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Intravenous thrombolysis (IVT)-ineligible patients undergoing direct thrombectomy tended to have poorer functional outcome as compared with IVT-eligible patients undergoing bridging therapy. We aimed to assess radiological and functional outcomes in large vessel occlusion-related stroke patients receiving direct thrombectomy in the presence of absolute exclusion criteria for IVT vs relative exclusion criteria for IVT and vs non-exclusion criteria for IVT. A cohort study on prospectively collected data from 2282 patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke cohort for treatment with direct thrombectomy (n = 486, absolute exclusion criteria for IVT alone; n = 384, absolute in combination with relative exclusion criteria for IVT; n = 777, relative exclusion criteria for IVT alone; n = 635, non-exclusion criteria for IVT). After adjustment for unbalanced variables (model 1), ORs for 3-month death was higher in the presence of absolute exclusion criteria for IVT alone (vs relative exclusion criteria for IVT alone) (1.595, 95% CI 1.042–2.440) and in the presence of absolute exclusion criteria for IVT alone (vs non-exclusion criteria for IVT) (1.235, 95% CI 1.014–1.504). After adjustment for predefined variables (model 2: age, sex, pre-stroke mRS ≤ 1, NIHSS, occlusion in the anterior circulation, onset-to-groin time, and procedure time), ORs for 3-month death was higher in the presence of absolute exclusion criteria for IVT alone (vs relative exclusion criteria for IVT alone) (1.235, 95% CI 1.014–1.504) and in the presence of absolute exclusion criteria for IVT alone (vs non-exclusion criteria for IVT) (1.246, 95% CI 1.039–1.495). No significant difference was found between the groups as regards any type of intracerebral hemorrhage and parenchymal hematoma within 24 h, successful and complete recanalization after procedure, and modified Rankin Scale score 0–2 at 3 months. After adjustment for predefined variables of model 2, ORs for death were higher in the presence of recent administration of IV heparin (OR: 2.077), platelet count

Endovascular procedures are a less invasive revascularization strategies than endoarterectomy for carotid stenosis, but to date Guidelines recommend surgery for a major periprocedural safety. Evidences come from randomized studies where operator’s experience in endovascular group was not considered. We retrospectively evaluated 524 endovascular procedures (carotid angioplasty ± stenting, CAS) performed between 1996 and 2010 on 486 patients (mean age 71.3 ± 7.8 years) with symptomatic or asymptomatic carotid stenosis from a single center. We evaluated efficacy (residual stenosis ≤30 % after postprocedural angiography) and safety [minor (TIAs or myocardial infarcts) and major (stroke or death) complications in the first 30 days] of procedures and correlated them with the increasing experience of the operator. CAS was successful in 504/524 cases (96.2 %); unsuccessful procedures occurred more frequently in case of angioplasty alone rather than angioplasty and stenting (13/61, 21.3 % vs. 7/463, 1.5 %, OR 17.64, 95 % CI 6.69–46.06). 17/524 (3.2 %) CAS met the combined safety endpoint: stroke in 2.4 % and death in 0.8 %; the rate of disabling stroke/death was 1.6 %. Center experience was inversely related to the rate of stroke/death (R 2 = 0.9375), passing from 5.0 % after 100 CAS to 2.8 % after 500 CAS; for disabling stroke/death (R 2 = 0.9386), the rate was 4 % after 100 CAS and 1.6 % after 500 CAS. CAS is an effective and safe revascularization procedure in both symptomatic and asymptomatic patients, if effected in experienced centers. The use of carotid artery stenting than angioplasty alone and emboli protection devices can much more improve the previous considerations.

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