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Background and Purpose: Sex-related differences exist in many aspects of acute stroke and were mainly investigated in the early time window with conflicting results. However, data regarding sex disparities in late presenters are scarce. Therefore, we sought to investigate differences in outcomes between women and men treated with endovascular treatment in the late time window. Methods: Analyses were based on the SOLSTICE Consortium (Selection of Late-Window Stroke for Thrombectomy by Imaging Collateral Extent), which was an individual-patient level analysis of seven trials and registries. Baseline characteristics, 90-day functional independence (modified Rankin Scale score ≤2), mortality, and symptomatic intracranial hemorrhage were compared between women and men. Effect of sex on the association of age and successful reperfusion (final Thrombolysis in Cerebral Infarction 2b–3) with outcomes was assessed using multivariable logistic regression adjusted for age, National Institutes of Health Stroke Scale score, Alberta Stroke Program Early CT Score, time from onset to puncture, occlusion location, intravenous thrombolysis, and successful reperfusion, with interaction terms. Results: Among 608 patients treated with endovascular treatment, 50.5% were women. Women were older than men (median age of 72 versus 68 years, P =0.02) and had a lower prevalence of tandem occlusions (14.0% versus 22.9%, P =0.005). Workflow times were similar between sexes. Adjusted outcomes did not differ between women and men. Functional independence at 90 days was achieved by 127 out of 292 women (43.5%) and 135 out of 291 men (46.4%). Mortality at 90 days (54 [18.5%] versus 48 [16.5%]) and symptomatic intracranial hemorrhage (37 [13.3%] versus 33 [11.6%]) were similar between women and men. There was no sex-by-age interaction on functional outcomes. However, men had higher likelihood of mortality ( P interaction =0.003) and symptomatic intracranial hemorrhage ( P interaction =0.017) with advancing age. Sex did not influence the relation between successful reperfusion and outcomes. Conclusions: In this multicenter analysis of late patients treated with endovascular treatment, sex was not associated with functional outcome. However, sex influenced the association between age and safety outcomes, with men experiencing worse outcomes with advancing age.

BackgroundClinical trials and observational studies have demonstrated the benefit of thrombectomy up to 16 or 24 hours after the patient was last known to be well. This study aimed to evaluate the outcome of stroke patients treated beyond 24 hours from onset.MethodsWe analyzed the outcome of 34 stroke patients (mean age 70.7±12.3 years; median National Institutes of Health Stroke Scale (NIHSS) score 13) treated with endovascular thrombectomy beyond 24 hours from onset who were recruited in the Italian Registry of Endovascular Thrombectomy in Acute Stroke. Selection criteria for patients were: pre-stroke modified Rankin scale (mRS) score of ≤2, non-contrast CT Alberta Stroke Program Early CT score of ≥6, good collaterals on single phase CT angiography (CTA) or multiphase CTA, and CT perfusion mismatch with an infarct core size ≤50% of the total hypoperfusion extent or involving less than one-third of the extent of the middle cerebral artery territory evaluated by visual inspection. The primary outcome measure was functional independence assessed by the mRS at 90 days after onset. Safety outcomes were 90 day mortality and the occurrence of symptomatic intracranial hemorrhage (sICH).ResultsSuccessful recanalization (Thrombolysis in Cerebral Infarction score of 2b or 3) was present in 76.5% of patients. Three month functional independence (mRS score 0–2) was observed in 41.1% of patients. The case fatality rate was 26.5%. and the incidence of sICH was 8.8%.ConclusionsThese findings suggest that, in a real world setting, very late endovascular therapy is feasible in appropriately selected patients.

Background and Purpose: We designed SITS (Safe Implementation of Treatment in Stroke) Open to determine benefit and safety of thrombectomy in clinical practice for large artery occlusion stroke, using selected stent retrievers plus standard care versus standard care alone. Methods: SITS Open was a prospective, open, blinded evaluation, international, multicenter, controlled, nonrandomized registry study. Centers lacking access to thrombectomy contributed controls. Primary end point was categorical shift in modified Rankin Scale score at 3 months in the per protocol (PP) population. Principal secondary outcomes were symptomatic intracranial hemorrhage, functional independency (modified Rankin Scale score 0–2) and death at 3 months. Patients independently evaluated by video-recorded modified Rankin Scale interviews blinded to treatment or center identity by central core laboratory were regarded as PP population. Propensity score matching with covariate adjusted analysis was performed. Results: During 2014 to 2017, 293 patients (257 thrombectomy, 36 control) from 26 centers in 10 countries fulfilled intention-to-treat and 200 (170 thrombectomy, 30 control) PP criteria; enrollment of controls was limited by rapid uptake of thrombectomy. In PP analysis, median age was 71 versus 71 years, and baseline National Institutes of Health Stroke Scale 17 versus 17 in the thrombectomy and control arms, respectively. The propensity score matching analysis for PP showed a significant shift for modified Rankin Scale at 3 months favoring the thrombectomy group (odds ratio, 3.8 [95% CI, 1.61–8.95]; P =0.002). Regarding safety, there were 4 cases of symptomatic intracranial hemorrhage in the thrombectomy group (2.4%) and none in the control group. Conclusions: In clinical practice, thrombectomy for patients with large artery occlusion stroke is superior to standard of care in our study. Registration: URL: https://www.clinicaltrials.gov . Unique Identifier: NCT02326428.

Endovascular thrombectomy (EVT) is well established as a highly effective treatment for acute ischemic stroke (AIS) due to proximal, large vessel occlusions (PLVOs). With iterative further advances in catheter technology, distal, medium vessel occlusions (DMVOs) are now emerging as a promising next potential EVT frontier. This consensus statement integrates recent epidemiological, anatomic, clinical, imaging, and therapeutic research on DMVO-AIS and provides a framework for further studies. DMVOs cause 25% to 40% of AISs, arising as primary thromboemboli and as unintended consequences of EVT performed for PLVOs, including emboli to new territories (ENTs) and emboli to distal territories (EDTs) within the initially compromised arterial field. The 6 distal medium arterial arbors (anterior cerebral artery [ACA], M2–M4 middle cerebral artery [MCA], posterior cerebral artery [PCA], posterior inferior cerebellar artery [PICA], anterior inferior cerebellar artery [AICA], and superior cerebellar artery [SCA]) typically have 25 anatomic segments and give rise to 34 distinct arterial branches nourishing highly differentiated, largely superficial cerebral neuroanatomical regions. DMVOs produce clinical syndromes that are highly heterogenous but frequently disabling. While intravenous fibrinolytics are more effective for distal than proximal occlusions, they fail to recanalize one-half to two-thirds of DMVOs. Early clinical series using recently available, smaller, more navigable stent retriever and thromboaspiration devices suggest EVT for DMVOs is safe, technically efficacious, and potentially clinically beneficial. Collaborative investigations are desirable to enhance imaging recognition of DMVOs; advance device design and technical efficacy; conduct large registry studies using harmonized, common data elements; and complete formal randomized trials, improving treatment of this frequent mechanism of stroke.

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

Background: Efficient healthcare workflow leads to faster reperfusion and better functional outcomes of stroke in the early-time window. We investigated the impact of care delays on the outcomes of stroke patients treated with endovascular thrombectomy (EVT) in the late window. Methods: Pooled data from seven randomized clinical trials and registries that only included patients who underwent EVT in the late time window (onset/last known well (LKW) time to imaging time of 6 hours or more) were combined for this analysis. The time intervals from stroke onset to successful reperfusion were analyzed. Logistic regression was used to estimate the likelihood of a functionally independent outcome at 90 days (modified Rankin scale 0-2) for each time interval while adjusting for relevant patients’ characteristics. Negative binomial regression was used to evaluate the relationship between each time interval and the predictors. Results: 584 patients were included in this analysis. The median age was 70 years (IQR: 21), 293 [50.17%] were females, 298 (53.31%) had wake-up strokes, and the median ASPECTS was 8 (IQR: 2). All patients had CT, and CTA imaging, and 360 (61.64%) underwent perfusion imaging. Successful reperfusion was achieved in 469 (80.45%) patients, and 249 (44.54%) had independent outcomes at 90 days. For every 30 minutes delay, the estimated probability of functional independence decreased by 19% for the emergency department (ED) arrival to imaging time interval, by 25% from groin puncture to end of EVT, and by 12% from ED arrival to end of EVT. Older age and higher NIHSS were associated with longer time from imaging to groin puncture. However, only age was associated with a longer estimated times from stroke onset/LKW to arrival in ED and from stroke onset/LKW to the end of EVT. Conclusion: Faster in-hospital care is associated with improved functional independence among late-window patients. Page 1

Background and Purpose: Sex-related differences exist in many aspects of stroke and were mainly investigated in the early time window with conflicting results. However, data regarding sex disparities in late presenters are scarce. Therefore, we sought to investigate differences in outcomes between women and men treated with endovascular treatment (EVT) in the late time window. Methods: Analyses were based on the Selection Of Late-window Stroke for Thrombectomy by Imaging Collateral Extent Consortium, which was an individual-patient level analysis of seven trials and registries. Baseline characteristics, functional independence (modified Rankin Scale ≤ 2), mortality, and symptomatic intracranial hemorrhage (sICH) were compared between women and men. Effect of sex on the association between age, successful reperfusion (Thrombolysis in cerebral infarction 2b-3) and outcomes was assessed using multivariable logistic regression with interaction terms. Results: Among 608 patients treated with EVT, 50.5% were women. Women were older than men by median 4 years and had a lower prevalence of tandem occlusions (14.0% vs. 22.9%). In the subset of patients with available perfusion volumes (n= 195), women had smaller penumbra (median IQR:97 mL [60- 130] vs. 109 mL [73-189]; p= 0.008), and mismatch volumes, (79 mL [49-101] vs. 91 mL [57-158] ; p= 0.02). Pre and intrahospital times were similar between sexes. Outcomes did not differ between women and men, and there was no sex-by-age interaction on functional independence. However, men had higher likelihood of mortality (p interaction = 0.004) and sICH (p interaction = 0.016) with advancing age. Sex did not influence the relation between successful reperfusion and outcomes. Conclusions: In this multicenter analysis of late presenters treated with EVT, sex was not associated with clinical outcomes. However, sex influenced the association between age and safety outcomes with men experiencing worse outcomes with advancing age.

Background and purpose We sought to investigate whether there are gender differences in clinical outcome after stroke due to large vessel occlusion (LVO) after mechanical thrombectomy (EVT) in a large population of real-world patients. Methods From the Italian Registry of Endovascular Thrombectomy, we extracted clinical and outcome data of patients treated for stroke due to large vessel occlusion. We compared clinical and safety outcomes in men and women who underwent EVT alone or in combination with intravenous thrombolysis (IVT) in the total population and in a Propensity Score matched set. Results Among 3422 patients included in the study, 1801 (52.6%) were women. Despite older age at onset (mean 72.4 vs 68.7; p Conclusions Subject to the limitations of a non-randomized comparison, women with stroke due to LVO treated with mechanical thrombectomy had a better chance to achieve complete recanalization, and 3-month functional independence than men. The results could be driven by women who underwent combined treatment.

The Careggi Collateral Score (CCS) (qualitative–quantitative evaluation) was developed from a single-centre cohort as an angiographic score to describe both the extension and effectiveness of the pial collateral circulation in stroke patients with occlusion of the anterior circulation. We aimed to examine the association between CCS (quantitative evaluation) and 3-month modified Rankin Scale (mRS) score in a large multi-center cohort of patients receiving thrombectomy for stroke with occlusion of middle cerebral artery (MCA). We conducted a study on prospectively collected data from 1284 patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke. According to the extension of the retrograde reperfusion in the cortical anterior cerebral artery (ACA)-MCA territories, CCS ranges from 0 (absence of retrograde filling) to 4 (visualization of collaterals until the alar segment of the MCA). Using CCS of 4 as reference, CCS grades were associated in the direction of unfavourable outcome on 3-month mRS shift (0 to 6); significant difference was found between CCS of 0 and CCS of 1 and between CCS of 3 and CCS of 4. CCS ≥ 3 was the optimal cut-off for predicting 3-month excellent outcome, while CCS ≥ 1 was the optimal cut-off for predicting 3-month survival. CCS of 0 and CCS

BackgroundThe benefit, safety, and time intervals of mechanical thrombectomy (MT) in patients with in-hospital stroke (IHS) are unclear. We sought to evaluate the outcomes and treatment times for IHS patients compared with out-of-hospital stroke (OHS) patients receiving MT.MethodsWe analyzed data from the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) between 2015 and 2019. We compared the functional outcomes (modified Rankin Scale (mRS) scores) at 3 months, recanalization rates, and symptomatic intracranial hemorrhage (sICH) after MT. Time intervals from stroke onset-to-imaging, onset-to-groin, and onset-to-end MT were recorded for both groups, as were door-to-imaging and door-to-groin for OHS. A multivariate analysis was performed.ResultsOf 5619 patients, 406 (7.2%) had IHS. At 3 months, IHS patients had a lower rate of mRS 0–2 (39% vs 48%, PConclusionDespite favorable time intervals for MT, IHS patients had worse functional outcomes than OHS patients. Delays in IHS management were detected.

Background and purposeCollateral assessment using CT angiography is a promising modality for selecting patients for endovascular thrombectomy (EVT) in the late window (6–24 hours). The outcome of these patients compared with those selected using perfusion imaging is not clear.MethodsWe pooled data from seven trials and registries of EVT-treated patients in the late-time window. Patients were classified according to the baseline imaging into collateral imaging alone (collateral cohort) and perfusion plus collateral imaging (perfusion cohort). The primary outcome was the proportion of patients achieving independent 90-day functional outcome (modified Rankin Scale ‘mRS’ 0–2). We used the propensity score–weighting method to balance important predictors between the cohorts.ResultsIn 608 patients, the median onset/last-known-well to emergency arrival time was 8.8 hours and 53.2% had wake-up strokes. Both cohorts had collateral imaging and 379 (62.3%) had perfusion imaging. Independent functional outcome was achieved in 43.1% overall: 168/379 patients (45.5%) in the perfusion cohort versus 94/214 (43.9%) in the collateral cohort (p=0.71). A logistic regression model adjusting for inverse-probability-weighting showed no difference in 90-day mRS score of 0–2 among the perfusion versus collateral cohorts (adjusted OR 1.05, 95% CI 0.69 to 1.59, p=0.83) or in a favourable shift in 90-day mRS (common adjusted OR 1.01, 95% CI 0.69 to 1.47, p=0.97).ConclusionThis pooled analysis of late window EVT showed comparable functional outcomes in patients selected for EVT using collateral imaging alone compared with patients selected using perfusion and collateral imaging.PROSPERO registration numberCRD42020222003.

Flow diverter devices have gained wide acceptance for the treatment of unruptured intracranial aneurysms. Most studies are based on the treatment of large aneurysms harboring on the carotid syphon. However, during the last years the “off-label” use of these stents has widely grown up even if not supported by randomized studies. This review examines the relevant literature concerning “off-label” indications for flow diverter devices, such as for distal aneurysms, bifurcation aneurysms, small aneurysms, recurrent aneurysms, and direct carotid cavernous fistulas.

Background Recent trials established the efficacy of mechanical stent-retriever thrombectomy for treatment of stroke patients with large vessel occlusion (LVO) in the anterior circulation. However, stent-retriever thrombectomy may not accomplish successful recanalization in all patients. The aim of this study is to report the role of bail-out permanent stenting after failure of mechanical thrombectomy. Methods Among 430 patients included in a prospectively maintained database, we analysed 325 cases of anterior circulation LVO. Mechanical thrombectomy (mTICI 2b-3) was effective in 213/325 (65%) and failed in 112/325 (35%). Bail-out intracranial stenting was performed in 17/325 (5.2%) patients. In all cases a fully retrievable detachable stent was used (Solitaire AB, Medtronic). Results No intraprocedural technical complications occurred. Successful reperfusion (mTICI 2b/3) was achieved in 12/17 patients (70.6%). Three (17.6%) patients died: one extensive infarction in the internal carotid artery territory, one large intracerebral haemorrhage, and one massive pulmonary embolism. Haemorrhagic conversion, both symptomatic and asymptomatic, occurred in 2/17 (11.7%). Good clinical outcome (mRS 0–2) at 3-months was achieved in 41.2% of patients. Conclusion Bail-out intracranial stenting after unsuccessful thrombectomy is technically feasible and the associated haemorrhagic risk seems acceptable in selected patients. We suggest that bail-out intracranial stenting, is safe and effective in selected patients with LVO stroke who failed to respond to thrombectomy.

BackgroundDuring the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study’s objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines.MethodsWe conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March–31 May 2020. The prior 1-year control period (1 March–31 May 2019) was obtained to account for seasonal variation.FindingsThere was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI −24.3% to −20.7%, pInterpretationThere was a relative decrease in the volume of SAH hospitalisations, aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic. These findings in SAH are consistent with a decrease in other emergencies, such as stroke and myocardial infarction.

In 2014, Chapot et al. introduced the pressure cooker technique (PCT), conceived to control undesired reflux of the embolic agent during the treatment of brain arterio-venous malformations (bAVMs). Since then, this technique increased in popularity and it has been extensively used. We present five consecutive cases in which the original PCT was simplified using nylon coils instead of platinum coils and acrylic glue, hence the name of ‘Simplified Pressure Cooker Technique’ (sPCT). The aim was to obtain a safer, precise and faster creation of the plug to control cohesive embolic agent reflux during the treatment of brain and facial vascular malformations.

Background and Purpose: Acute ischemic stroke and large vessel occlusion can be concurrent with the coronavirus disease 2019 (COVID-19) infection. Outcomes after mechanical thrombectomy (MT) for large vessel occlusion in patients with COVID-19 are substantially unknown. Our aim was to study early outcomes after MT in patients with COVID-19. Methods: Multicenter, European, cohort study involving 34 stroke centers in France, Italy, Spain, and Belgium. Data were collected between March 1, 2020 and May 5, 2020. Consecutive laboratory-confirmed COVID-19 cases with large vessel occlusion, who were treated with MT, were included. Primary investigated outcome: 30-day mortality. Secondary outcomes: early neurological improvement (National Institutes of Health Stroke Scale improvement ≥8 points or 24 hours National Institutes of Health Stroke Scale 0–1), successful reperfusion (modified Thrombolysis in Cerebral Infarction grade ≥2b), and symptomatic intracranial hemorrhage. Results: We evaluated 93 patients with COVID-19 with large vessel occlusion who underwent MT (median age, 71 years [interquartile range, 59–79]; 63 men [67.7%]). Median pretreatment National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score were 17 (interquartile range, 11–21) and 8 (interquartile range, 7–9), respectively. Anterior circulation acute ischemic stroke represented 93.5% of cases. The rate modified Thrombolysis in Cerebral Infarction 2b to 3 was 79.6% (74 patients [95% CI, 71.3–87.8]). Thirty-day mortality was 29% (27 patients [95% CI, 20–39.4]). Early neurological improvement was 19.5% (17 patients [95% CI, 11.8–29.5]), and symptomatic intracranial hemorrhage was 5.4% (5 patients [95% CI, 1.7–12.1]). Patients who died at 30 days exhibited significantly lower lymphocyte count, higher levels of aspartate, and LDH (lactate dehydrogenase). After adjustment for age, initial National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, and successful reperfusion, these biological markers remained associated with increased odds of 30-day mortality (adjusted odds ratio of 2.70 [95% CI, 1.21–5.98] per SD-log decrease in lymphocyte count, 2.66 [95% CI, 1.22–5.77] per SD-log increase in aspartate, and 4.30 [95% CI, 1.43–12.91] per SD-log increase in LDH). Conclusions: The 29% rate of 30-day mortality after MT among patients with COVID-19 is not negligible. Abnormalities of lymphocyte count, LDH and aspartate may depict a patient’s profiles with poorer outcomes after MT. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT04406090.

BACKGROUND AND PURPOSE The aim was to assess functional and radiological outcomes after bridging therapy (intravenous thrombolysis plus mechanical thrombectomy) versus direct mechanical thrombectomy (MT) in unknown onset stroke patients. METHODS A cohort study was conducted on prospectively collected data from unknown onset stroke patients who received endovascular procedures at ≤6 h from symptom recognition or awakening time. RESULTS Of the 349 patients with a 10-point Alberta Stroke Program Early Computed Tomography Score (ASPECTS), 248 received bridging and 101 received direct MT. Of the 134 patients with 6-9-point ASPECTS, 123 received bridging and 111 received direct MT. Each patient treated with bridging was propensity score matched with a patient treated with direct MT for age, sex, study period, pre-stroke disability, stroke severity, type of stroke onset, symptom recognition to groin time (or awakening to groin time), ASPECTS and procedure time. In the two matched groups with 10-point ASPECTS (n = 73 vs. n = 73), bridging was associated with higher rates of excellent outcome (46.6% vs. 28.8%; odds ratio 2.302, 95% confidence interval 1.010-5.244) and successful recanalization (83.6% vs. 63%; odds ratio 3.028, 95% confidence interval 1.369-6.693) compared with direct MT; no significant association was found between bridging and direct MT with regard to rate of symptomatic intracerebral hemorrhage (0% vs. 1.4%). In the two matched groups with 6-9-point ASPECTS (n = 45 vs. n = 45), no significant associations were found between bridging and direct MT with regard to rates of excellent functional outcome (44.4% vs. 31.1%), successful recanalization (73.3% vs. 76.5%) and symptomatic intracerebral hemorrhage (0% vs. 0%). CONCLUSIONS Bridging at ≤ 6 h of symptom recognition or awakening time was associated with better functional and radiological outcomes in unknown onset stroke patients with 10-point ASPECTS.

Background: We aim to evaluate the speed and rates of reperfusion in tandem large vessel occlusion acute stroke patients undergoing upfront cervical lesion treatment (Neck-First: angioplasty and/or stent before thrombectomy) as compared to direct intracranial occlusion therapy (Head-First) in a large international multicenter cohort. Methods: The Thrombectomy In TANdem Lesions (TITAN) collaboration pooled individual data of prospectively collected thrombectomy international databases for all consecutive anterior circulation tandem patients who underwent emergent thrombectomy. The co-primary outcome measures were rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b/3) and time from groin puncture to successful reperfusion. Results: In total, 289 patients with tandem atherosclerotic etiology were included in the analysis (182 Neck-First and 107 Head-First patients). Except for differences in the Alberta Stroke Program Early CT Score (ASPECTS; median 8 [range 7–10] Neck-First vs. 7 [range 6–8] Head-First; p < 0.001) and cervical internal carotid artery (ICA) lesion severity (complete occlusion in 35% of the Neck-First vs. 57% of the Head-First patients; p < 0.001), patient characteristics were well balanced. After adjustments, there was no difference in successful reperfusion rates between the study groups (odds ratio associated with Neck-First: 1.18 [95% confidence interval, 0.60–2.17]). The time to successful reperfusion from groin puncture was significantly shorter in the Head-First group after adjustments (median 56 min [range 39–90] vs. 70 [range 50–102]; p = 0.001). No significant differences in the rates of full reperfusion, symptomatic hemorrhage, 90-day independence, or mortality were observed. Sensitivity analysis excluding patients with complete cervical ICA occlusion yielded similar results. Conclusions: The upfront approach of the intracranial lesion in patients with tandem large vessel occlusion strokes leads to similar reperfusion rates but faster reperfusion as compared to initial cervical revascularization followed by mechanical thrombectomy. Controlled studies are warranted.

Background Shunt-dependent hydrocephalus significantly complicates subarachnoid hemorrhage (SAH), and reliable prognosis methods have been sought in recent years to reduce morbidity and costs associated with delayed treatment or neglected onset. Machine learning (ML) defines modern data analysis techniques allowing accurate subject-based risk stratifications. We aimed at developing and testing different ML models to predict shunt-dependent hydrocephalus after aneurysmal SAH. Methods We consulted electronic records of patients with aneurysmal SAH treated at our institution between January 2013 and March 2019. We selected variables for the models according to the results of the previous works on this topic. We trained and tested four ML algorithms on three datasets: one containing binary variables, one considering variables associated with shunt-dependency after an explorative analysis, and one including all variables. For each model, we calculated AUROC, specificity, sensitivity, accuracy, PPV, and also, on the validation set, the NPV and the Matthews correlation coefficient (ϕ). Results Three hundred eighty-six patients were included. Fifty patients (12.9%) developed shunt-dependency after a mean follow-up of 19.7 (± 12.6) months. Complete information was retrieved for 32 variables, used to train the models. The best models were selected based on the performances on the validation set and were achieved with a distributed random forest model considering 21 variables, with a ϕ = 0.59, AUC = 0.88; sensitivity and specificity of 0.73 (C.I.: 0.39–0.94) and 0.92 (C.I.: 0.84–0.97), respectively; PPV = 0.59 (0.38–0.77); and NPV = 0.96 (0.90–0.98). Accuracy was 0.90 (0.82–0.95). Conclusions Machine learning prognostic models allow accurate predictions with a large number of variables and a more subject-oriented prognosis. We identified a single best distributed random forest model, with an excellent prognostic capacity (ϕ = 0.58), which could be especially helpful in identifying low-risk patients for shunt-dependency.

Purpose: Intracranial carotid artery occlusion represents an underinvestigated cause of acute ischemic stroke as well as an indication for mechanical thrombectomy. We investigated baseline and procedural characteristics, outcomes and predictors of outcome in patients with acute ischemic stroke secondary to intracranial carotid artery occlusion. Methods: A retrospective analysis of the Italian Registry of Endovascular Treatment in Acute Stroke was performed. Patients with intracranial carotid artery occlusion (infraclinoid and supraclinoid) with or without cervical artery occlusion but with patent intracranial arteries were included. The 3‑month functional independence, mortality, successful reperfusion and symptomatic intracranial hemorrhage were evaluated. Results: Intracranial carotid artery occlusion with patent intracranial arteries was diagnosed in 387 out of 4940 (7.8%) patients. The median age was 74 years and median baseline National Institute of Health Stroke Scale (NIHSS) was 18. Functional independence was achieved in 130 (34%) patients, successful reperfusion in 289 (75%) and symptomatic intracranial hemorrhage in 33 (9%), whereas mortality occurred in 111 (29%) patients. In univariate analysis functional independence was associated with lower age, lower NIHSS at presentation, higher rate of successful reperfusion and lower rate of symptomatic intracranial hemorrhage. Multivariable regression analysis found age (odds ratio, OR:1.03; P = 0.006), NIHSS at presentation (OR: 1.07; P < 0.001), diabetes (OR: 2.60; P = 0.002), successful reperfusion (OR:0.20; P < 0.001) and symptomatic intracranial hemorrhage (OR: 4.17; P < 0.001) as the best independent predictors of outcome. Conclusion: Our study showed a not negligible rate of intracranial carotid artery occlusion with patent intracranial arteries, presenting mostly as severe stroke, with an acceptable rate of 3‑month functional independence. Age, NIHSS at presentation and successful reperfusion were the best independent predictors of outcome. © 2020, Springer-Verlag GmbH Germany, part of Springer Nature.

Background and Purpose: As numerous questions remain about the best anesthetic strategy during thrombectomy, we assessed functional and radiological outcomes in stroke patients treated with thrombectomy in presence of general anesthesia (GA) versus conscious sedation (CS) and local anesthesia (LA). Methods: We conducted a cohort study on prospectively collected data from 4429 patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke. Results: GA was used in 2013 patients, CS in 1285 patients, and LA in 1131 patients. The rates of 3-month modified Rankin Scale score of 0–1 were 32.7%, 33.7%, and 38.1% in the GA, CS, and LA groups: GA versus CS: odds ratios after adjustment for unbalanced variables (adjusted odds ratio [aOR]), 0.811 (95% CI, 0.602–1.091); and GA versus LA: aOR, 0.714 (95% CI, 0.515–0.990). The rates of modified Rankin Scale score of 0–2 were 42.5%, 46.6%, and 52.4% in the GA, CS, and LA groups: GA versus CS: aOR, 0.902 (95% CI, 0.689–1.180); and GA versus LA: aOR, 0.769 (95% CI, 0.566–0.998). The rates of 3-month death were 21.5%, 19.7%, and 14.8% in the GA, CS, and LA groups: GA versus CS: aOR, 0.872 (95% CI, 0.644–1.181); and GA versus LA: aOR, 1.235 (95% CI, 0.844–1.807). The rates of parenchymal hematoma were 9%, 12.6%, and 11.3% in the GA, CS, and LA groups: GA versus CS: aOR, 0.380 (95% CI, 0.262–0.551); and GA versus LA: aOR, 0.532 (95% CI, 0.337–0.838). After model of adjustment for predefined variables (age, sex, thrombolysis, National Institutes of Health Stroke Scale, onset-to-groin time, anterior large vessel occlusion, procedure time, prestroke modified Rankin Scale score of Conclusions: GA during thrombectomy was associated with worse 3-month functional outcomes, especially when compared with LA. The inclusion of an LA arm in future randomized clinical trials of anesthesia strategy is recommended.

Background Flow diversion for basilar apex aneurysms has rarely been reported. Objective To assess flow diversion for basilar apex aneurysms in a multicenter cohort. Methods Retrospective review of prospectively maintained databases at 8 academic institutions was performed from 2009 to 2016 to identify patients with basilar apex aneurysms treated with flow diversion. Clinical and radiographic data were analyzed. Results Sixteen consecutive patients (median age 54.5 yr) underwent 18 procedures to treat 16 basilar apex aneurysms with either the Pipeline Embolization Device (Medtronic Inc, Dublin, Ireland) or Flow Redirection Endoluminal Device (Microvention, Tustin, California). Five aneurysms (31.3%) were treated in the setting of subarachnoid hemorrhage. Seven aneurysms (43.8%) were treated with flow diversion alone, while 9 (56.2%) underwent flow diversion and adjunctive coiling. At a median follow-up of 6 mo, complete (100%) and near-complete (90%-99%) occlusion was noted in 11 (68.8%) aneurysms. Incomplete occlusion occurred more commonly in patients treated with flow diversion alone compared to those with adjunctive coiling. Patients with partial occlusion were significantly younger. Retreatment with an additional flow diverter and adjunctive coiling occurred in 2 aneurysms with wide necks. There was 1 mortality in a patient (6.3%) who experienced posterior cerebral artery and cerebellar strokes as well as subarachnoid hemorrhage after the placement of a flow diverter. Minor complications occurred in 2 patients (12.5%). Conclusion Flow diversion for the treatment of basilar apex aneurysms results in acceptable occlusion rates in highly selected cases. Both primary flow diversion and rescue after failed clipping or coiling resulted in a modified Rankin Scale score that was either equal or better than at presentation and the technology represents a viable alternative or adjunctive option.

Objective The safety and efficacy of flow diversion for distal circulation aneurysms of the cerebral vasculature has not been well evaluated. The objective of this study was to assess the use of flow diversion for distal circulation aneurysms (defined as at or beyond the M1, P1, and A1 segments of the middle cerebral artery, posterior cerebral artery, and anterior cerebral artery, respectively) in an international multicenter cohort. Methods Clinical and radiologic records from all patients undergoing flow diversion treatment of distal circulation aneurysms at 3 academic centers (2 in the USA and 1 in Europe) from 2014 until 2017 were retrospectively reviewed. Results Forty-six patients (mean age, 58.2 years; 33 women) harboring 46 aneurysms who underwent treatment with either the Pipeline Embolization Device (Medtronic Inc., Dublin, Ireland) or the Flow Re-Direction Endoluminal Device (MicroVention, Tustin, California, USA) were included in these analyses. Thirty-four aneurysms (74%) were located in the anterior circulation and 12 (26%) were located in the posterior circulation. With a mean follow-up of 13.0 months, complete (100%) and near-complete (90%–99%) occlusion was noted in 36 aneurysms (78.2%). Angiographic evidence of side branch or perforator vessel coverage was present in 35 aneurysms (76.1%) but was not associated with failure to occlude at follow-up (P = 0.06). All patients had good functional outcomes after treatment (modified Rankin Scale score 0–2). There were 2 cases (4.3%) of perforator vessel stroke and no hemorrhagic complications. Conclusions Flow diversion for aneurysms beyond the circle of Willis has occlusion rates comparable to alternative treatments and low morbidity. The clinical significance of flow limitation through covered side branches requires further investigation.

Background and Purpose— Despite the recent technical evolution of the endovascular treatment of acute ischemic stroke, late and incomplete recanalization can be achieved after several maneuvers but with a potentially higher risk of futile reperfusion and complications, such as clot fragmentation. The aim of this article is to investigate the impact of the angiographic phenotype of M1-middle cerebral artery occlusions, classified as regular and irregular in aspect, on the results of treatment by stent retrievers (SRs) or contact aspiration (CA). Methods— From January to April 2016, 84 consecutive patients, admitted for acute ischemic stroke with a middle cerebral artery occlusion, were treated by endovascular therapy. Among them, 60 patients (26M, 34F, median age, 70.5; interquartile range, 58.5–80.0) were treated by SR (25/60, 41.7%) or CA (35/60, 58.3%) as a first-line approach in 2 experienced centers. Patients’ characteristics, timing, and procedural data were prospectively recorded and compared between the 2 study subgroups (regular and irregular phenotype). Results— A regular phenotype at the occlusion site was observed in 24 patients (40%). Among these, successful recanalization after the first-line strategy (Thrombolysis in Cerebral Infarction 2b-3) was achieved in 100% of patients treated by CA and in only 33.3% of patients treated by SR ( P =0.001). For irregular phenotypes, SR achieved Thrombolysis in Cerebral Infarction 2b-3 in 73.9% and CA, in 38.5% ( P =0.036) of cases. Among regular phenotype patients, the average number of maneuvers was 1.3 (median, 1; range 1–3) with first-line CA and 2.7 (median, 3; range 1–5) with first-line SR ( P =0.008). Conclusions— The angiographic phenotype of the occlusion site may be associated with a different response to SR and CA in this preliminary experience.

Background PulseRider (Pulsar Vascular, Los Gatos, California, USA) is a new endovascular device designed to treat wide-neck bifurcation intracranial aneurysms. Deployment of a stent through a PulseRider to treat an aneurysm's recurrence has never been described before. Case Description We report the case of a 55-year-old man who underwent coiling of an 8-mm anterior communicating artery aneurysm with assistance of a PulseRider neck reconstruction device. The 6-month digital subtraction angiography control showed aneurysm recurrence, so we deployed an Enterprise 2 closed-cell stent (Codman, Miami Lakes, Florida, USA) in the A1-A2 segment passing across the previously implanted PulseRider. Enterprise correctly expanded and allowed for adequate coiling of the aneurysm. Conclusion An Enterprise stent can be safely opened through a PulseRider in order to treat aneurysm recurrence.

Background/Objective PulseRider is a new endovascular stent dedicated to treat bifurcation intracranial aneurysms with a wide neck. Our purpose was to evaluate 6-month clinical and anatomic results of the device when used to facilitate endovascular coiling of wide-neck bifurcation aneurysms. Methods Unruptured intracranial aneurysms coiled with PulseRider, in 6 European centers and 1 U.S. center, were retrospectively reviewed from June 2014 to October 2015. Immediate and 6-month results were evaluated independently by using the Raymond classification scale. Recanalization was defined as worsening, and progressive thrombosis was defined as improvement on the Raymond scale. Results Nineteen patients (10 women, 9 men; mean age, 63 years) harboring 19 bifurcation aneurysms (mean dome size, 8.8 mm; mean neck size, 5.8 mm) were included. Immediate angiographic outcome showed 11 complete aneurysm occlusions, 6 neck remnants, and 2 residual aneurysms. Follow-up at 6 months, obtained in all patients, included 12 complete aneurysm occlusions (63.1%), 6 neck remnants (31.6%), and 1 residual aneurysm (5.3%). Adequate occlusion (defined as complete occlusion and neck remnant combined) was observed in 94.7%. Progressive thrombosis was observed in 2 cases (10.6%) and recanalization in 1 case (5.3%). There was no in-stent stenosis or jailed branch occlusion. No bleeding was observed during the follow-up period. Permanent morbidity rate was 5.3% (1/19), and the mortality rate was 0% at 6 months. Conclusions The PulseRider allows endovascular treatment of wide-neck bifurcation intracranial aneurysms. Larger series are needed to confirm our preliminary results.

BACKGROUND Y-stenting is an effective but challenging approach for wide-neck aneurysms. PulseRider (PR) (Pulsar/Cerenovus) is a new device designed to provide scaffolding during coiling but has never been compared with other techniques. OBJECTIVE To compare the immediate and 6-mo results of Y-stenting vs PR assisted coiling. METHODS A total of 105 consecutive patients were retrospectively divided into 2 groups (73 Y-stenting and 32 PR). All underwent angiographic 6-mo follow-up. We evaluated if some anatomical features could influence treatment results. RESULTS The groups were homogeneous. Immediate adequate occlusions as well as complication rates were similar in Y-stenting and PR group (94.5% vs 96.9% and 8.2% vs 6.2%, respectively). At 6 mo, adequate occlusion was 93.1% after Y-stenting and 84.3% after PR (P = .28), complete occlusion was significantly higher after Y-stenting: 90.3% vs 62.5% (P = .0017). Occlusion grade worsening occurred in 6.9% of Y-stenting and 18.7% of PR patients (P = .09).Neck size was associated with occlusion grade in both groups. Maximal aneurysm size was associated with occlusion grade in the PR group (P = .023) but not in the Y-stenting group (P = .06). After PR, 6-mo occlusion rate was higher in small (< 10 mm) than in large aneurysms (P = .0094); this was not observed after Y-stenting (P = .54).Location did not significantly affect the mid-term occlusion rate in both the groups. After PR, occlusion was more stable in basilar than anterior or middle cerebral artery aneurysms. CONCLUSION Y-stenting and PR are both effective with similar immediate and mid-term results. However, treatment stability seems higher after Y-stenting. Aneurysm size seems to negatively affect PR results.

BackgroundThe persistent trigeminal artery (PTA) is an adult carotid-basilar anastomosis with debated pathologic aspects, such as its association with brain aneurysms. True trigeminal artery aneurysms are rare vascular anomalies, reported in a few case reports.ObjectiveTo report our experience with a ruptured trigeminal artery aneurysm and to provide a systematic review of the literature in order to analyse potential links between the anatomic configuration of the PTA and PTA aneurysm (PTAA) type, and implications of each PTAA type for the diagnostic and therapeutic approach.MethodsWe reviewed the medical literature on trigeminal artery aneurysms according to the PRISMA guidelines. Population characteristics, aneurysms features, and PTA type and side were assessed.Results40 previously published cases of PTAAs were included in the analysis. The mean age of subjects was 55 years, with a strong female predominance (77%). Four PTAAs were accidentally discovered, while 16 caused compressive symptoms and 20 were ruptured. Successful endovascular treatment was performed in 62% of cases.ConclusionsPTAAs are rare vascular anomalies, underdiagnosed in the presence of a trigemino-cavernous fistula. Parent vessel occlusion seems to be the best therapeutic option for ruptured or symptomatic unruptured PTAAs in Saltzman type II and III PTAs. Patency of the parent vessel is the main target in Saltzman type I PTA.

Background: Acute tandem occlusion (ATO) management is technically challenging and was not sufficiently evaluated in trials. There is evidence suggesting the efficacy and safety of emergent carotid stenting in conjunction with mechanical thrombectomy (MT) for ATO treatment. However, the safety of carotid stenting (CS) post intravenous tPA (IVT) treatment remains unclear. Objective: to report the safety and functional outcomes of emergent CS post IVT, and compare it to non-IVT patients. Methods: This was a retrospective multicenter international TITAN collaboration including 18 endovascular databases. In the present analysis, patients were included if they presented with acute ischemic stroke (AIS) due to ATO and were treated with CS in conjunction with MT. ATO was defined as an extracranial internal carotid artery (ICA) lesion (complete occlusion or stenosis >=90%) and an intracranial proximal occlusion (distal ICA and/or first or second segment of the middle cerebral artery). Outcome measures included final mTICI score, 90 day-modified Rankin Scale (mRS), mortality, procedural complications, and symptomatic intracerebral hemorrhage. Mixed effects logistic model was used to determine the predictors of each outcome Results: Among 454 patients with ATO, 289 were treated with CS and included in the present analysis. One hundred seventy-five patients (60%) of the included patients received IVT prior to MT. Onset to groin was shorter in the IVT group (259 ±251 vs. 353±238; p=0.013). Otherwise, there was no difference in baseline characteristics between the two groups. Heparin use during procedure was less in IVT group (20% vs. 54%; p Conclusion: Emergent CS in association with MT after IVT was safe and was not associated with an increased risk of sICH or procedural complications.

Introduction: Previous studies showed that mechanical thrombectomy (MT) is safe and effective in tandem steno-occlusive lesion. The effect on initial tandem extracranial internal carotid artery (ICA) lesion severity on outcome is unknown. In this study, we aimed to compare angiographic, functional and hemorrhagic outcomes according to initial lesion severity Methods: A multicenter international retrospective study that included 18 stroke centers. Patients were included if they presented with ischemic stroke due to tandem lesion and were treated with MT with or without carotid stenting. Tandem lesion was defined as proximal intracranial occlusion (distal ICA, M1/M2) and extracranial internal carotid artery (ICA) occlusion or ≥90% stenosis NASCET. We divided patients into two groups based on extracranial ICA lesion severity (severe stenosis vs. complete occlusion) at the first angiographic run. Outcome measures included 90 day mRS, final mTICI score, procedural complications and symptomatic hemorrhage. Symptomatic hemorrhage (Sich) was defined based on ECASS criteria. Results: A total of 305 patients were included in the present analysis. 134 patients had complete ICA occlusion (group 1) ,and 170 had ≥90% ICA stenosis (group 2). Hyperlipidemia was more frequent in group 1 ((46.5% vs. 33.6%, p=0.032), and diabetes was less frequent (12.4 vs. 23.8%;p=0.011). Otherwise there was no significant difference in baseline characteristics, pretreatment tPA , and ASPECTS between two groups. With respect to outcome, successful recanalization (TICI 2b-3) was lower in group 1 than group 2 (70% vs. 80%; p=0.038). Similarly TICI 3 was achieved in less patients in group 1 (24% vs. 40%;p=0.022). Favorable outcome (mRS 0-2), sICH and procedural complications were similar in both groups. Conclusion: Initial angiographic severity of extracranial ICA lesion in tandem occlusions was associated with lower recanalization rates after MT, without impact on clinical outcomes.

Multiple carotid cavernous fistula (CCF) classifications have been proposed. However, they lacked predictive factors for the clinical presentation, natural history, and hemorrhagic risk. Our aim was to externally validate a new classification according to venous drainage (i.e., the Thomas classification [TC]) to assess its relationship with symptoms, endovascular treatment, and outcomes.We performed a multicenter retrospective review of CCFs at 2 major academic institutions. The CCFs were classified using the Barrow classification (BC) and TC systems.The data from 94 patients with a diagnosis of CCF were collected during a study period 23 years, 4 months. Of these 94 patients, 89 had undergone CCF treatment and 5 had experienced spontaneous occlusion. Complete occlusion was achieved in 89.9% of the treated patients. Complications occurred in 5.3% of the patients, including permanent deficits in 2.1%. TC type 4 was associated with cortical symptoms compared with type 2 (P = 0.003) and type 3 (P0.001). The BC was not able to detect significant differences among the symptom types. Significant differences were found using the TC for the transarterial-only, transvenous anterior-only, and transvenous posterior-only approaches (P0.001, P = 0.03, and P = 0.001, respectively). The transvenous posterior and transvenous anterior approach were significantly associated with type 2 and 3 TC, respectively. Excluding direct CCFs, the BC was not related to the treatment approach. No significant differences in the outcomes were found. However, a trend toward a lower occlusion rate for TC type 4 compared with type 3 was observed.The TC provided useful information regarding the fistula anatomy and venous hemodynamics, which correlated with the clinical symptoms and treatment strategy.

BACKGROUND: Flow diversion for anterior communicating artery aneurysms required further investigation. PURPOSE: Our aim was to analyze outcomes after treatment of anterior communicating artery aneurysms with flow-diverter stents. DATA SOURCES: A systematic search of 3 data bases was performed for studies published from 2008 to 2018. STUDY SELECTION: According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies reporting anterior communicating artery aneurysms treated with flow diversion. DATA ANALYSIS: Random-effects meta-analysis was used to pool the following: aneurysm occlusion rate, complications, and factors influencing the studied outcomes. DATA SYNTHESIS: We included 14 studies and 148 unruptured saccular anterior communicating artery aneurysms treated with flow diversion. The long-term complete/near-complete (O'Kelly-Marotta C–D) occlusion rate was 87.4% (91/105; 95% CI, 81.3%–93.6%; I(2) = 0%) (mean radiologic follow-up of 11 months). The treatment-related complication rate was 8.6% (14/126; 95% CI, 4%–13.1%; I(2) = 0%), with morbidity and mortality rates of 3.5% (5/126; 95% CI, 2%–7%; I(2) = 0%) and 2.5% (2/148; 95% CI, 0.3%–5%; I(2) = 0%), respectively. Most complications were periprocedural (12/126 = 7%; 95% CI, 3%–11%; I(2) = 0%). Thromboembolic events were slightly higher compared with hemorrhagic complications (10/126 = 6%; 95% CI, 2%–10%; I(2) = 0% and 4/126 = 3%; 95% CI, 1%–6%; I(2) = 0%). Branching arteries (A2 or the recurrent artery of Heubner) covered by the stent were occluded in 16% (7/34; 95% CI, 3.5%–28%; I(2) = 25%) of cases. Pre- and posttreatment low-dose and high-dose of antiplatelet therapy was not associated with significantly different complication and occlusion rates. LIMITATIONS: We reviewed small and retrospective series. CONCLUSIONS: Flow diversion for unruptured saccular anterior communicating artery aneurysms appears to be an effective alternative treatment for lesions difficult to treat with coiling or microsurgical clipping. The treatment-related complication rate was relatively low. However, larger studies are needed to confirm these results.

Background Mechanical thrombectomy is now standard of care for treatment of acute ischemic stroke secondary to large vessel occlusion in the setting of high NIHSS. We analysed a large nationwide registry focusing on patients with large vessel occlusion and low NIHSS on admission to evaluate the efficacy and safety of thrombectomy in this patient population Methods 2826 patients treated with mechanical thrombectomy were included in a multicentre registry from January 1, 2011 to December 31, 2015. We included patients with large vessel occlusion and NIHSS ≤ 6 on admission. Baseline characteristics, imaging, clinical outcome, procedure adverse events and positive and negative outcome predictors were analysed. Results 134 patients were included. 90/134 had an anterior circulation and 44 a posterior circulation stroke. One patient died before treatment. Successful revascularization (mTICI 2b-3) was achieved in 73.7% (98/133) of the patients. Intraprocedural adverse event was observed in 3% (4/133) of cases. Symptomatic intracranial haemorrhage rate was 5.3% (7/133). At three months, 70.9% (95/134) of the patients had mRS score 0-2, 15.7% (21/134) mRS 3-5 and 13.4% (18/134) mRS 6. Age and successful recanalization were significant predictors of a good clinical outcome on both univariate (p= 0.005 and p=0.007) and multivariable (p=0.0018 and p=0.009 [nat log]) analysis. Absence of vessel recanalization and symptomatic intracranial hemorrhage were independent predictors of poor outcome (p=0.021) . Conclusions Our study suggests that patients with large vessel occlusion and low NIHSS score on admission can benefit from mechanical thrombectomy. Randomized trials are warranted.

IntroductionEndovascular treatment (EVT) for tandem occlusion (TO) of the anterior circulation is complex but effective. The effect of extracranial internal carotid artery (EICA) lesion severity on the outcomes of EVT is unknown. In this study we investigated the effect of EICA lesion severity on the outcomes of tandem occlusion EVT.MethodsA multicenter retrospective TITAN (Thrombectomy In TANdem lesions) study that included 18 international endovascular capable centers was performed. Patients who received EVT for atherosclerotic TO with or without EICA lesion intervention were included. Patients were divided into two groups based on the EICA lesion severity (high-grade stenosis (≥90% North American Symptomatic Carotid Endarterectomy Trial) vs complete occlusion). Outcome measures included the 90-day clinical outcome (modified Rankin Scale score (mRS)), angiographic reperfusion (modified Thrombolysis In Cerebral Ischemia (mTICI) at the end of the procedure), procedural complications, and intracranial hemorrhage at 24 hours follow-up.ResultsA total of 305 patients were included in the study, of whom 135 had complete EICA occlusion and 170 had severe EICA stenosis. The EICA occlusion group had shorter mean onset-to-groin time (259±120 min vs 305±202 min; p=0.037), more patients with diabetes, and fewer with hyperlipidemia. With respect to the outcome, mTICI 2b–3 reperfusion was lower in the EICA occlusion group (70% vs 81%; p=0.03). The favorable outcome (90-day mRS 0–2), intracerebral hemorrhage and procedural complications were similar in both groups.ConclusionAtherosclerotic occlusion of the EICA in acute tandem strokes was associated with a lower rate of mTICI 2b–3 reperfusion but similar functional and safety outcomes when compared with high-grade EICA stenosis.

The growing impact of the emergency neurology of trauma centers and of mechanical thrombectomy for the treatment of acute ischemic stroke is revolutionizing the domain of eurosciences. A census focused on the demographic distribution of the three main cohorts of neurosciences (neurologists, neuroradiologists, and neurosurgeons) was conducted in Italy between December 2015 and February 2017, and results were compared to the estimated retirement rates and loss for other reasons. The total number of neurosciences specialists active in Italy was 4394 at the end of the period of the survey. The estimated retirement rates and losses seem not be supplied by the physicians in training in the same period. A proper redistribution of the resources and the modification of the training programs seem to be mandatory to maintain acceptable standards of care for the Italian neurosciences during the next decade.

BACKGROUND: Y-stent-assisted coiling for wide-neck intracranial aneurysms required further investigation. PURPOSE: Our aim was to analyze outcomes after Y-stent placement in wide-neck aneurysms. DATA SOURCES: We performed a systematic search of 3 data bases for studies published from 2000 to 2018. STUDY SELECTION: According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies reporting Y-stent-assisted coiling of wide-neck aneurysms. DATA ANALYSIS: Random-effects meta-analysis was used to pool the following: aneurysm occlusion rate, complications, and factors influencing the studied outcomes. DATA SYNTHESIS: We included 27 studies and 750 aneurysms treated with Y-stent placement. The immediate complete/near-complete occlusion rate was 82.2% (352/468; 95% CI, 71.4%–93%; I(2) = 92%), whereas the long-term complete/near-complete occlusion rate was 95.4% (564/598; 95% CI, 93.7%–97%; I(2) = 0%) (mean radiologic follow-up of 14 months). The aneurysm recanalization rate was 3% (20/496; 95% CI, 1.5%–4.5%; I(2) = 0%), and half of the recanalized aneurysms required retreatment. The treatment-related complication rate was 8.9% (63/614; 95% CI, 5.8%–12.1%; I(2) = 44%). Morbidity and mortality after treatment were 2.4% (18/540; 95% CI, 1.2%–3.7%; I(2) = 0%) and 1.1% (5/668; 95% CI, 0.3%–1.9%; I(2) = 0%), respectively. Crossing Y-stent placement was associated with a slightly lower complication rate compared with the kissing configuration (56/572 = 8.4%; 95% CI, 5%–11%; I(2) = 46% versus 4/30 = 12.7%; 95% CI, 3%–24%; I(2) = 0%). Occlusion rates were quite comparable among Enterprise, Neuroform, and LVIS stents, whereas the Enterprise stent was associated with lower rates of complications (8/89 = 6.5%; 95% CI, 1.6%–11%; I(2) = 0%) compared with the others (20/131 = 14%; 95% CI, 5%–26%; I(2) = 69% and 9/64 = 11%; 95% CI, 3%–20%; I(2) = 18%). LIMITATIONS: This was a small, retrospective series. CONCLUSIONS: Y-stent-assisted coiling yields high rates of long-term angiographic occlusion, with a relatively low rate of treatment-related complications. Y-stent placement with a crossing configuration appears to be associated with better outcomes. Although Y-configuration can be obtained using many types of stents with comparable occlusion rates, the Enterprise stent is associated with lower complication rates.

BACKGROUND AND PURPOSE: Flow diversion with the Pipeline Embolization Device is increasingly used for endovascular treatment of intracranial aneurysms due to high reported obliteration rates and low associated morbidity. While obliteration of covered branches in the anterior circulation is generally asymptomatic, this has not been studied within the posterior circulation. The aim of this study was to evaluate the association between branch coverage and occlusion, as well as associated ischemic events in a cohort of patients with posterior circulation aneurysms treated with the Pipeline Embolization Device. MATERIALS AND METHODS: A retrospective review of prospectively maintained databases at 8 academic institutions from 2009 to 2016 was performed to identify patients with posterior circulation aneurysms treated with the Pipeline Embolization Device. Branch coverage following placement was evaluated, including the posterior inferior cerebellar artery, anterior inferior cerebellar artery, superior cerebellar artery, and posterior cerebral artery. If the Pipeline Embolization Device crossed the ostia of the contralateral vertebral artery, its long-term patency was assessed as well. RESULTS: A cohort of 129 consecutive patients underwent treatment of 131 posterior circulation aneurysms with the Pipeline Embolization Device. Adjunctive coiling was used in 40 (31.0%) procedures. One or more branches were covered in 103 (79.8%) procedures. At a median follow-up of 11 months, 11% were occluded, most frequently the vertebral artery (34.8%). Branch obliteration was most common among asymptomatic aneurysms (P < .001). Ischemic complications occurred in 29 (22.5%) procedures. On multivariable analysis, there was no significant difference in ischemic complications in cases in which a branch was covered (P = .24) or occluded (P = .16). CONCLUSIONS: There was a low occlusion incidence in end arteries following branch coverage at last follow-up. The incidence was higher in the posterior cerebral artery and vertebral artery where collateral supply is high. Branch occlusion was not associated with a significant increase in ischemic complications.

Background Ethmoidal dural arteriovenous fistulas (DAVFs) are rare and aggressive lesions, usually treated by microsurgical disconnection of the fistula. Transarterial embolization rarely is performed because of the risk of retinal ischemia. Transvenous embolization has been reported as an alternative approach. We describe our experience in transvenous embolization of ethmoidal DAVFs and review the literature focusing on technical and safety aspects of the procedure. Methods We retrospectively identified 4 patients with ethmoidal DAVFs treated by transvenous embolization in a single center. Clinical data and angiographic images were reviewed. We reviewed the literature after PubMed searching for articles describing patients treated by a transvenous approach. Results One patient was treated by transvenous coiling and 3 patients by retrograde Onyx injection through a detachable-tip microcatheter. Three fistulas drained in an ascending cortical frontal vein and one drained posteriorly in the olfactory vein. In all patients the fistula was occluded, in one case an asymptomatic hemorrhage occurred. In the literature 12 further cases of transvenous embolization of ethmoidal DAVFs have been reported. Conclusions Transvenous embolization is an effective approach for the treatment of ethmoidal DAVFs in properly selected patients. Onyx injection through detachable-tip microcatheters increases the feasibility of the intervention.

Anton-Babinski syndrome is a rare neuropsychiatric syndrome characterized by bilateral cortical blindness and anosognosia with visual confabulation. We present the case of a patient presenting with occlusion of both posterior cerebral arteries (PCA), with Anton-Babinski syndrome, completely solved after combined systemic thrombolysis and mechanical thrombectomy with a stent-retriever.

The experience with Woven EndoBridge (WEB) device is still limited. The aim of this study is to discuss the efficacy of this new device, focusing on any anatomical and procedural factors influencing aneurysm occlusion.Between October 2011 and November 2016, 24 patients (10 female, 14 male) harboring 24 cerebral aneurysms treated with WEB in a single center were retrospectively reviewed. Patients underwent 6-month and 12- to 24-month (median 18 months) clinical and neuroradiologic follow-up. We evaluated whether any procedural or anatomical aspect influenced the occlusion rate.Adequate occlusion (AO) was achieved in 68% of cases at 6 months' and in 87% at 18 months' follow-up respectively. Technical difficulties occurred in 3 procedures (12.5%). No postprocedural morbidity was reported. One patient (4%) died after 1 month for reasons unrelated to the procedure. Neck size and dome-to-neck ratio were significantly associated with aneurysm occlusion (P0.05). AO was not associated with postoperative dual antiplatelet therapy (P0.99) or device compression at both first and second follow-up (P0.99). Immediate contrast agent stagnation was more common in aneurysms that were occluded at first (P = 0.37) and second follow-up (P = 0.24), but statistical significance was not reached.Endovascular treatment with WEB is a safe treatment for unruptured cerebral aneurysms, also resulting in a good AO rate in aneurysms that would otherwise require complex assisted coiling techniques. However, results are less favorable in cases of very large aneurysmal neck. Nevertheless, further series with larger patient populations and longer follow-up will define the role of WEB in the treatment of aneurysms.

Background and Purpose— Tandem steno-occlusive lesions were poorly represented in randomized trials and represent a major challenge for endovascular thrombectomy in acute anterior circulation strokes. The impact of the cervical carotid lesion cause (ie, atherosclerotic versus dissection) on outcome of tandem patients endovascularly treated remains to be assessed. Methods— We retrospectively analyzed individual data of prospectively collected consecutive tandem patients treated with endovascular thrombectomy. The primary outcome was favorable outcome at 90 days (modified Rankin Scale score of 0–2). Secondary efficacy outcomes included successful reperfusion (modified Thrombolysis in Cerebrovascular Infarction scores of 2b-3), time to reperfusion, and safety outcomes encompassed procedural complications, symptomatic intracerebral hemorrhage, and 90-day mortality. Results— Among the 295 included patients, 65 had cervical carotid dissection and 230 had cervical carotid atherosclerotic cause. The rate of favorable outcome was 56.3% in the dissection group versus 47.6% in the atherosclerotic arm (center-, age-, and admission National Institutes of Health Stroke Scale–adjusted odds ratio, 1.08; 95% confidence interval, 0.50–2.30; P =0.85). No significant differences were observed in secondary outcomes. The rates of successful reperfusion, symptomatic intracerebral hemorrhage, and 90-day mortality were 78.5% versus 74.5% ( P =0.13), 4.6% versus 5.2% ( P =1.0), and 7.8% versus 15.3% ( P =0.94) in the dissection versus atherosclerotic groups, respectively. The median procedural time was 76 minutes (interquartile range, 52–95 minutes) in the dissection group and 67 minutes (interquartile range, 45–98 minutes) in the atherosclerotic group ( P =0.24). Conclusions— We found no differences in the outcomes of patients with anterior circulation tandem atherosclerotic and dissection lesions treated with endovascular thrombectomy. Further studies are warranted.

Background Although secondary trigeminal neuralgia is usually due to tumors or multiple sclerosis, other major neurologic diseases, such as aneurysms, should be taken into account when the history or the symptoms suggest a secondary origin. Case Description A 67-year-old lady presented with a 6-month history of trigeminal neuralgia involving exclusively the right ophthalmic division. A dedicated 3-dimensional–magnetic resonance imaging–magnetic resonance angiography study documented rare contact with a wide-necked aneurysm of the superior cerebellar artery, which distorted the trigeminal root. The patient underwent an endovascular treatment by stent-assisted coiling with the complete disappearance of neuralgic pain attacks within 24 hours. Conclusion The complete relief from the neuralgic paroxysms immediately after endovascular stent-assisted occlusion of a superior cerebellar artery aneurysm demonstrates the crucial role of a pulsating stimulus on the demyelinated nerve fibers in evoking the ectopically generated discharges.

BackgroundCollateral flow (CF) is an effective predictor of outcome in acute ischemic stroke (AIS) with potential to sustain the ischemic penumbra. However, the clinical prognostic value of CF in patients with AIS undergoing mechanical thrombectomy has not been clearly established. We evaluated the relationship of CF with clinical outcomes in patients with large artery anterior circulation AIS treated with mechanical thrombectomy.MethodsBaseline collaterals of patients with AIS (n=135) undergoing mechanical thrombectomy were independently evaluated by CT angiography (CTA) and conventional angiography and dichotomized into poor and good CF. Multivariable analyses were performed to evaluate the predictive effect of CF on outcome and the effect of time to reperfusion on outcome based on adequacy of the collaterals.ResultsEvaluation of CF was consistent by both CTA and conventional angiography (pConclusionsCTA is a valid tool for assessing the ability of CF to predict clinical outcome in patients with AIS treated with mechanical thrombectomy. Limiting time to reperfusion is of definite value in patients with good collaterals and also to some extent in those with poor collaterals.

BackgroundY-stent assisted coiling has been proposed for the treatment of wide-neck bifurcation aneurysms, but there are many technical variations. We report our single-center experience of Y-stent assisted coiling of bifurcation aneurysms with the closed cell Enterprise stent in order to evaluate the safety and long-term results of this technique. The literature on Y-stenting and its hemodynamic effects are reviewed.MethodsFifty-two consecutive patients with wide-neck bifurcation aneurysms underwent Y-stent assisted coiling with two Enterprise stents. The procedure was completed in 48 cases (92.3%) and technical failure occurred in 4 cases (7.3%). Cases performed with other stents were excluded. All procedures were performed under double antiplatelet therapy. Periodic clinical and neuroradiological follow-up was performed.ResultsMean neuroradiological follow-up time was 26 months. Complete immediate occlusion was obtained in 87.5% of patients. Two remnants had regrown at follow-up and were recoiled, achieving complete occlusion. The late neuroradiological occlusion rate was: complete occlusion 93.6%, neck remnant 4.3%, sac remnant 2.1%. No in-stent stenosis was detected at follow-up. Among the 48 procedures, two complications occurred (4.2%). Mortality was 2.1%. No delayed ischemic stroke occurred.ConclusionsY-stent assisted coiling has a high immediate occlusion rate and very good long-term stability. The procedure is relatively safe, although the complication and mortality rates are not negligible. Two Enterprise stents can be safely used for Y-stenting and, indeed, offer the advantage of easier catheterization, delivery and deployment into distal and tortuous vessels than open cell stents.

Brain arteriovenous malformations (AVMs) are a rare pathology, and their treatment is discussed. The development of techniques and materials in endovascular, radiosurgical, and neurosurgical fields led to higher rates of complete occlusions and good clinical outcomes.84 patients (52 men, 32 women; mean age 38.2 years; range, 9-70 years) were treated at our institution with Onyx18 from 2001 to 2011. Patients treated with other embolic agents, with micro-AVMs, were not included in the analysis.Complete occlusion was achieved in 27/84 patients (32.2%), in 40/84 (47.6%) brain AVMs occlusion of 80-90% of the nidus was obtained, and in 17/84 (20.3%) cases80% of the nidus was occluded. Intraprocedural adverse events occurred in 11/84 patients (13.1%), and overall mortality and disabling permanent morbidity were 2.3% (2/84) and 4.7% (4/84), respectively.Endovascular treatment may be considered a safe and effective approach in superficial small brain AVMs in addition to surgery, mostly in ruptured AVMs. The therapeutic strategy should be to cure small and medium AVMs with endovascular treatment alone or combined treatment. Large unruptured AVMs (Spetzler-Martin grades IV-V) should be treated with target embolization of high flow fistulas or intranidal aneurysms.

Background Arteriovenous malformation (AVM) treatment is multidisciplinary, and the patient may undergo embolization, neurosurgery, or radiosurgery combined. Great improvement in endovascular techniques was provided by the introduction of Onyx with different kinds of approach. Objective To evaluate the efficacy and the safety of Onyx embolization of brain AVMs with the double arterial catheterization technique (DACT). Methods This was a retrospective study. From January 2006 until June 2011, 61 AVMs eligible for the DACT were treated. Forty-one of the 61 AVMs were treated with single arterial catheterization technique and 20 of 61 with DACT; patient age and Spetzler-Martin AVM grade were similar in the 2 groups. Results In the DACT group, we obtained complete occlusion of the nidus in all small AVMs, whereas in the single arterial catheterization technique group, we obtained complete occlusion in only 1 of the 36% of the cases. Among the medium-size AVMs, there were no significant differences in the 2 groups, but we performed fewer procedures per patient when we used the DACT (1.4 vs 2.2). In the DACT group, we observed fewer hemorrhagic complications (3.4% vs 12.5% per procedure) and lower morbidity (5% vs 7% per patient) and mortality (0% vs 2.4%) rates. Conclusion The DACT in multifeeder AVMs may lead to a higher occlusion rate of the nidus for small AVMs and reduce the number of procedures, ensuring a higher standard of safety because of the possibility of managing the progression of Onyx into venous drainage.

We describe the use of time-resolved MR angiography in the diagnosis of cervical epidural arteriovenous fistula before final diagnosis and embolization was achieved by digital subtraction angiography. A 42-year-old woman was referred to us because of headache and dizziness, in addition to radiculopathy of the right superior limb. Angiographic examinations documented a direct high-flow arteriovenous fistula between the right vertebral artery and the cervical epidural venous plexus. The point of fistula was located in the upper third of the cervical segment below the C2 arch. Time-resolved MR angiography might add important information in case of suspected arteriovenous fistula, helpful both for therapeutic decisions and follow-up.

A new era of stroke treatment may have begun with mechanical thrombectomy (MT) by fully deployed closed-cell self-expanding stents (stent-triever). Multiple case series and the first randomised controlled trials (RCTs) have now been published. More studies are under way involving large numbers of patients, which in turn has resulted in less strict "pragmatic" study protocols. Problems with current trials include a lack of standardisation in the conduct of the recanalisation procedure, the definition of primary endpoints such as the grade of arterial recanalisation and tissue reperfusion, and the post-surgical care provided. In Part 1 of this two part series, we outline the current situation and the major research questions.

Dural arteriovenous fistula (DAVF) may present with a variety of neurological symptoms, ranging from tinnitus to fatal hemorrhage. We report a case of rapidly progressive cognitive impairment due to cerebral venous engorgement that reversed after endovascular treatment in a patient with DAVF, cerebral sinus thrombosis and protein S deficiency. DAVF may be a cause of vascular cognitive impairment and should be considered particularly in cases with a rapidly progressive course because they are potentially treatable.