First-Pass Effect in M1-Occlusion Stroke Patients Treated with Combined Stent-Retriever/Large-Bore Distal Aspiration Catheter Thrombectomy

INTRODUCTION

Combined stent-retriever/large-bore distal aspiration catheter (LB-DAC) thrombectomy was recently introduced to treat large-vessel occlusion; however, it is unclear whether larger inner diameters improve outcomes. We compared angiographic and clinical outcomes in patients with occlusions of the M1 segment of the middle cerebral artery treated with mechanical thrombectomy using extra-LB-DAC versus LB-DAC in combination with stent-retrievers.

METHODS

We analyzed consecutive patients with M1 occlusion included in the ROSSETTI registry treated with non-balloon guide catheter combined LB-DAC/stent-retriever thrombectomy between June 2019 and April 2022. We compared demographics, baseline clinical variables, procedural variables, angiographic outcomes, and clinical outcomes [National Institute of Health Stroke Scale score at 24 h (24h-NIHSS) and modified Rankin scale score at 3 months] between patients treated with extra-LB-DAC (Sofia Plus, MIVI Q6, Catalyst7; inner diameter, 0.068″-0.070″) versus LB-DAC (Sofia 5F, MIVI Q5, Catalyst 6; inner diameter, 0.055″-0.064″). Primary outcome was the first-pass effect (FPE) rate, defined as near-complete/complete reperfusion (mTICI 2c-3) after a single pass of the device.

RESULTS

We included 324 patients (extra-LB-DAC, 185, 57.1% patients). Demographics, clinical data, and clinical outcomes were similar between the two groups; however, there was a trend towards improvement in National Institute of Health Stroke Scale score at 24 h (24h-NIHSS) in the cohort treated with extra-LB-DAC 9 points (IQR 4;16 points) vs. 12 points (IQR 4;18 points, P = 0.083). Patients treated with extra-LB-DAC had higher FPE rate (47% vs. 30.9%; P = 0.003) and higher modified FPE (mTICI ≥ 2b after a single pass) rate (65.9% vs 46.8%; P = 0.001). The use of extra-LB-DAC was an independent factor in predicting FPE (odds ratio 1.982, 95% confidence interval 1.250-3.143, P = 0.004).

CONCLUSION

Our results suggest that in combined LB-DAC/stent-retriever thrombectomy, a larger aspiration catheter inner diameter is associated with higher rates of FPE and mFPE.

Calcified cerebral embolism: a 9 case series and review of the literature

OBJECTIVE

Calcified cerebral embolism (CCE), a rarely reported and underdiagnosed cause of stroke, may be the first manifestation of a vascular or cardiac disease. Our purpose is to describe the characteristics of CCE in a series of 9 cases and review the literature on the subject.

PATIENTS AND METHODS

We included patients with CCE from 3 different hospitals. We described the diagnostic approach, neuroimaging findings, origin of the embolism, treatment, and prognosis of these patients.

RESULTS

We identified a total of 9 patients presenting spontaneous CCE as the cause of acute ischaemic stroke. In all cases, the middle cerebral artery was affected; all patients underwent CT. A possible calcific source was found in 6 patients (66.6%), originated in the carotid arteries in 3 (33.3%) and in the heart in the other 3 patients (33.3%). Only one patient was treated in the acute phase (trombectomy) and only 11% of patients had modified ranking scale scores ≤ 2 at 3 months.

CONCLUSIONS

CCE is more frequent than previously thought and, although the condition continues to be underdiagnosed, it is of considerable prognostic relevance in the aetiological study of stroke.

Calcified cerebral embolism: a 9-case series and review of the literature

OBJECTIVE

Calcified cerebral embolus (CCE), a rarely reported and underdiagnosed cause of stroke, may be the first manifestation of a vascular or cardiac disease. We describe the characteristics of CCE in a series of 9 cases and review the literature on the subject.

PATIENTS AND METHODS

We included patients with CCE from 3 different hospitals. We describe the diagnostic approach, neuroimaging findings, origin of the embolism, treatment, and prognosis of these patients.

RESULTS

We identified a total of 9 patients presenting spontaneous CCE as the cause of acute ischaemic stroke. In all cases, the middle cerebral artery was affected; all patients underwent CT. A possible calcific source was found in 6 patients (66.6%), originating in the carotid arteries in 3 (33.3%) and in the heart in the other 3 patients (33.3%). Only one patient was treated in the acute phase (trombectomy) and only 11% of patients had modified Ranking Scale scores ≤ 2 at 3 months.

CONCLUSIONS

CCE is more frequent than previously thought and, although the condition continues to be underdiagnosed, it is of considerable prognostic relevance in the aetiological study of stroke.

Silk flow-diverter stent for the treatment of complex intracranial aneurysms: A one-year follow-up multicenter study

Background Flow-diverter stents have been successfully used in the treatment of complex aneurysms with limited therapeutic alternatives. We report our experience using the Silk flow diverter (SFD; Balt Extrusion, Montmorency, France) for the treatment of complex aneurysms in four Argentine centers. Methods We conducted a retrospective review of 246 consecutive patients who were treated with the SFD at four Argentine centers between January 2009 and January 2017. The patient and aneurysm characteristics, as well as the details of the procedure, were analyzed. The angiographic and clinical findings were recorded during and immediately after the procedure and at 12-month follow-up. Results Angiography follow-up at 12 months was possible in 235 patients (95.5%) with 282 aneurysms. A total of 265 aneurysms (93.9%) presented with complete occlusion of the aneurysmal sac (class 1) and 17 aneurysms (6.1%) presented with partial occlusion (class 2). The 12-month clinical follow-up showed 11 patients with major events (seven, scale 2; five, scale 3; and two, scale 4). The morbidity and mortality rates were 4.2% (11/289) and 2.1% (5/289), respectively. Conclusions The treatment of aneurysms with the SFD was associated with a low rate of complications and a high percentage of aneurysmal occlusion. These findings suggest that SFD is an effective and safe alternative in the endovascular treatment of complex aneurysms.

Expanding the use of flow diverters beyond their initial indication: treatment of small unruptured aneurysms

Background

Experience with the endovascular treatment of unruptured small intracranial aneurysms by flow diverter devices is still limited.

Objective

To assess the safety and efficacy of the SILK flow diverter (SFD) in the treatment of small unruptured cerebral aneurysms (<10 mm).

Methods

We performed a retrospective review of a prospectively maintained database of patients treated with a SFD between July 2008 and December 2013 at 4 institutions in Spain to identify all patients with small unruptured aneurysms (<10 mm). Data for patient demographics, aneurysm characteristics, and technical procedures were analyzed. Angiographic and clinical findings were recorded during the procedure and at 6- and 12-month follow-ups.

Results

A total of 109 small aneurysms were treated with a SFD in 104 patients (78 women; 26 men; mean, median, and range of age: 55.2, 57.1, and 19–80 years, respectively). A total of 60 patients were asymptomatic (57.7%). All except 7 aneurysms (6.4%) arose from the anterior circulation. The mean size of the aneurysms was 4.7±1.9 mm. At 6 months, the neuromorbidity and neuromortality rates were 2.9% and 0.9%, respectively. Imaging at the 12-month follow-up showed complete occlusion, neck remnants, and residual aneurysm in 88.5% (69/78), 7.7% (6/78), and 3.3% (3/78) of cases, respectively. No delayed hemorrhage occurred.

Conclusions

The findings suggest that the indications for SFD can be safely extended to small intracranial aneurysms.

Long-term Follow-up Angiography of Intracranial Aneurysms Treated with Cook Detachable Coil System

The long-term outcome of detachable coil embolization of cerebral aneurysms is still unknown. The purpose of this study was to evaluate the stability of the anatomic occlusion of aneurysms treated with the Cook detachable coil system and assess the rate of recanalization and recurrence. A study involving 250 patients with 271 ruptured aneurysms treated with the Cook detachable system between January 1997 and September 2003 who subsequently underwent six month, one year and two year follow-up angiography were enrolled in the study. Angiographic findings were reviewed to determine the percentage of aneurysm occlusion. Long-term follow-up angiograms (at two years) demonstrated complete occlusion in 75% of cases, and subtotal occlusion in 25% of cases. Overall morbidity was 7.3%, aneurysm recurrence 3.2%, and aneurysm re-treatment 3.2%. Recurrent subarachnoid hemorrhage occurred in only one patient. Angiographic follow-up demonstrated the stability and durability of treatment with the Cook detachable coil system.

LEO stent monotherapy for the endovascular reconstruction of fusiform aneurysms of the middle cerebral artery

We present the case of a patient with a fusiform aneurysm of the M1 segment of the middle cerebral artery (MCA) in which endovascular stent placement without coiling was performed. A 3.5-mm x 25-mm LEO self-expanding stent was deployed along the fusiform aneurysm of the horizontal MCA M1 segment. Digital subtraction angiography showed progressive thrombosis at 6 months and complete thrombosis of the fusiform MCA aneurysm at 12 months.

Exclusion of a cavernous aneurysm by leo stent

SUMMARY

The Leo stent is a cranial self-expanding stent recently developed for the treatment of wideneck aneurysms.We report the first case with total occlusion of a cavernous aneurysm nine months after stent placement without complementary coiling.

CT and MR imaging findings in methanol intoxication

We present the CT and MR imaging findings in acute methanol intoxication in a 35-year-old man who was admitted to the emergency department with weakness, blurred vision, mild bilateral areactive mydriasis, and a progressive decrease in the level of consciousness. CT and MR imaging showed bilateral putaminal hemorrhagic necrosis and subcortical white matter lesions with peripheral contrast enhancement. There was only partial improvement in patient's Glasgow Coma Scale score during follow-up.

The clinical-DWI mismatch: a new diagnostic approach to the brain tissue at risk of infarction

OBJECTIVE

To evaluate the usefulness of a mismatch between the severity of acute clinical manifestations and the diffusion-weighted imaging (DWI) lesion in predicting early stroke outcome and infarct volume.

METHODS

One hundred sixty-six patients with a hemispheric ischemic stroke of <12 hours' duration were studied. The NIH Stroke Scale (NIHSS) score and the volume of DWI lesion were measured on admission and at 72 +/- 12 hours. Infarct volume was measured on T2-weighted or fluid-attenuated inversion recovery images at day 30. Early neurologic deterioration (END) was defined as an increase of > or =4 points between the two NIHSS evaluations. Thirty-eight patients received IV thrombolysis or abciximab. Clinical-DWI mismatch (CDM) was defined as NIHSS score of > or =8 and ischemic volume on DWI of < or =25 mL on admission. The adjusted influence of CDM on END, DWI lesion enlargement at 72 hours, and infarct growth at day 30 was evaluated by logistic regression analysis and generalized linear models.

RESULTS

CDM was found in 87 patients (52.4%). Patients with CDM had a higher risk of END than patients without CDM because NIHSS < 8 (odds ratio [OR], 9.0; 95% CI,1.9 to 42) or DWI lesion > 25 mL (OR, 2.0; 95% CI, 0.8 to 4.9). CDM was associated with an increase of 46 to 68 mL in the mean volume of DWI lesion enlargement and infarct growth in comparison with non-CDM. All the effects were even greater and significant in patients not treated with reperfusion therapies.

CONCLUSIONS

Acute stroke patients with an NIHSS score of > or =8 and DWI volume of < or =25 mL have a higher probability of infarct growth and early neurologic deterioration. The new concept of CDM may identify patients with tissue at risk of infarction for thrombolytic or neuroprotective drugs.

[Cerebral atrophy in multiple sclerosis patients treated periodically with boluses of methylprednisolone]

INTRODUCTION

In the last years advances in the treatment of the remittant and secondary progressive forms of the multiple sclerosis (MS) have taken place. In the primary progressive forms (PP) the side effects of potentially useful drugs prevent their use; in some studies an improvement of the evolution with the intravenous administration of periodic pulses of methylprednisolone (MP) has been observed.

OBJECTIVE

To evaluate if periodic pulses of intravenous MP injected every 4-6 weeks increase the degree of cerebral atrophy of the patients with PP MS.

PATIENTS AND METHODS

We studied 11 patients with PP MS treated during 33 months with periodic pulses of intravenous MP. The degree of cerebral atrophy was evaluated in axial cuts of 10 mm of studies of magnetic resonance with the indices of Evans, bicaudate, bifrontal, frontal spears and bithalamic. The statistical evaluation of the results was made applying the test of Wilcoxon-Mann-Whitney.

RESULTS

There are not statistically significant differences in the degree of cerebral atrophy with any of the used indices.

CONCLUSIONS

Periodic pulses of intravenous MP do not accelerate the cerebral atrophy in patients with progressive forms of multiple sclerosis.

Headache as a surrogate marker of the molecular mechanisms implicated in progressing stroke

The mechanism for headache in patients with acute ischaemic stroke are not completely understood. We analysed the relationship between headache and the early worsening of neurological symptoms in patients with acute ischaemic stroke, and we studied the possible biochemical mechanisms implicated. Headache at the onset of ischaemic stroke predicted progression with a sensitivity, specificity, and positive predictive value of 56%, 99%, and 98%, respectively. CSF concentrations of glutamate, Interleukin-6, and NO-m were significantly greater in patients with progressing stroke than in patients with nonprogressing stroke, and these biochemical markers were also significantly higher in patients with headache than in those without headache. Results of this study suggest that headache at the onset of ischaemic stroke is an independent predictor of neurological worsening and we hypothesize that headache might be a surrogate marker of the molecular mechanisms involved in neurological worsening after acute stroke.

Molecular signatures of brain injury after intracerebral hemorrhage

BACKGROUND

The mechanisms of cellular death in the tissue surrounding an intracerebral hemorrhage (ICH) are not defined.

OBJECTIVE

To investigate the relationship of markers of excitotoxicity and inflammation to brain injury after ICH.

METHODS

A total of 124 consecutive patients with spontaneous ICH admitted within 24 hours of stroke onset were prospectively investigated. The volumes of the initial ICH, peripheral edema on days 3 to 4, and the residual cavity at 3 months were measured on CT scan. Glutamate, cytokines, and adhesion molecules were measured in blood samples obtained on admission. Stroke severity and neurologic outcome were evaluated with the Canadian Stroke Scale.

RESULTS

Poor neurologic outcome at 3 months (Canadian Stroke Scale < 7) was observed in 53 patients (43%). Stroke severity and glutamate concentrations (by each increment of 10 micromol/L, odds ratio 1.23; 95% CI 1.09 to 1.41), but not the initial volume of ICH, were independent predictors of poor outcome. In the multiple linear regression analyses, tumor necrosis factor-alpha concentration was correlated (r = 0.83, p < 0.0001) with the volume of perihematoma edema, and glutamate concentrations were correlated (r = 0.78, p < 0.0001) with the volume of the residual cavity. These same results were observed when lobar (n = 58) and deep (n = 66) ICH were analyzed separately.

CONCLUSIONS

High plasma levels of proinflammatory molecules within 24 hours of intracerebral hemorrhage onset are correlated with the magnitude of the subsequent perihematoma brain edema, whereas poor neurologic outcome and the volume of the residual cavity are related to increased plasma glutamate concentrations.

Neurological deterioration in acute lacunar infarctions: the role of excitatory and inhibitory neurotransmitters

BACKGROUND AND PURPOSE

The mechanisms involved in the neurological deterioration of acute lacunar strokes are unknown. Although accumulating evidence suggests that glutamate release plays a role in the progression of territorial infarctions, it remains to be established whether excitotoxicity also participates in lacunar stroke progression. We investigated whether excitatory and inhibitory amino acid concentrations in blood predict subsequent progressive motor deficits in lacunar infarctions.

METHODS

We studied 113 consecutive patients with lacunar infarct, defined by clinical and computed tomography/magnetic resonance imaging criteria, within the first 24 hours after stroke onset. Neurological deterioration was defined as a decrease of >/=1 points in the motor items of the Canadian Stroke Scale in the first 48 hours after admission. Glutamate, glycine, and GABA were determined by high-performance liquid chromatography in plasma samples obtained on admission. Predictive values, sensitivity, specificity, and accuracy of specific glutamate and GABA concentrations and glutamatexglycine/GABA index for progression of lacunar stroke were calculated.

RESULTS

Twenty-seven patients (23.9%) had neurological worsening. Plasma concentrations of glutamate (253+/-70 versus 123+/-73 micromol/L, mean+/-SD) were higher and those of GABA (140+/-63 versus 411+/-97 nmol/L) were lower in the progressing group than in the nonprogressing group (both P<0.001). Glutamate concentrations >200 micromol/L and GABA levels <240 nmol/L had a positive predictive value for neurological deterioration of 67% and 84%, respectively. A excitotoxic index >106 had a positive predictive value of 85%.

CONCLUSIONS

These findings suggest that an imbalance between the glutamate and GABA concentrations may play a role in the pathophysiology of progressing lacunar infarctions.

[The evaluation of the temporal lobe size by magnetic resonance in Alzheimer's disease]

The estimation of the size of the structures of the temporal lobe using magnetic resonance (MR) can be of assistance when diagnosing early degenerative dementia. We have carried out a survey on 17 patients with Alzheimer type dementia (ATD). They were classified in clinical stages according to the Reisberg global deterioration scale. As diagnostic criteria for ATD we used those developed by DSM-III-R and NINCDS-ADRDA. We carried out axial sequences of 10 mm thickness in protonic density and in T2, and crown sequences of 5mm in T1 perpendicular to the axis of the hypofield. We selected the crown incisions at the level of the interpeduncular cistern. We determined the areas of the temporal lobe, hypocampus and ventricular and two linear measurements (the interhypocampus distance and the maximum transverse diameter between internal layers of the craneum). The images were processed by means of a computer programme. The average area of both hypofields in patients at stages 3-5 on the Reisberg scale was 378.6 +/- 86.1 mm2 and in stages 6-7 was of 364.7 +/- 62.2 mm2. The average area of both temporal lobes in patients at stages 3-5 was of 2,177.03 +/- 411.4 mm2 and in stages 6-7, was of 1,945.0 +/- 303.3 mm2. The shrinkage in size of the temporal lobe and the hypocampus in patients with Alzheimer's disease was not found to be related with the degree of dementia.

Magnetic resonance imaging of muscles in myotonic dystrophy

The MR findings in 27 patients with myotonic dystrophy were compared with those observed in 11 patients with other muscular dystrophies: six with limb-girdle dystrophy, three with facioscapulohumeral muscular dystrophy and two with Becker-type muscular dystrophy. Clinical status was graded into 10 stages. The MR study was performed at the medium third of the thigh, with a slice thickness of 7.5 mm (TR: 750/TE: 25 for T1; TR: 2200/TE: 30/90 for DP/T2). Muscle signal intensity was evaluated with a four-point grading scale using subcutaneous fat as a reference. Statistical analysis was done using the Mann-Whitney-Wilcoxon's test and simple linear regression. In the myotonic dystrophy group, 81.4% of the patients showed an abnormal signal at the crural muscle level, adopting a semilunar shape around the anteroexternal side of the femur. The presence and intensity of this hyperintense signal correlated positively with the duration of disease (r = 0.54) and the clinical stage (r = 0.69). Of the 11 patients with other muscular dystrophies, only three (27.2%) showed hyperintense signal at the crural muscle level. MR imaging of patients with muscle disease may contribute to the in vivo study of muscular dystrophy, its differential diagnosis and the detection of asymptomatic patients.

Pseudoaneurysm of the cervical carotid artery with hypoglossal and glossopharyngeal nerve paralysis

We report a case of a pseudoaneurysm of the internal carotid artery with associated hypoglossal and glossopharyngeal nerve paralysis. Correlative findings with magnetic resonance imagery and arteriography are described.

[The use of computed tomography in assessing parotid masses]

Thirty-one patients with suspected parotid masses have been studied by computed tomography (CT) without and with contrast to demonstrate the existence of this and to value possible relation between degrees of malignancy and the morphological characteristics of the masses.