A Rare Case of Cervical Spinal Arteriovenous Malformation: A Case Report.

Arteriovenous malformation (AVM) is an abnormal connection of vasculature resulting in capillary bed bypassing and leading to neurological deterioration and high risk of bleeding. Intramedullary AVMs in the cervical spinal cord are rare and require precise diagnostics and treatment. We present a clinical case of recurrent AVMs in a 28-year-old Caucasian female with sudden and severe neck pain and variable neurological symptoms along with current diagnostic and treatment modalities. Conservative treatment was partially effective. MRI and DSA confirmed AVMs at C4 level with subsequent several endovascular treatment sessions at the age of 15 and 24 with mild neurological improvement. Afterwards the patient underwent rehabilitation with minor neurological improvement. This case highlights the clinical progression and treatment of AVMs along with showcasing current pathophysiology, classification, and imaging.

RapidpulseTM cyclic aspiration system for acute ischemic stroke due to large vessel occlusions.

BACKGROUND: The best strategy to achieve optimal reperfusion outcomes during mechanical thrombectomy remains to be defined. The RapidPulseTM Cyclic Aspiration System is a novel technology, delivering high-frequency pulsed vacuum forces to increase the efficiency of aspiration thrombectomy. METHODS: Prospective, multicenter, open-label, core lab-adjudicated, two-arm study comparing safety and efficacy of a feasibility version of the RapidPulseTM system compared with contemporary controls. Primary endpoint was the rate of mTICI ≥ 2c after first-pass effect (FPE). Additional efficacy endpoints were the rates of mTICI ≥ 2b after first pass (modified FPE (mFPE)), last pass with study device defined as frontline technical success, and after all passes including rescue therapy. The primary safety endpoints included symptomatic ICH (sICH) within 24 h post-procedure. RESULTS: Between February 2022 to December 2022, 80 subjects were consented and enrolled in the study (n = 40 treatment arm, n = 40 control arm). In the intent to treat (ITT) population, mean age was 67.8 ± 11.5 years; 19 (47.5%) were male. Median NIHSS score was 16 (IQR: 13-22). Median ASPECTS score was 9 (IQR: 8-10). The rate of mTICI ≥ 2c after first pass was 53.9% in ITT population (60.0% in per-protocol population) versus 38.5% in the corresponding control population. Functional independence (mRS 0-2) at 90 days was achieved in 61.1% (22/36) in the RapidPulseTM arm and 52.8% (19/36) in the control arm. In the RapidPulseTM arm, no sICH within 24 h and no device-related morbidity or mortality occurred. CONCLUSION: Preliminary data suggests RapidPulseTM Aspiration System is highly effective and safe for recanalization of large vessel occlusions.

The Stream Device-A Retrospective Review of 51 Cases.

Mechanical thrombectomy is the gold-standard treatment for patients that have suffered large-vessel occlusion (LVO) stroke. Various different stent-retrievers, aspiration catheters, and techniques have been developed to perform this procedure. We present our initial results regarding the Stream device. MATERIALS AND METHODS: We performed a retrospective review of a prospectively maintained database at our high-volume centre to identify all patients treated with the Stream device between February 2021 and January 2023. We recorded baseline demographics, NIHSS, ASPECT scores, eTICI scores, complications, and 90-day mRS. RESULTS: We identified 51 patients, 49.0% of whom were male (n = 25), with a median age of 73 (range: 51-89) and a median NIHSS score of 17 (range 4-22), and 68.6% received IV tPA. The median ASPECT score was 10 (range 6-10). Hyperdense clots were seen in 34 cases (66.7%), with a mean clot length of 12 ± 6.2 mm (range 2-26 mm). Clots were located in the anterior circulation in 49 patients. The standard Stream device was used in 78.4% of cases, with Stream 17 being used in 19.6% of cases. The FPE was observed in 25.5% of cases (n = 13), with the mFPE being seen in 31.4% of cases (n = 16). A final eTICI score of ≥2b was achieved in 90.2% of cases (n = 46), and eTICI 2c/3 was seen in 84.3% of cases (n = 43). Furthermore, 24 h CT scans showed that the median ASPECT score was 8 (range 0-10). Good functional outcomes at 90 days (mRS ≤ 2) were achieved in 21.6% of cases (n = 11). CONCLUSIONS: The Stream device shows acceptable rates of FPE and mFPE compared to existing devices. Further larger studies are required alongside an understanding of the optimal technique for this device's use.

Tenecteplase or Alteplase Better in Patients with Acute Ischemic Stroke Due to Large Vessel Occlusion: A Single Center Observational Study.

Background and Objectives: The study aimed to investigate the efficacy of intravenous thrombolysis with Tenecteplase before thrombectomy for acute ischemic stroke (AIS) patients compared with previous results using Alteplase. Previous trials for Tenecteplase have indicated an increased incidence of vascular reperfusion. In April 2021, we started to primarily give Tenecteplase to patients eligible to undergo thrombectomy. Materials and Methods: In this retrospective observational single-center non-randomized study, we analyzed directly admitted patients with AIS who had occlusion of the internal carotid, middle cerebral, or basilar artery and who underwent thrombectomy, as well as the recanalization rate for these patients at the first angiographic assessment (mTICI score 2b-3), and complications. Results: We included 184 patients (demographic characteristics did not differ between Tenecteplase and Alteplase groups (mean age 68.4 vs. 73.0 years; female sex 53.3% vs. 51.1%, NIHSS 14 (IQR 4-26) vs. 15 (2-31). Forty-five patients received Tenecteplase and 139 Alteplase before endovascular treatment (EVT). Pre-EVT (endovascular treatment) recanalization was more likely to occur with Tenecteplase rather than Alteplase (22.2% vs. 8.6%, p = 0.02). Successful reperfusion (mTICI 2b-3) after EVT was achieved in 155 patients (42 (93.4%) vs. 113 (81.3), p = 0.07). Hemorrhagic imbibition occurred in 15 (33.3%) Tenecteplase-treated patients compared with 39 (28.1%) Alteplase-treated patients (p = 0.5). Patients treated with Tenecteplase had higher odds of excellent functional outcome than Alteplase-treated patients (Tenecteplase 48.6% vs. Alteplase 26.1%; OR 0.37 (95% CI 0.17-0.81), p = 0.01). Conclusions: Tenecteplase (25 mg/kg) could have superior clinical efficacy over Alteplase for AIS patients with large-vessel occlusion (LVO), administered before EVT. The improvement in reperfusion rate and the better excellent functional outcome could come without an increased safety concern.

Endovascular thrombectomy in anterior circulation stroke and clinical value of bridging with intravenous thrombolysis.

BACKGROUND: Bridging treatment with intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) in acute ischemic stroke is applied under the assumption of benefits for patients with large vessel occlusion (LVO). However, the benefit of this additional step has not yet been proven. PURPOSE: To compare procedural parameters (procedural time, number of attempts), complications, and clinical outcome in patients receiving EVT vs. patients with bridging treatment. MATERIAL AND METHODS: In this prospective study all patients had acute anterior cerebral circulation occlusion and were treated with EVT. All patients were selected for treatment based on clinical criteria, multimodal computed tomography (CT) imaging. Eighty-four patients were treated with bridging IVT followed by EVT; 62 patients were treated with EVT only. RESULTS: Bridging therapy did not influence endovascular procedure time ( P = 0.71) or number of attempts needed ( P = 0.63). Bleeding from any site was more common in the bridging group (27, 32%) vs. the EVT group (12, 19%) ( P = 0.09). Functional independence modified Rankin Scale after 90 days was slightly higher in the bridging group (44%) vs. the EVT group (42%) ( P = 0.14). Mortality did not differ significantly at 90 days: 17% in the bridging group vs. 21% in EVT alone ( P = 0.57). Both treatment methods showed high recanalization rates: 94% in the bridging group and 89% for EVT alone. CONCLUSION: Bridging treatment in LVO did not show benefits or elevated risks of complications in comparison to EVT only. The bridging group did not show significantly better neurological outcome or significant impact on procedural parameters vs. EVT alone.

Fatty liver index and hepatic steatosis index for prediction of non-alcoholic fatty liver disease in type 1 diabetes.

BACKGROUND AND AIM: Little is known about the diagnostic value of hepatic steatosis index (HSI) and fatty liver index (FLI), as well as their link to metabolic syndrome in type 1 diabetes mellitus. We have screened the effectiveness of FLI and HSI in an observational pilot study of 40 patients with type 1 diabetes. METHODS: FLI and HSI were calculated for 201 patients with type 1 diabetes. Forty patients with FLI/HSI values corresponding to different risk of liver steatosis were invited for liver magnetic resonance study. In-phase/opposed-phase technique of magnetic resonance was used. Accuracy of indices was assessed from the area under the receiver operating characteristic curve. RESULTS: Twelve (30.0%) patients had liver steatosis. For FLI, sensitivity was 90%; specificity, 74%; positive likelihood ratio, 3.46; negative likelihood ratio, 0.14; positive predictive value, 0.64; and negative predictive value, 0.93. For HSI, sensitivity was 86%; specificity, 66%; positive likelihood ratio, 1.95; negative likelihood ratio, 0.21; positive predictive value, 0.50; and negative predictive value, 0.92. Area under the receiver operating characteristic curve for FLI was 0.86 (95% confidence interval [0.72; 0.99]); for HSI 0.75 [0.58; 0.91]. Liver fat correlated with liver enzymes, waist circumference, triglycerides, and C-reactive protein. FLI correlated with C-reactive protein, liver enzymes, and blood pressure. HSI correlated with waist circumference and C-reactive protein. FLI ≥ 60 and HSI ≥ 36 were significantly associated with metabolic syndrome and nephropathy. CONCLUSIONS: The tested indices, especially FLI, can serve as surrogate markers for liver fat content and metabolic syndrome in type 1 diabetes.

Long-term treatment with the oncolytic ECHO-7 virus Rigvir of a melanoma stage IV M1c patient, a small cell lung cancer stage IIIA patient, and a histiocytic sarcoma stage IV patient-three case reports.

Oncolytic virotherapy is a recent addition to cancer treatment. Here, we describe positive treatment outcomes in three patients using Rigvir virotherapy. One of the patients is diagnosed with melanoma stage IV M1c, one with small cell lung cancer stage IIIA, and one with histiocytic sarcoma stage IV. The diagnoses of all patients are verified by histology or cytology. All patients started Rigvir treatment within a few months after being diagnosed and are currently continuing Rigvir treatment. The degree of regression of the disease has been determined by computed tomography. Safety assessment of adverse events graded according to NCI CTCAE did not show any value above grade 1 during Rigvir(®) treatment. Using current standard treatments, the survival of patients with the present diagnoses is low. In contrast, the patients described here were diagnosed 3.5, 7.0, and 6.6 years ago, and their condition has improved and been stabile for over 1.5, 6.5, and 4 years, respectively. These observations suggest that virotherapy using Rigvir can successfully be used in long-term treatment of patients with melanoma stage IV M1c, small cell lung cancer stage IIIA, and histiocytic sarcoma stage IV and therefore could be included in prospective clinical studies.