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Background: Intracranial artery dissection is a rare and generally under-recognized cause of ischaemic stroke or subarachnoid haemorrhage., Objectives: The aim of this study was to analyse the efficacy of cone-beam computed tomography angiography (CBCT-A) to detect arterial ultrastructural alterations in intracranial artery dissection., Method: This is an observational and retrospective case series., Results: Between January 2018 and November 2020, four patients were admitted with an acute ischaemic stroke due to intracranial dissection studied with CBCT-A. In all cases, the CBCT-A documented vascular ultrastructural alterations related with the intracranial dissection., Conclusions: CBCT-A is an intraprocedural diagnostic technique that is useful for the diagnosis of intracranial dissections.

Background: The applicability of the current models for predicting functional outcome after thrombectomy in strokes with large vessel occlusion (LVO) is affected by a moderate predictive performance., Aims: We aimed to develop and validate a nomogram with pre- and post-treatment factors for prediction of the probability of unfavorable outcome in patients with anterior and posterior LVO who received bridging therapy or direct thrombectomy <6 h of stroke onset., Methods: We conducted a cohort study on patients data collected prospectively in the Italian Endovascular Registry (IER). Unfavorable outcome was defined as three-month modified Rankin Scale (mRS) score 3-6. Six predictors, including NIH Stroke Scale (NIHSS) score, age, pre-stroke mRS score, bridging therapy or direct thrombectomy, grade of recanalization according to the thrombolysis in cerebral ischemia (TICI) grading system, and onset-to-end procedure time were identified a priori by three stroke experts. To generate the IER-START, the pre-established predictors were entered into a logistic regression model. The discriminative performance of the model was assessed by using the area under the receiver operating characteristic curve (AUC-ROC)., Results: A total of 1802 patients with complete data for generating the IER-START was randomly dichotomized into training ( n  = 1219) and test ( n  = 583) sets. The AUC-ROC of IER-START was 0.838 (95% confidence interval [CI]): 0.816-0.869) in the training set, and 0.820 (95% CI: 0.786-0.854) in the test set., Conclusions: The IER-START nomogram is the first prognostic model developed and validated in the largest population of stroke patients currently candidates to thrombectomy which reliably calculates the probability of three-month unfavorable outcome.

Background: There are no current evidence-based recommendations on mechanical thrombectomy (MT) in M2 or other distal occlusions. The objective of this paper was to investigate clinical and radiologic outcomes of MT in distal locations using the new generation of mini-0.017 microcatheter compatible-stent retrievers (SRs) compared with a direct aspiration first pass technique (ADAPT) MT., Methods: A systematic search was performed for studies published from January 2016 to March 2019. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies that reported clinical and radiologic outcomes of patients undergoing MT using new generation of SRs or ADAPT in distal locations. The cumulative prevalence was estimated for each outcome. Heterogeneity of the data was assessed by the Higgins index (I 2 ), and a random-effects model was applied., Results: Fifteen studies and 494 patients were included; 7 studies reported on patients treated with a new SR and 8 studies analyzed patients treated with ADAPT. The rate of thrombolysis in cerebral infarction score 2b-3 after MT for distal occlusions was 80.6% (383 of 494; 95% confidence interval [CI], 74.8%-86.3%; I 2  = 64.4%). Successful recanalization was comparable after SR use with low-profile devices and ADAPT (176 of 226; 82%; 95% CI, 72.6%-1.5%; I 2  = 70.5% vs. 207 of 268; 79.4%; 95% CI, 71.8%-86.9%; I 2  = 60.8%, respectively; P = 0.4). The rate of the modified Rankin scale score of 0-2 at 3 months was higher in the ADAPT group (160 of 251; 68.9%; 95% CI, 51.8%-85.9%; I 2  = 92.2%) than the SR group (92 of 177; 58.7%; 95% CI, 37.3%-80%; I 2  = 58.7%; P = 0.01). The mortality rate was lower among the ADAPT group (20 of 251; 5.4%; 95% CI, 1.4%-9%; I 2  = 63%) than the SR group (16 of 108; 13%; 95% CI, 6%-19%; I 2  = 13%; P = 0.008)., Conclusions: MT in distal locations using the new generation of SR yields comparable results compared with ADAPT in terms of recanalization; however, the use of SR is associated with lower functional independence and higher mortality rate., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background and Purpose- As a reliable scoring system to detect the risk of symptomatic intracerebral hemorrhage after thrombectomy for ischemic stroke is not yet available, we developed a nomogram for predicting symptomatic intracerebral hemorrhage in patients with large vessel occlusion in the anterior circulation who received bridging of thrombectomy with intravenous thrombolysis (training set), and to validate the model by using a cohort of patients treated with direct thrombectomy (test set). Methods- We conducted a cohort study on prospectively collected data from 3714 patients enrolled in the IER (Italian Registry of Endovascular Stroke Treatment in Acute Stroke). Symptomatic intracerebral hemorrhage was defined as any type of intracerebral hemorrhage with increase of ≥4 National Institutes of Health Stroke Scale score points from baseline ≤24 hours or death. Based on multivariate logistic models, the nomogram was generated. We assessed the discriminative performance by using the area under the receiver operating characteristic curve. Results- National Institutes of Health Stroke Scale score, onset-to-end procedure time, age, unsuccessful recanalization, and Careggi collateral score composed the IER-SICH nomogram. After removing Careggi collateral score from the first model, a second model including Alberta Stroke Program Early CT Score was developed. The area under the receiver operating characteristic curve of the IER-SICH nomogram was 0.778 in the training set (n=492) and 0.709 in the test set (n=399). The area under the receiver operating characteristic curve of the second model was 0.733 in the training set (n=988) and 0.685 in the test set (n=779). Conclusions- The IER-SICH nomogram is the first model developed and validated for predicting symptomatic intracerebral hemorrhage after thrombectomy. It may provide indications on early identification of patients for more or less postprocedural intensive management.

Background: It has been amply demonstrated that endovascular procedures can be successful treatment for stroke, both in terms of revascularization and clinical outcome. There is not, however, a published comparison of any histological or ultrastructural damage to the vessels that may be caused by a direct aspiration first pass technique (ADAPT) or stent retrievers (SR) used in these procedures. This study analyses and compares acute damage to the arterial wall caused by ADAPT or SR., Material and Methods: Damage to the walls of swine extracranial arteries was evaluated after ADAPT with the Penumbra system or thrombectomy with an SR (Solitaire 6×30). The procedures were performed after injecting thrombi into the selected arteries (arteries with diameters similar to those of the human internal carotid artery and first segment of the middle cerebral artery). After the procedures, the animal was euthanized and 12 arterial samples were obtained for analysis by optical and electronic microscopy., Results: Tissue samples from the vessels treated with SR showed almost complete loss of endothelium, thickening of the internal elastic lamina, and degeneration of the elastic fibers of the bordering lamina media and adventitia. In contrast, tissue samples of the vessels treated with ADAPT had a clear integral internal elastic lamina and uninterrupted endothelial lining, although cell alignment was altered and there were surface lacerations due to manipulation of the samples., Conclusions: Both techniques caused acute damage to the vessel walls, however, thrombectomy with SR appeared to be more harmful to all layers of the arterial wall, particularly the endothelium., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background and Purpose: Aspiration thrombectomy of large vessel occlusions has made a comeback among recanalization techniques thanks to recent advances in catheter technology resulting in faster recanalization and promising clinical results when used either alone or as an adjunct to stent retriever. This multicenter retrospective study reports angiographic data, complications, and clinical outcome in patients treated with aspiration thrombectomy as the first-line option., Materials and Methods: We analysed the clinical and procedural data of patients treated from January 2014 to March 2015. Recanalization was assessed according to the Thrombolysis in Cerebral Infarction score. Clinical outcome was evaluated at discharge and after 3 months., Results: Overall, 152 patients (mean age 68 years) were treated. Sites of occlusion were 90.8% anterior circulation (including 16.4% tandem extracranial/intracranial occlusions) and 9.2% basilar artery. In 79 patients administration of intravenous tissue plasminogen activator was attempted. Recanalization of the target vessel was obtained in 115/152 cases (75.6%) whereas direct aspiration alone was successful in 83/152 cases (54.6%) with an average puncture to revascularization time of 44.67 min. Symptomatic intracranial hemorrhage occurred in 7.8% and embolization to new territories in 1.9%. 77 patients (50.6%) had a good outcome at 90-day follow-up: 55/96 in the direct aspiration alone group and 22/56 in the aspiration-stent retriever group., Conclusions: Direct aspiration thrombectomy appears a feasible technique with good revascularization results achieved in more than half the patients. In light of the self-reported data, inhomogeneous patient selection, absence of a core imaging laboratory, and a non-standardized approach, the results should be validated in a larger trial., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: There is uncertainty about the optimal method for measuring the decompressive craniectomy (DC) surface area and how large the DC should be., Methods: A radiological technique for measuring the surface area of removed bone flaps in a series of 73 DCs was developed. Preoperative and early postoperative computed tomography scans of each patient were evaluated. Midline shift (MLS) was considered the key factor for successful DC and was assigned to either normal (0-4 mm) or pathological (≥5 mm) ranges. The association between postoperative MLS and patient survival at 12 months was assessed., Results: Measurements of all removed bone flaps yielded a mean surface area of 7759 mm 2 . The surface area of the removed bone flap did not influence survival (surviving 7643 mm 2 vs. deceased 7372 mm 2 ). The only factor associated with survival was reduced postoperative MLS (P < 0.034). Risk of death was 14.4 (3.0-70.1)-fold greater in patients with postoperative shift ≥5 mm (P < 0.001)., Conclusion: The ideal surface area for "large" square bone flaps should result in an MLS of <5 mm. Enlargement of the craniectomy edges should be considered for patients in whom MLS ≥5 mm persists according to early postoperative computed tomography scans., (Copyright © 2016 Elsevier Inc. All rights reserved.)