Early-versus-Late Endovascular Stroke Treatment: Similar Frequencies of Nonrevascularization and Postprocedural Cerebrovascular Complications in a Large Single-Center Cohort Study.

BACKGROUND AND PURPOSE: Endovascular treatment of acute ischemic stroke is now performed more frequently in the late window in radiologically selected patients. However, little is known about whether the frequency and clinical impact of incomplete recanalization and postprocedural cerebrovascular complications differ between early and late windows in the real world. MATERIALS AND METHODS: We retrospectively reviewed all patients with acute ischemic stroke receiving endovascular treatment within 24 hours from 2015 to 2019 and included in the Acute STroke Registry and Analysis of Lausanne. We compared rates of incomplete recanalization and postprocedural cerebrovascular complications (parenchymal hematoma, ischemic mass effect, and 24-hour re-occlusion) in the early (<6 hours) versus late window (6-24 hours, including patients with unknown onset) populations and correlated them with the 3-month clinical outcome. RESULTS: Among 701 patients with acute ischemic stroke receiving endovascular treatment, 29.2% had late endovascular treatment. Overall, incomplete recanalization occurred in 56 patients (8%), and 126 patients (18%) had at least 1 postprocedural cerebrovascular complication. The frequency of incomplete recanalization was similar in early and late endovascular treatment (7.5% versus 9.3%, adjusted P =.66), as was the occurrence of any postprocedural cerebrovascular complication (16.9% versus 20.5%, adjusted P = .36). When analyzing single postprocedural cerebrovascular complications, rates of parenchymal hematoma and ischemic mass effect were similar (adjusted P = .71, adjusted P = .79, respectively), but 24-hour re-occlusion seemed somewhat more frequent in late endovascular treatment (4% versus 8.3%, unadjusted P = .02, adjusted P = .40). The adjusted 3-month clinical outcome in patients with incomplete recanalization or postprocedural cerebrovascular complications was comparable between early and late groups (adjusted P = .67, adjusted P = .23, respectively). CONCLUSIONS: The frequency of incomplete recanalization and of cerebrovascular complications occurring after endovascular treatment is similar in early and well-selected late patients receiving endovascular treatment. Our results demonstrate the technical success and safety of endovascular treatment in well-selected late patients with acute ischemic stroke.

Predictors of Endovascular Treatment Procedural Complications in Acute Ischemic Stroke: A Single-Center Cohort Study.

BACKGROUND AND PURPOSE: Procedural complications occur in 4%-29% of endovascular treatments in acute ischemic stroke. However, little is known about their predictors and clinical impact in the real world. We aimed to investigate the frequency and clinical impact of procedural complications of endovascular treatment and identify associated risk factors. MATERIALS AND METHODS: From 2015-2019, we retrospectively reviewed all patients with acute ischemic stroke receiving endovascular treatment within 24 hours included in the Acute STroke Registry and Analysis of Lausanne. We identified patients having an endovascular treatment procedural complication (local access complication, arterial perforation, dissection or vasospasm, and embolization in a previously nonischemic territory) and performed logistic regression analyses to identify associated predictors. We also correlated procedural complications with long-term clinical outcome. RESULTS: Of the 684 consecutive patients receiving endovascular treatment, 113 (16.5%) had at least 1 procedural complication. The most powerful predictors were groin puncture off-hours (OR = 2.24), treatment of 2 arterial sites (OR = 2.71), and active smoking (OR = 1.93). Patients with a complication had a significantly less favorable short-term clinical outcome (Δ-NIHSS score of -2.2 versus -4.33, P-value adjusted < .001), but a similar long-term clinical outcome (mRS at 3 months = 3 versus 2, P-value adjusted = .272). CONCLUSIONS: Procedural complications are quite common in endovascular treatment and lead to a less favorable short-term but similar long-term outcome. Their association with treatment off-hours and at 2 arterial sites requires particular attention in these situations to optimize the overall benefit of endovascular treatment.

Lymphographic-Like Technique for the Treatment of Microcystic Lymphatic Malformation Components of <3 mm.

BACKGROUND AND PURPOSE: The treatment of microcystic lymphatic malformations remains challenging. Our aim was to describe the lymphographic-like technique, a new technique of slow bleomycin infusion for the treatment of microcyst components of <3 mm, performed at our institution. MATERIALS AND METHODS: A retrospective analysis of a prospectively collected lymphatic malformation data base was performed. Patients with at least 1 microcystic lymphatic malformation component demonstrated on MR imaging treated by lymphographic-like technique bleomycin infusion were included in the study. Patient interviews and MR imaging were performed to assess subjective and objective (microcystic lymphatic malformation size decrease of >30%) clinical improvement, respectively. Patients were reviewed 3 months after each sclerotherapy session. Lymphographic-like technique safety and efficacy were assessed. RESULTS: Between January 2012 and July 2016, sixteen patients (5 males, 11 females; mean age, 15 years; range, 1-47 years) underwent the bleomycin lymphographic-like technique for microcystic lymphatic malformations. Sixty sclerotherapy sessions were performed, with a mean of 4 sessions per patient (range, 1-8 sessions) and a mean follow-up of 26 months (range, 5-58 months). We observed no major and 3 minor complications: 1 eyelid infection, 1 case of severe postprocedural nausea and vomiting, and 1 case of skin discoloration. One patient was lost to follow-up. Overall MR imaging objective improvement was observed in 5/16 (31%) patients; overall improvement of clinical symptoms was obtained in 93% of treated patients. CONCLUSIONS: The bleomycin lymphographic-like technique for microcystic lymphatic malformations is safe and feasible with objective improvement in about one-third of patients. MR signal intensity changes after the lymphographic-like technique are associated with subjective improvement of the patient's symptoms.

Cerebral venous thrombosis after embolization of pediatric AVM with jugular bulb stenosis or occlusion: management and prevention.

PURPOSE: Thrombosis of cerebral arteriovenous malformation after embolization is rare, but can involve the normal venous network with extensive venous thrombosis. We report angioarchitecture findings, our management and prevention strategy for this complication in pediatric AVMs. METHODS: In this 5.5-year retrospective series, we reviewed records of 13 patients under 15 years who were anticoagulated after embolization. In our initial experience 4 children who didn't receive any prophylactic anticoagulation presented with extensive venous thrombosis after embolization (group 1). Following this, nine children with similar angioarchitecture and embolization modalities were treated with prophylactic anticoagulation immediately after embolization (group 2). We analyzed the type of AVM, angioarchitecture, dose of prophylactic anticoagulant, efficacy/complications of treatment and late outcome. RESULTS: All patients in group 1 had severe jugular bulb stenosis/occlusion associated with cerebral venous dilatation. In group 2 with similar angioarchitecture, only three patients (33%) developed extensive thrombosis. In both groups, thrombosis occurred within two days of treatment in six children and two weeks in one child. The diagnosis was suspected on intracranial hypertension in five patients and occulomotor disorder in one. One was asymptomatic. All children were treated with therapeutic doses of LMWH (anti-Xa: 0.5-1). No hemorrhagic complications occurred. Good venous remodeling was observed in all but one patient. CONCLUSION: Anticoagulation in extensive venous thrombosis after AVM embolization in children appears to be safe and effective. In cases with angioarchitectural features of dilatation of the cerebral venous network and occlusion/severe stenosis of the jugular bulbs, full dose anticoagulation may be required to prevent thrombosis.

[Arterial hypertension during the rehabilitation phase of cerebral stroke. Study with nicardipine]. / L'ipertensione arteriosa nella fase riabilitativa dell'ictus cerebrale. Studio con nicardipina.

Arterial blood pressure was recorded in 15 hypertensive patients with ischemic cerebrovascular disease in the post-acute stage and under treatment with nicardipine, a drug with tropism for the muscular cells of cerebral vessels. Blood pressure was measured at rest and during rehabilitation sessions. Patients were periodically assessed by Doppler examination of the cerebral vessels in order to evaluate the effect of the drug on vascular resistance. A significant reduction of blood pressure was observed without changes in pulse rate and without significant side effects. Hemodynamic parameters showed reduced resistance of cerebral vessels. These findings confirm the need for accurate control of arterial blood pressure during neurologic rehabilitation; they also bear out the efficacy and safety of nicardipine in this clinical situation.