patients with IS. There is an urgent need to devise strategies to improve risk factor control. [Copyright &y& Elsevier]

Abstract: Administration of microbubbles (MB) may augment the effect of ultrasound-enhanced systemic thrombolysis in acute stroke. Bubble structural characteristics may influence the effect of MB on sonothrombolysis. We aimed to compare the effects of galactose-based air-filled MB (Levovist) and sulphur hexafluoride-filled MB (Sonovue) on recanalization and clinical outcome. One hundred thirty-eight i.v. recombinant tissue plasminogen activator-(tPA-) treated patients with middle cerebral artery (MCA) occlusion were studied. Presence and location of arterial occlusion and recanalization (RE) were assessed using the thrombolysis in brain ischemia (TIBI) flow grading system. Patients underwent 2 h of continuous transcranial Doppler (TCD) monitoring and received three bolus of MB after 2, 20 and 40 min of tPA bolus. Ninety-one patients received Levovist (LV) and 47 received Sonovue (SV). NIHSS scores were obtained at baseline and after 24 h. Modified Rankin Scale (mRS) score was used to assess outcome at 3 mo. Median admission NIHSS was 17. On TCD, 96 (69.6%) patients had a proximal and 42 (30.4%) a distal MCA occlusion. Age, baseline NIHSS, clot location, stroke subtypes and time to treatment were similar between LV and SV groups. Recanalization rates after 1 h (32.2%/35.6%), 2 h (50.0%/46.7%) and 6 h (63.8%/54.5%) were similar in LV/SV groups (p > 0.3). Clinical improvement (NIHSS decrease ≥ 4 points) at 24 h was similar in both groups (54.9%/51.1%, p = 0.400), as well as symptomatic intracranial haemorrhage rate (3.3%/2.1%, p = 0.580) and in-hospital mortality (8.1%/9.3%, p = 0.531). Similarly, the type of MB administered did not affect long-term outcome after sonothrombolysis. Forty-four percent of patients in the LV group and 48.5% in the SV group achieved functional independence (mRS ≤ 2) at 3 mo (p = 0.440). MB administration during sonothrombolysis is associated with a high RE rate. However, RE rates, clinical course and long-term outcome are comparable when administering galactose-based air-filled MB (Levovist) or sulphur hexafluoride-filled MB (Sonovue). (E-mail: mrubifu@hotmail.com) [Copyright &y& Elsevier]

Background: The use of carotid stenting in octogenarian patients is controversial; some authors consider this population at high risk for the procedure. Anatomic vascular complexity may be an important reason for the high reported rates of periprocedural thromboembolic complications. Transcervical carotid angioplasty and stenting (TCS) with flow reversal avoids aortic arch instrumentation. In this study, we analyzed our experience with TCS in octogenarian patients and compared the results with those of carotid endarterectomy (CEA) in the same age group in terms of safety. Methods: The study included 81 patients, ≥80 years, a retrospective cohort of 45 consecutive patients treated with CEA (January 2002 to January 2005), and a prospective cohort of 36 consecutive patients treated with TCS with protective flow reversal (January 2005 to January 2007). Patients were considered symptomatic according to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria. Stenting indication was established on the SAPPHIRE criteria. General anesthesia was used in patients undergoing CEA, and local anesthesia in those receiving TCS. Primary endpoints were: stroke, death, or acute myocardial infarction within 30 days. Secondary endpoints were peripheral nerve paralysis and cervical hematoma. Statistical significance for between-group differences was assessed by Pearson χ2 or Fisher exact test, and Student t test. A P value of <.05 was considered statistically significant. Follow-up was limited to 30 days. Results: Baseline epidemiological characteristics and revascularization indications were similar between both groups. Mean age was significantly higher in the TCS group (83.5 ± 3.35) than the CEA group (81.7 ± 1.55) (P = .004). Percentage of symptomatic lesions was similar: 30.6% in TCS vs 44.4% in CEA (P = .2). Comorbid conditions (respiratory or cardiac) were more frequent in TCS group (61.6% vs 26.6%; P = .002). There were no significant differences between groups for the primary endpoints: 4.4% (one stroke, one acute myocardial infarction) for CEA vs 0% for TCS (P = .5). Among CEA patients, there were two peripheral nerve palsies (4.4%) and one cervical hematoma (2.2%); there were no such complications with TCS (P = .5 and P = 1, respectively). In one asymptomatic TCS patient, Doppler study at 24 hours following the procedure showed a common carotid artery dissection, which was treated by a common carotid to internal carotid bypass. Conclusions: In this preliminary experience, transcervical carotid angioplasty and stenting with flow reversal for cerebral protection was as safe at short term as carotid endarterectomy in octogenarian patients, who additionally had considerable comorbidity; thus, it may be possible to extend the indications for carotid revascularization in this population. Studies in larger patient series are required to confirm the trends observed in this study. [Copyright &y& Elsevier]

Background: Carotid angioplasty and stenting (CAS) with cerebral embolic protection is a safe alternative to carotid endarterectomy in high-risk patients. Among the various systems proposed for cerebral protection, transcervical CAS avoids crossing the lesion without protection and eliminates the complications associated with transfemoral access. This study analyzes our experience and the results obtained with a transcervical stenting technique for carotid revascularization. Methods: From January 2005 to June 2006, 62 CAS were performed in our center in high-risk patients with >70% stenosis (38.7% had a previous neurologic event and 61.3% were asymptomatic). The indications for CAS were severe heart disease (45.1%), severe pulmonary disease (6.4%), paralysis of the contralateral laryngeal nerve (6.4%), recurrent stenosis (3.2%), and high carotid lesion (1.6%). Twenty-one patients were >80 years old. A complete neurologic examination was performed by a stroke neurologist in all patients before and after stenting. The protection system used was carotid flow reversal by transcervical access. Transcranial Doppler monitoring was done during the procedure in 35 patients. We analyzed technical success, the presence of high-intensity transient signals during the procedure, neurologic morbidity and mortality at 30 days and 6 months, and stent patency at 6 months (range, 1 to 18 months). Technical success was 96.8%. Perioperative high-intensity transient signals were observed in two patients (5.7%). In the immediate postoperative period, one patient had a transient ischemic attack of the anterior cerebral artery and another had a stroke, with contralateral hemiplegia. At 48 hours after discharge, a third patient returned to the hospital with a severe cerebral hemorrhage that required surgical drainage; hence, neurologic morbidity was 4.9%. There were no deaths at 6 months. Among the total, 98.4% of the stents remained patent, two showed restenosis of 50% to 70%, and one restenosis of >70%. No patients presented a neurologic event during the follow-up. Conclusions: Transcervical carotid artery stenting with flow reversal cerebral protection is a relatively simple, safe technique that avoids instrumentation of the aortic arch and crossing the target lesion without protection. It is less expensive than techniques requiring a filter device and provides excellent outcome with an acceptable incidence of complications. [Copyright &y& Elsevier]

Background: An increased rate of thrombotic events has been associated to Coronavirus Disease 19 (COVID-19) with a variable rate of acute stroke. Our aim is to uncover the rate of acute stroke in COVID-19 patients and identify those cases in which a possible causative relationship could exist.Methods: We performed a single-center analysis of a prospective mandatory database. We studied all patients with confirmed COVID-19 and stroke diagnoses from March 2nd to April 30th. Demographic, clinical, and imaging data were prospectively collected. Final diagnosis was determined after full diagnostic work-up unless impossible due to death.Results: Of 2050 patients with confirmed SARS-CoV-2 infection, 21 (1.02%) presented an acute ischemic stroke 21 and 4 (0.2%) suffered an intracranial hemorrhage. After the diagnostic work-up, in 60.0% ischemic and all hemorrhagic strokes patients an etiology non-related with COVID-19 was identified. Only in 6 patients the stroke cause was considered possibly related to COVID-19, all of them required mechanical ventilation before stroke onset. Ten patients underwent endovascular treatment; compared with patients who underwent EVT in the same period, COVID-19 was an independent predictor of in-hospital mortality (50% versus 15%; Odds Ratio, 6.67; 95% CI, 1.1-40.4; p 0.04).Conclusions: The presence of acute stroke in patients with COVID-19 was below 2% and most of them previously presented established stroke risk factors. Without other potential cause, stroke was an uncommon complication and exclusive of patients with a severe pulmonary injury. The presence of COVID-19 in patients who underwent EVT was an independent predictor of in-hospital mortality. [ABSTRACT FROM AUTHOR]

Objective: To present guidance for clinicians caring for adult patients with acuteischemic stroke with confirmed or suspected COVID-19 infection.Methods: The summary was prepared after review of systematic literature reviews,reference to previously published stroke guidelines, personal files, and expert opinionby members from 18 countries.Results: The document includes practice implications for evaluation of stroke patientswith caution for stroke team members to avoid COVID-19 exposure, during clinicalevaluation and conduction of imaging and laboratory procedures with specialconsiderations of intravenous thrombolysis and mechanical thrombectomy in strokepatients with suspected or confirmed COVID-19 infection.Results: Conclusions-The summary is expected to guide clinicians caring for adult patientswith acute ischemic stroke who are suspected of, or confirmed, with COVID-19infection. [ABSTRACT FROM AUTHOR]

Our objective was to evaluate hand-held echocardiography as point of care ultrasound scanning (POCUS) to detect sources of embolism in the acute phase of stroke. Prospective, unicentric observational cohort study of non-lacunar ischemic stroke patients evaluated by V Scan device. The main sources of embolism (MSEs) were classified into embolic valvulopathies and severe ventricular dysfunction. We looked for atrial fibrillation (AF) predictors in strokes of undetermined etiology. MSEs were detected in 19.23% (25/130). Large vessel occlusion (LVO) (odds ratio [OR]: 4.24, 95% confidence interval [CI]: 1.01-17.85) and chronic heart failure (OR: 13.25, 95% CI: 3.54-49.50) were independent predictors of MSEs. LVO (OR: 6.54, 95% CI: 1.62-26.27) and left atrial area >20 cm2 (OR: 7.01, 95% CI: 1.75-28.09) independently predicted AF. Patients with LVO and chronic heart disease may benefit from hand-held echocardiography as part of POCUS in the acute phase of ischemic stroke. Left atrial area measured was an independent predictor of AF in strokes of undetermined etiology. [ABSTRACT FROM AUTHOR]

Corrigendum to 'Screening of Embolic Sources by Point-of-Care Ultrasound in the Acute Phase of Ischemic Stroke' [Ultrasound in Med. [Extracted from the article]