Intracranial stents in the endovascular treatment of acute ischemic stroke. / Uso del stent intracraneal en el tratamiento endovascular en agudo del ictus.

OBJECTIVE: To evaluate the efficacy and safety of intracranial stenting as a rescue therapy after failed mechanical thrombectomy in patients with acute ischemic stroke. MATERIAL AND METHODS: We retrospectively studied 42 patients treated with intracranial stenting after failed mechanical thrombectomy between December 2008 and January 2016. We compared outcomes before and after the incorporation of stentrievers. We assessed the degree of recanalization in the carotid and basilar territories (modified TIMI score), prognostic factors, and outcome (modified Rankin Score at 3 months). Safety was evaluated in function of the appearance of symptomatic intracranial hemorrhage (SICH). RESULTS: Median NIHSS was 17 in patients with carotid territory strokes and 26 in those with vertebrobasilar territory strokes. Median time from onset of symptoms to treatment was 225minutes in carotid territory strokes and 390minutes in vertebrobasilar territory strokes. A total of 10 patients underwent intravenous fibrinolytic therapy before treatment with stentrievers. Two patients developed SICH; both had undergone intravenous fibrinolytic therapy (p=0.0523). Recanalization was effective in 30 (71.4%) in the entire series: in 7 (50%) of 14 patients treated before the incorporation of stentrievers and in 23 (82.1%) of 28 treated after the incorporation of stentrievers (p=0.0666). Outcome at 3 months was good in 2 (14.3%) patients in the earlier group and in 14 (50%) patients in the later group (p=0.042). We found significant associations between recanalization and outcome (p=0.0415) and between shorter time to treatment and outcome (p=0.002). Outcome was good in 14 (48.3%) of the 29 patients with carotid territory strokes and in 2 (15.4%) of the 13 patients with vertebrobasilar territory strokes (p=0.078). CONCLUSIONS: Intracranial stenting is the rescue treatment when the usual treatment fails. Stentrievers must be used to eliminate the clot burden before stenting. In our study, antiplatelet treatment did not seem to increase the risk of SICH except in patients with prior intravenous fibrinolytic treatment.

[Vertebrobasilar recanalization techniques before the placement of stent-retrievers: reopening is not synonymous with good outcome]. / Técnicas de recanalización vertebrobasilar antes de la introducción de las endoprótesis recuperadoras: la reapertura no es sinónimo de buena evolución.

OBJECTIVES: To evaluate the recanalization rate and clinical outcome three months after endovascular treatment for vertebrobasilar occlusion before the placement of stentrievers. MATERIAL AND METHODS: We reviewed all cases of basilar thrombosis treated with endovascular techniques at our center. We reviewed the clinical outcomes with the main objective of determining the recanalization rate and the secondary objective of evaluating the outcome using the modified Rankin scale (mRS) three months after treatment. We assessed clinical and angiographic variables and correlated them with outcome and complications. RESULTS: We reviewed a total of 27 consecutive patients (mean age, 58.1±15.5 y; median National Institutes of Health Stroke Scale (NIHSS), 21, interquartile range, 18-29; median Glasgow coma score (GCS) 7, interquartile range, 4-9.5). The mean time between the onset of symptoms and endovascular treatment was 26.3±41.7hours. Complete or partial recanalization was achieved in 23 (85.1%) patients. Three months after treatment, 16 (59.2%) had died and 6 (22.2%) had good outcome (mRS ≤ 2). CONCLUSION: Endovascular treatment achieved a high rate of recanalization of occlusions of the basilar artery. Nevertheless, a high percentage of the patients did not have a good outcome. New materials might improve the prognosis in these patients.

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.

Treatment of posterior circulation strokes by mechanical thrombectomy with a stent-retriever: a retrospective observational study at a single center. / Tratamiento del ictus de circulación posterior mediante trombectomía mecánica con stent-retriever: un estudio observacional, monocéntrico y retrospectivo.

OBJECTIVES: To determine the rate of recanalization, functional outcome at three months, and independent prognostic factors in patients with posterior circulation strokes treated with stent-retrievers and to compare these results with those of patients in an earlier series treated with "classical methods". MATERIAL AND METHODS: This was a retrospective study of consecutive patients with posterior circulation strokes treated with stent-retrievers at our center between December 1, 2011 and May 1, 2018. The main outcome variables were the rate of recanalization according to the Thrombosis in Cerebral Infarction (TICI) scale and functional independence score 90 days after treatment according to the modified Rankin Scale (mRS). We analyzed demographics, cerebrovascular risk factors, clinical findings, and probable origin. Descriptive statistics and a binary logistic regression model were used to analyze the data. RESULTS: We included 75 patients: 27 treated with "classical methods" and 48 treated with stent-retrievers (10 women; mean age, 63.9 years; median National Institute of Health Stroke Score, 15.8 (IQR 9-25); median Glasgow Coma Scale (GCS), 9.1 (IQR 6-14,5). TICI 2b-3 recanalization was achieved in 46 (95.8%) patients treated with stent-retrievers and in 15 (55.6%) patients treated with "classical methods" (p<0.0001). No significant differences were observed in the rate of patients achieving mRS 0-2 at 90 days (19 (39.6%) of those treated with stent-retrievers vs. 6 (22.2%) of those treated with "classical methods"). Mortality was lower among patients treated with stent-retrievers (14 (29.2% vs. 15 (55.6%) in those treated with "classical methods", p=0.024). GCS score was independently associated with mRS at 90 days (OR:0.67; 95%CI:0.5-0.91; p=0.01). CONCLUSIONS: In patients with posterior circulation infarcts, treatment with stent-retrievers achieved high rates of recanalization and functional independence at 90 days. The rate of complications was similar to those reported in other studies. GCS is an independent predictor of functional independence at 90 days.

[Tuberculosis in La Rioja from 1988 to 1993. Clinical course, localization, influence of human immunodeficiency virus infection, and sensitivity of mycobacterial tests]. / Tuberculosis en La Rioja de 1988 a 1993. Evolución, localizaciones, influencia de la infección por el virus de la inmunodeficiencia humana y sensibilidad de la baciloscopia.

BACKGROUND: The present study was performed to analyze the evolution of the incidence of tuberculosis in La Rioja (Spain) from January 1988 to March 1993. The influence of factors such as HIV infection and alcoholism was analyzed. The sensitivity of the bacilloscopy in the diagnosis was studied. METHODS: The cases were collected from the Regional Tuberculosis Program of the Public Health Department in La Rioja, with clinical histories being collected from the Internal Medicine Department of the Hospital San Millán in Logroño. Cases of tuberculosis were microbiologically confirmed by cultures of Mycobacterium tuberculosis. RESULTS: The total number of cases studied was 649 with the incidence of tuberculosis in La Rioja being 51 cases/100,000 inhabitants in 1992. The mean age of all the patients was 45 years with 80% of the tuberculosis being pulmonary and 20% extrapulmonary. Twelve percent of the patients were HIV+; 18% being extrapulmonary tuberculosis and 10.8% pulmonary tuberculosis, p < 0.02. Pleural and urogenital tuberculosis were present in fewer HIV+ patients. Bacilloscopy was negative requiring a culture for diagnosis in 28.6% of the cases with this circumstance more frequently occurring in the pleural and urogenital forms of the diseases. Treatment has evolved from the use of ethambutol in the first few years to the present use of pyrazinamide. CONCLUSIONS: No trend towards an increase in the incidence of tuberculosis in the time period studied was observed in La Rioja. Extrapulmonary tuberculosis was the type of tuberculosis most frequently found in HIV positive patients, with pleural and urogenital forms of the disease being less frequently found in these patients. In these case the bacilloscopy was also found to be negative more frequently.

[Presurgical endovascular treatment of symptomatic carotid stenosis caused by a meningioma of the planum sphenoidale]. / Tratamiento endovascular prequirurgico de la estenosis carotidea sintomatica provocada por un meningioma del plano esfenoidal.

INTRODUCTION: Cerebral infarction is a very rare presenting symptom of a meningioma. This form of clinical onset poses the challenge of treating ischaemic events before dealing with the tumour surgically. CASE REPORT: A 48-year-old woman from Georgia who visited due to loss of strength in the right-hand side of the body, intense headache and self-limiting episodes of forgetting her own language. Computerised axial tomography scans of her head revealed a left frontal expansive process and hypodense lesions in the left caudate nucleus. The patient underwent an unfavourable progression, with episodes of neurological deterioration and hemiparesis of the right-hand side and aphasia, which alternated with periods of improvement. Magnetic resonance imaging and an angiographic study revealed tumour occlusion of the left middle cerebral artery, secondary to a clinoidal meningioma. Treatment involved endovascular recanalisation of the middle cerebral artery and later surgical removal of the meningioma. CONCLUSIONS: Endovascular treatment by means of angioplasty, prior to the surgical excision of the tumour, is a technique that enables the incidence of ischaemic events to be diminished.

Unprotected carotid artery stenting in symptomatic patients with high-grade stenosis: results and long-term follow-up in a single-center experience.

BACKGROUND AND PURPOSE: The use of cerebral protection during CAS is an extended practice. Paradoxically it is open to question because it can lead to potential embolic complications. The aim of this study was to evaluate the safety and efficacy of CASWPD in patients with severe symptomatic carotid artery stenosis. MATERIALS AND METHODS: A prospective study was performed including 210 consecutive patients (201 symptomatic and 9 asymptomatic) with carotid artery stenosis >70%. All patients were treated by CASWPD. Angiographic results and neurologic complications were recorded during the procedure and within 30 days after it. All patients underwent clinical evaluation and Doppler sonography follow-up at 3, 6, and 12 months after the procedure. RESULTS: Two hundred twenty carotid arteries were treated. The average degree of stenosis was 88.9%. The procedure was successfully completed in 212 (96.4%) arteries. After stent placement, 98.6% of arteries showed no residual stenosis or <30%. Balloon angioplasty dilation before stent placement was performed in 16% of cases. During the 30-day periprocedural period, there were 3 major complications (1.4%), including 1 disabling ischemic stroke, 1 acute stent thrombosis, and 1 MI. The last 2 patients died from these complications. At 1-year follow-up 24 (12.8%) restenoses, 2 new ipsilateral strokes, 1 contralateral stroke, and 5 deaths (2.7%) had occurred. None of these deaths were related to the initial stroke. CONCLUSIONS: In our study, unprotected stent placement in symptomatic patients with severe carotid artery stenosis has demonstrated a low incidence of complications. We believe that this is due to the reduction of maneuvering and manipulation through the stenosis and to the protective effect of the stent placement before angioplasty balloon dilation.