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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

BACKGROUND AND PURPOSE: Successful vessel recanalization in posterior circulation large-vessel occlusion is considered crucial, though the evidence of clinical usefulness, compared with the anterior circulation, is not still determined. The aim of this study was to evaluate predictors of favorable clinical outcome and to analyze the effect of first-pass thrombectomy. MATERIALS AND METHODS: A retrospective, multicenter, observational study was conducted in 10 high-volume stroke centers in Europe, including the period from January 2016 to July 2019. Only patients with an acute basilar artery occlusion or a single, dominant vertebral artery occlusion (“functional” basilar artery occlusion) who had a 3-month mRS were included. Clinical, procedural, and radiologic data were evaluated, and the association between these parameters and both the functional outcome and the first-pass effect was assessed. RESULTS: A total of 191 patients were included. A lower baseline NIHSS score (adjusted OR, 0.77; 95% CI, 0.61–0.96; P = .025) and higher baseline MR imaging posterior circulation ASPECTS (adjusted OR, 3.01; 95% CI, 1.03–8.76; P = .043) were predictors of better outcomes. The use of large-bore catheters (adjusted OR, 2.25; 95% CI, 1.08–4.67; P = .030) was a positive predictor of successful reperfusion at first-pass, while the use of a combined technique was a negative predictor (adjusted OR, 0.26; 95% CI, 0.09–0.76; P = .014). CONCLUSIONS: The analysis of our retrospective series demonstrates that a lower baseline NIHSS score and a higher MR imaging posterior circulation ASPECTS were predictors of good clinical outcome. The use of large-bore catheters was a positive predictor of first-pass modified TICI 2b/3; the use of a combined technique was a negative predictor.

The benefit of mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) and baseline mild neurological symptoms remains unclear. The purpose of this study was to evaluate the effectiveness of MT in this subgroup of patients. The databases of 9 high-volume Italian stroke centers were retrospectively screened for patients with LVO in the anterior circulation and a baseline National Institute of Health Stroke Scale (NIHSS) score ≤ 5 that received either immediate MT or best medical management (BMM) with the possibility of rescue MT upon neurological worsening. Primary outcome measure was a modified Rankin Scale score of 0–1 at 90 days. Propensity score matching (PSM) analysis was used to estimate the treatment effect of immediate MT compared to BMM/rescue MT. Two hundred and seventy-two patients received immediate MT (MT group). The BMM/rescue MT group included 41 patients. The primary outcome was achieved in 78.6% (n = 246) of overall patients, with a higher proportion in the MT group (80.5% vs. 65.9%, p = 0.03) in unadjusted analysis. After PSM, patients in the MT group had a 19.5% higher chance of excellent outcome at 90 days compared to the BMM/Rescue MT group with a similar risk of death from any cause. Our experience is in favor of a potential benefit of MT also in patients with LVO and a NIHSS score ≤ 5 at the time of groin puncture. Nonetheless, this issue waits for a clear-cut recommendation in a dedicated clinical trial.

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.

Resume Objectifs Rapporter notre experience recente dans l’embolisation par voie arterielle des malformations arterio-veineuses durales (MAVD) en utilisant un nouvel agent d’embolisation, l’Onyx®18. Patients et methodes Notre serie inclut 6 patients. La presentation clinique se repartissait en 2 groupes : symptomatologie agressive (n = 4), symptomatologie non agressive (n = 2). La MAVD etait localisee sur le sinus longitudinal superieur (n = 1), sur le sinus transverse (n = 2), dans la region du canal condylien (n = 1), au niveau de la fente sphenoidale (n = 1), et dans la region de la tente du cervelet (n = 1). Le drainage de la MAVD se faisait directement par une veine corticale ou condylienne dans trois cas et par un sinus veineux anatomiquement exclu de la circulation veineuse cerebrale dans trois cas. Resultats Une angiographie cerebrale extensive incluant les deux arteres carotides internes, les deux arteres carotides externes et l’artere vertebrale homo-laterale a la MAVD a ete realisee avant et apres chaque traitement. L’afference arterielle choisie pour l’injection de l’Onyx®18 etait toujours meningee. Chaque traitement consistait en un catheterisme selectif et une injection unique de l’agent embolique. Une exclusion anatomique a pu etre obtenue et demontree par l’angiographie realisee en fin de traitement, dans tous les cas, sans aucune complication clinique post-therapeutique. Conclusion L’utilisation de l’Onyx®18 dans les MAVD est peu risquee. Quand il est injecte dans des conditions optimales, cet agent embolique liquide permet le remplissage de la totalite de la MAVD incluant son drainage veineux cortical ou sinusien apres un catheterisme arteriel unique.

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.

Acute basilar artery occlusion has a poor prognosis and best treatment has not been assessed yet; as for intra-arterial treatment, no “gold standard” exists. We evaluated a series of ten patients treated with intra-arterial combination of recombinant tissue plasminogen activator (rtPA) and abciximab. Partial/complete recanalisation was achieved in all patients and good outcome (1 month Modified Rankin Scale 0–2) in eight cases, while one patient had symptomatic intracranial haemorrhage and died. Such outcome appears significantly better if compared with the results of Basilar Artery International Cooperation Study, suggesting that intra-arterial administration of rtPA and abciximab may be a promising option in patients with acute basilar artery occlusion undergoing endovascular treatment.

Purpose. The long-term efficacy of carotid artery stenting is debated. Predictors of stent restenosis are not fully investigated. Our aim was to assess the incidence of long term restenosis after CAS and to identify some predictors of restenosis.Methods. We retrospectively selected 189 treated patients and we obtained the survival Kaplan-Meier curves for overall survival, for freedom from stroke or death and from restenosis. To correlate clinical, radiological, and procedural variables to stent restenosis, an univariate analysis was performed while to determine independent predictors of restenosis, a multivariate analysis was applied.Results. At 1, 3, and 5 years, the cumulative overall survival rate was 98%, 94%, and 92% with a cumulative primary patency rate of 87%, 82.5%, and 82.5%. The percentage residual stenosis after CAS and multiple stents deployment were independent predictors of restenosis, while diabetes and tumors are suggestive but not significant predictors of restenosis.Conclusions. In our CAS experience, encouraging long-term results seem to derive from both neurological event free rate and restenosis incidence. Adequate recanalization of the treated vessel is important to limit the development of stent restenosis. Multiple stents deployment, and with less evidence, diabetes, or neoplasms has to be considered to facilitate restenosis.

The rotational variance dependence of diffusion tensor imaging (DTI) derived parameters on the number of diffusion weighting directions (N) has been investigated by several Monte Carlo simulation studies. However, the dependence of fractional anisotropy (FA) and mean diffusivity (MD) maps on N, in terms of accuracy and contrast between different anatomical structures, has not been assessed in detail. This experimental study further investigated in vivo the effect of the number of diffusion weighting directions on DTI maps of FA and MD. Human brain FA and MD maps of six healthy subjects were acquired at 1.5T with varying N (6, 11, 19, 27, 55). Then, FA and MD mean values in high (FAH,MDH) and low (FAL,MDL) anisotropy segmented brain regions were measured. Moreover, the contrast‐to‐signal variance ratio (CVRFA,CVRMD) between the main white matter and the surrounding regions was calculated. Analysis of variance showed that FAL,FAH and CVRFA significantly (p0.05) depend on N. Unlike MD values, FA values significantly vary with N. It is noteworthy that the observed variation is opposite in low and high anisotropic regions. In clinical studies, the effect of N may represent a confounding variable for anisotropy measurements and the employment of DTI acquisition schemes with high N(>20) allows an increased CVR and a better visualization of white matter structures in FA maps. PACS number: 87.61.Tg, 82.56.Lz

Objectives – To assess midbrain atrophy through morphometric (linear, surface and volumetric) measurements in patients with clinically diagnosed progressive supranuclear palsy (PSP) and to establish the most accurate measure to be implemented in routine magnetic resonance (MR) protocol in distinguishing PSP from healthy subjects and MSA-p (multiple system atrophy, parkinsonian form) patients. Materials and methods – We studied 15 patients with the diagnosis of probable PSP, seven patients with the diagnosis of probable MSA-p and 14 age-matched healthy volunteers. MR protocol includes a sagittal SE T1-weighted sequence for cross-sectional area and linear brainstem measurements and a 3D-FSPGR sequence for brainstem volume measurements. Results – A highly significant difference in the antero-posterior midbrain diameter, area and volume in PSP compared with control subjects was found. Only a measurement of the midbrain area and pons area enabled one to distinguish between PSP and MSA-p. Receiver operating characteristic analysis revealed that the midbrain area has the highest diagnostic accuracy in distinguishing between PSP and other conditions, with a sensitivity of 100% and specificity of 90.5%. The addition of the midbrain area/pons area ratio (Ams/Apn ratio) measurement improves the specificity in distinguishing between PSP and MSA. Conclusions – Morphological indexes indicate midbrain atrophy in PSP patients The combination of the Ams and Ams/Apn ratio measurements allows to discriminate between PSP and other conditions.

To report our recent experience in transarterial embolisation of dural arteriovenous malformations (DAVM) using a new liquid embolic agent, Onyx18.6 patients were enrolled in this series. Clinical presentation was separated into 2 groups: aggressive (n=2), non aggressive (n=4). The DAVM was located at the superior sagittal sinus (n=1), at the transverse sinus (n=2), at the condylian canal (n=1), in the lesser sphenoid wing region (n=1), and in the tentorium region (n=1). The DAVM drained directly into a condylian or a cortical vein for three patients and into a venous sinus with cortical venous reflux for the three others. In this latter situation, the sinus was anatomically excluded from the normal brain venous drainage.A full brain angiogram including both internal carotid arteries, both external carotid arteries and ipsilateral vertebral artery, was performed before and after each treatment. The feeder chosen after a selective catheterisation for Onyx18 injection was always meningeal. Each treatment consisted of a single Onyx injection after one unique feeder catheterisation. Complete anatomical exclusion of the DAVM was achieved and demonstrated by the post treatment angiogram in all cases. There was no clinical complication after the treatment.Onyx18 used is a safe treatment for DAVMs. When its injection is performed in optimal conditions, it fills the total DAVM and its drainage vein or sinus after a single arterial feeder catheterisation.

Background and Purpose— Percutaneous transluminal angioplasty with stent (CAS) is an alternative method to endarterectomy in the revascularization of carotid artery stenosis. Protected CAS is currently used to prevent distal embolization. Diffusion-weighted MRI (DWI) is the most sensitive tool to evaluate silent cerebral ischemia. The purpose of this research was to assess the incidence of cerebral embolic lesions during CAS and to evaluate whether cerebral protection devices can reduce the number of silent cerebral ischemia with respect to unprotected CAS. Methods— Fifty-two patients with high-grade internal stenosis underwent CAS; 30 patients (group a) were treated with a cerebral protection device, and 22 (group b) were treated without it. All of the patients were evaluated preoperatively and postoperatively with fluid-attenuated inversion recovery and DWI sequences to depict the number of new embolic silent cerebral lesions. Results— Embolic silent cerebral lesions occurred in 30% of CAS. Cerebral protection devices reduce the number of new lesions significantly reducing the consistent lesions ipsilateral to the treated vessel. Inconsistent lesions do not differ in both groups of patients. Clinical, radiological, and procedural variables do not correlate with the appearance of new cerebral lesions. Conclusions— Embolic cerebral lesions detected with DWI are more frequent with unprotected CAS, although they are present also with the use of cerebral protection devices. Probably a part of silent cerebral lesions arise from the procedural maneuver in the aortic arch.

To prospectively evaluate several diffusion-tensor magnetic resonance (MR) imaging indexes (mean diffusivity [MD], fractional anisotropy [FA], and eigenvalues) of corticospinal tract impairment in patients with progressive muscular atrophy (PMA) and patients with amyotrophic lateral sclerosis (ALS).This study had institutional review board approval, and written informed consent was obtained from all subjects. Eight male patients with PMA (mean age, 63 years +/- 13 [standard deviation]), eighteen patients with ALS (14 men and four women; mean age, 64 years +/- 7), and twelve control subjects (four men and eight women; mean age, 65 years +/- 6) underwent diffusion-tensor MR imaging at which 25 spin-echo echo-planar imaging diffusion-weighted images (b = 1000 sec/mm2) were acquired along noncollinear directions. MD and FA were measured along the corticospinal tracts in each patient and subject. Changes in diffusion along and orthogonal to fiber bundles in patients were evaluated by using diffusion-tensor eigenvalues. Differences in diffusion-tensor imaging indexes between patients with PMA and those with ALS, as compared with these indexes in control subjects, were evaluated with Mann-Whitney testing. Correlations between diffusion-tensor imaging indexes and clinical variables were estimated with Pearson and Spearman rank correlation testing.As compared with MD (697.1 x 10(-6) mm2/sec +/- 28.1) and FA (0.585 +/- 0.032) in control subjects, MD was typically significantly increased (734.7 x 10(-6) mm2/sec +/- 41.2, P = .035) and FA significantly decreased (0.534 +/- 0.053, P = .037) along the corticospinal tracts in patients with ALS, while these parameters showed no significant change in patients with PMA (MD, 707.0 x 10(-6) mm2/sec +/- 44.2; FA, 0.559 +/- 0.028). Estimation of diffusion-tensor eigenvalues revealed normal diffusion along fiber tracts in all patients, while diffusion was increased orthogonal to fiber tracts only in patients with typical ALS. In patients with ALS, MD correlated with disease duration while FA correlated with disease severity.Diffusion-tensor MR imaging reveals corticospinal tract impairment in ALS but not in PMA.