Effect of anesthetic strategies on distal stroke thrombectomy in the anterior and posterior cerebral artery.

BACKGROUND: Numerous questions regarding procedural details of distal stroke thrombectomy remain unanswered. This study assesses the effect of anesthetic strategies on procedural, clinical and safety outcomes following thrombectomy for distal medium vessel occlusions (DMVOs). METHODS: Patients with isolated DMVO stroke from the TOPMOST registry were analyzed with regard to anesthetic strategies (ie, conscious sedation (CS), local (LA) or general anesthesia (GA)). Occlusions were in the P2/P3 or A2-A4 segments of the posterior and anterior cerebral arteries (PCA and ACA), respectively. The primary endpoint was the rate of complete reperfusion (modified Thrombolysis in Cerebral Infarction score 3) and the secondary endpoint was the rate of modified Rankin Scale score 0-1. Safety endpoints were the occurrence of symptomatic intracranial hemorrhage and mortality. RESULTS: Overall, 233 patients were included. The median age was 75 years (range 64-82), 50.6% (n=118) were female, and the baseline National Institutes of Health Stroke Scale score was 8 (IQR 4-12). DMVOs were in the PCA in 59.7% (n=139) and in the ACA in 40.3% (n=94). Thrombectomy was performed under LA±CS (51.1%, n=119) and GA (48.9%, n=114). Complete reperfusion was reached in 73.9% (n=88) and 71.9% (n=82) in the LA±CS and GA groups, respectively (P=0.729). In subgroup analysis, thrombectomy for ACA DMVO favored GA over LA±CS (aOR 3.07, 95% CI 1.24 to 7.57, P=0.015). Rates of secondary and safety outcomes were similar in the LA±CS and GA groups. CONCLUSION: LA±CS compared with GA resulted in similar reperfusion rates after thrombectomy for DMVO stroke of the ACA and PCA. GA may facilitate achieving complete reperfusion in DMVO stroke of the ACA. Safety and functional long-term outcomes were comparable in both groups.

Impact of atrial fibrillation on the treatment effect of bridging thrombolysis in ischemic stroke patients undergoing endovascular thrombectomy: a multicenter international cohort study.

BACKGROUND: The role of bridging intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) in the treatment of acute ischemic stroke (AIS) remains debatable. Atrial fibrillation (AF) associated strokes may be associated with reduced treatment effect from IVT. This study compares the effect of bridging IVT in AF and non-AF patients. METHODS: This retrospective cohort study comprised anterior circulation large vessel occlusion (LVO) AIS patients receiving EVT alone or bridging IVT plus EVT within 6 hours of symptom onset. Primary outcome was good functional outcome defined as modified Rankin Scale (mRS) 0-2 at 90 days. Secondary outcomes were successful reperfusion defined as expanded Thrombolysis In Cerebral Infarction (eTICI) grading ≥2b flow, symptomatic intracerebral hemorrhage (sICH), and in-hospital mortality. RESULTS: We included 705 patients (314 AF and 391 non-AF patients). The mean age was 68.6 years and 53.9% were male. The odds of good functional outcomes with bridging IVT was higher in the non-AF (adjusted odds ratio (aOR) 2.28, 95% CI 1.06 to 4.91, P=0.035) compared with the AF subgroups (aOR 1.89, 95% CI 0.89 to 4.01, P=0.097). However, this did not constitute a significant effect modification by the presence of AF on bridging IVT (interaction aOR 0.12, 95% CI -1.94 to 2.18, P=0.455). The rate of successful reperfusion, sICH, and mortality were similar between bridging IVT and EVT for both AF and non-AF patients. CONCLUSION: The presence of AF did not modify the treatment effect of bridging IVT. Further individual patient data meta-analysis of randomized trials may shed light on the comparative efficacy of bridging IVT in AF versus non-AF LVO strokes.

Benefit and risk of intravenous alteplase in patients with acute large vessel occlusion stroke and low ASPECTS.

BACKGROUND: The benefit of best medical treatment including intravenous alteplase (IVT) before mechanical thrombectomy (MT) in patients with acute ischemic stroke and extensive early ischemic changes on baseline CT remains uncertain. The purpose of this study was to evaluate the benefit of IVT for patients with low ASPECTS (Alberta Stroke Programme Early CT Score) compared with patients with or without MT. METHODS: This multicenter study pooled consecutive patients with anterior circulation acute stroke and ASPECTS≤5 to analyze the impact of IVT on functional outcome, and to compare bridging IVT with direct MT. Functional endpoints were the rates of good (modified Rankin Scale (mRS) score ≤2) and very poor (mRS ≥5) outcome at day 90. Safety endpoint was the occurrence of symptomatic intracranial hemorrhage (sICH). RESULTS: 429 patients were included. 290 (68%) received IVT and 168 (39%) underwent MT. The rate of good functional outcome was 14.4% (95% CI 7.1% to 21.8%) for patients who received bridging IVT and 24.4% (95% CI 16.5% to 32.2%) for those who underwent direct MT. The rate of sICH was significantly higher in patients with bridging IVT compared with direct MT (17.8% vs 6.4%, p=0.004). In multivariable logistic regression analysis, IVT was significantly associated with very poor outcome (OR 2.22, 95% CI 1.05 to 4.73, p=0.04) and sICH (OR 3.44, 95% CI 1.18 to 10.07, p=0.02). Successful recanalization, age, and ASPECTS were associated with good functional outcome. CONCLUSIONS: Bridging IVT in patients with low ASPECTS was associated with very poor functional outcome and an increased risk of sICH. The benefit of this treatment should therefore be carefully weighed in such scenarios. Further randomized controlled trials are required to validate our findings.

Endovascular treatment of acute tandem lesions in patients with mild anterior circulation stroke.

BACKGROUND: In patients with mild strokes the risk-benefit ratio of endovascular treatment (EVT) for tandem lesions has yet to be evaluated outside of current guideline recommendations. This study investigates the frequency as well as procedural and safety outcomes in daily clinical practice. METHODS: Using data from the German Stroke Registry-Endovascular Treatment (GSR-ET) we analyzed patients with anterior circulation stroke due to tandem-lesions and mild deficits. These patients were defined as ≤5 on the National Institutes of Health Stroke Scale (NIHSS). Recanalization was assessed with the modified Thrombolysis in Cerebral Infarction Scale (mTICI). Early neurological and long-term functional outcomes were assessed with the NIHSS change and modified Rankin scale (mRS), respectively. Safety assessment included periprocedural complications and the rate of symptomatic intracerebral hemorrhage (sICH). RESULTS: A total of 61 patients met the inclusion criteria and were treated endovascularly for tandem lesions. The median age was 68 (IQR:59-76) and 32.9% (20) were female. Patients were admitted to the hospital with a median NIHSS score of 4 (IQR:2-5) and a median Alberta Stroke Programme Early CT Score (ASPECTS) of 9 (IQR:8-10). Successful recanalization (mTICI 2b-3) was observed in 86.9% (53). NIHSS decreased non-significantly (p=0.382) from baseline to two points (IQR:1-9) at discharge. Excellent (mRS≤1) and favorable (mRS≤2) long-term functional outcome at 90-days was 55.8% (29) and 69.2% (36), respectively. Mortality rates at 90-days were 9.6% (5) and sICH occurred in 8.2% (5). CONCLUSIONS: EVT for tandem lesions in patients with mild anterior circulation stroke appears to be feasible but may lead to increased rates of sICH. Further studies comparing endovascular with best medical treatment (BMT) especially investigating the risk of periprocedural hemorrhagic complications, are needed.

Artificial intelligence-driven ASPECTS for the detection of early stroke changes in non-contrast CT: a systematic review and meta-analysis.

BACKGROUND: Recent advances in machine learning have enabled development of the automated Alberta Stroke Program Early CT Score (ASPECTS) prediction algorithms using non-contrast enhanced computed tomography (NCCT) scans. The applicability of automated ASPECTS in daily clinical practice is yet to be established. The objective of this meta-analysis was to directly compare the performance of automated and manual ASPECTS predictions in recognizing early stroke changes on NCCT. METHODS: The MEDLINE, Scopus, and Cochrane databases were searched. The last database search was performed on March 10, 2022. Studies reporting the diagnostic performance and validity of automated ASPECTS software compared with expert readers were included. The outcomes were the interobserver reliability of outputs between ASPECTS versus expert readings, experts versus reference standard, and ASPECTS versus reference standard by means of pooled Fisher's Z transformation of the interclass correlation coefficients (ICCs). RESULTS: Eleven studies were included in the meta-analysis, involving 1976 patients. The meta-analyses showed good interobserver reliability between experts (ICC 0.72 (95% CI 0.63 to 0.79); p<0.001), moderate reliability in the correlation between automated and expert readings (ICC 0.54 (95% CI 0.40 to 0.67); p<0.001), good reliability between the total expert readings and the reference standard (ICC 0.62 (95% CI 0.52 to 0.71); p<0.001), and good reliability between the automated predictions and the reference standard (ICC 0.72 (95% CI 0.61 to 0.80); p<0.001). CONCLUSIONS: Artificial intelligence-driven ASPECTS software has comparable or better performance than physicians in terms of recognizing early stroke changes on NCCT.

Thrombectomy for secondary distal, medium vessel occlusions of the posterior circulation: seeking complete reperfusion.

BACKGROUND: Whether to approach distal occlusions endovascularly or not in medium-sized vessels secondary to proximal large vessel occlusion stroke remains unanswered. OBJECTIVE: To investigates the technical feasibility and safety of thrombectomy for secondary posterior circulation distal, medium vessel occlusions (DMVO). METHODS: TOPMOST (Treatment fOr Primary Medium vessel Occlusion STroke) is an international, retrospective, multicenter, observational registry of patients treated for distal cerebral artery occlusions. This study subanalysis endovascularly treated occlusions of the posterior cerebral artery in the P2 and P3 segment secondary preprocedural or periprocedural thrombus migration between January 2014 and June 2020. Technical feasibility was evaluated with the modified Thrombolysis in Cerebral Infarction (mTICI) scale. Procedural safety was assessed by the occurrence of symptomatic intracranial hemorrhage (sICH) and intervention-related serious adverse events. RESULTS: Among 71 patients with secondary posterior circulation DMVO who met the inclusion criteria, occlusions were present in 80.3% (57/71) located in the P2 segment and in 19.7% (14/71) in the P3 segment. Periprocedural migration occurred in 54.9% (39/71) and preprocedural migration in 45.1% (32/71) of cases. The first reperfusion attempt led in 38% (27/71) of all cases to mTICI 3. On multivariable logistic regression analysis, increased numbers of reperfusion attempts (adjusted odds ratio (aOR)=0.39, 95% CI 0.29 to 0.88, p=0.009) and preprocedural migration (aOR=4.70, 95% CI,1.35 to 16.35, p=0.015) were significantly associated with mTICI 3. sICH occurred in 2.8% (2/71). CONCLUSION: Thrombectomy for secondary posterior circulation DMVO seems to be safe and technically feasible. Even though thrombi that have migrated preprocedurally may be easier to retract, successful reperfusion can be achieved in the majority of patients with secondary DMVO of the P2 and P3 segment.

Feasibility and safety of thrombectomy for isolated occlusions of the posterior cerebral artery: a multicenter experience and systematic literature review.

BACKGROUND: Substantial clinical evidence supporting the benefit of mechanical thrombectomy (MT) for distal occlusions within the posterior circulation is still missing. This study aims to investigate the procedural feasibility and safety of MT for isolated occlusions of the posterior cerebral artery. METHODS: We retrospectively reviewed patients from three stroke centers with acute ischemic stroke attributed to isolated posterior cerebral artery occlusion (IPCAOs) who underwent MT between January 2014 and December 2019. Procedural and safety assessment included successful recanalization rates (defined as Thrombolysis in Cerebral Infarction Scale (TICI) ≥2b), number of MT attempts and first-pass effect (TICI 3), intracranial hemorrhage (ICH), mortality, and intervention-related serious adverse events. Treatment effects were evaluated by the rate of early neurological improvement (ENI) and early functional outcome was assessed with the modified Rankin Scale (mRS) at discharge. A systematic literature review was conducted to identify and summarize previous reports on MT for IPCAOs. RESULTS: Forty-three patients with IPCAOs located in the P1 (55.8%, 24/43), P2 (37.2%, 16/43), and P3 segment (7%, 3/43) were analyzed. The overall rate of successful recanalization (TICI ≥2b) was 86% (37/43), including a first pass-effect of 48.8% (21/43) leading to TICI 3. sICH occurred in 7% (3/43) and there were two cases with iatrogenic vessel dissection and one perforation. ENI was observed in 59% (23/39) and excellent functional outcome (mRS ≤1) in 46.2% (18/39) of patients who were discharged. The in-hospital mortality rate was 9.3% (4/43). CONCLUSION: Our study suggests the technical feasibility and safety of thrombectomy for IPCAOs. Further studies are needed to investigate safety and long-term functional outcomes with posterior circulation stroke-adjusted outcome assessment.

Repeated mechanical thrombectomy in short-term large vessel occlusion recurrence: multicenter study and systematic review of the literature.

BACKGROUND: Data on the frequency and outcome of repeated mechanical thrombectomy (MT) in patients with short-term re-occlusion of intracranial vessels is limited. Addressing this subject, we report our multicenter experience with a systematic review of the literature. METHODS: A retrospective analysis was conducted of consecutive acute stroke patients treated with MT repeatedly within 30 days at 10 tertiary care centers between January 2007 and January 2020. Baseline demographics, etiology of stroke, angiographic outcome and clinical outcome evaluated by the modified Rankin Scale (mRS) at 90 days were noted. Additionally, a systematic review of reports with repeated MT due to large vessel occlusion (LVO) recurrence was performed. RESULTS: We identified 30 out of 7844 (0.4%) patients who received two thrombectomy procedures within 30 days due to recurrent LVO. Through systematic review, three publications of 28 participants met the criteria for inclusion. Combined, a total of 58 participants were analyzed: cardioembolic events were the most common etiology for the first (65.5%) and second LVO (60.3%), respectively. Median baseline NIHSS (National Institutes of Health Stroke Scale) was 13 (IQR 8-16) before the first MT and 15 (IQR 11-19) before the second MT (p=0.031). Successful reperfusion was achieved in 91.4% after the first MT and in 86.2% patients after the second MT (p=0.377). The rate of functional independence (mRS 0-2) was 46% at 90 days after the second procedure. CONCLUSION: Repeated MT in short-term recurrent LVO is a rarity but appears to be safe and effective. The second thrombectomy should be pursued with the same extensive effort as the first procedure as these patients may achieve similar good outcomes.

Mechanical thrombectomy in nonagenarians with acute ischemic stroke.

BACKGROUND: Mechanical thrombectomy (MT) is a safe and effective therapy for ischemic stroke. Nevertheless, very elderly patients aged ≥90 years were either excluded or under-represented in previous trials. It remains uncertain whether MT is warranted for this population or whether there should be an upper age limit. METHODS: We retrospectively reviewed 79 patients with stroke aged ≥90 years from three neurointerventional centers who underwent MT between 2013 and 2017. Good functional outcome was defined as modified Rankin scale (mRS) ≤2 and assessed at 90-day follow-up. Successful recanalization was graded by Thrombolysis in Cerebral Infarction Scale (TICI) ≥2 b. Feasibility and safety assessments included unsuccessful recanalization attempts (TICI 0), time from groin puncture to recanalization, symptomatic intracranial hemorrhage (sICH), mortality, and intervention-related serious adverse events. RESULTS: Only occlusions within the anterior circulation were included. Median time from groin puncture to recanalization was 39 min (IQR 25-57 min). The rate of successful recanalization (TICI ≥2 b) was 69.6% (55/79). Good functional outcome (mRS ≤2) at 90 days was observed in 16% (12/75) of patients. In-hospital mortality was 29.1% (23/79) and increased significantly at 90 days (46.7%, 35/75; p<0.001). sICH occurred in 5.1% (4/79) of patients. No independent predictor for good functional outcome (mRS ≤2) at 90 days was identified through logistic regression analysis. CONCLUSION: MT in nonagenarians leads to high mortality rates and less frequently good functional outcome compared with younger patient cohorts in previous large randomized trials. However, MT appears to be safe and beneficial for a certain number of very elderly patients and therefore should generally not be withheld from nonagenarians.

Endovascular therapy versus thrombolysis in patients with large vessel occlusions within the anterior circulation aged ≥80 years.

BACKGROUND AND PURPOSE: In patients with large vessel occlusions, endovascular treatment (ET) has been shown to be superior to intravenous thrombolysis (IVT) in recent trials. However, the effectiveness of ET in elderly patients is uncertain. METHODS: Using our stroke database, we compared the rates of good outcome (modified Rankin scale (mRS) ≤2), excellent outcome (mRS 0-1), poor outcome (mRS 5-6) at discharge, in-hospital death, infarct size, and symptomatic intracranial hemorrhage (SICH) in patients aged ≥80 years with distal intracranial carotid artery, M1 and M2 occlusions during two time periods. RESULTS: From January 2008 to October 2012, 217 patients were treated with IVT and, from November 2012 to October 2017, 209 patients received ET with stent retrievers (with or without IVT). Significantly more patients in the ET group than in the IVT group had a good outcome (25% vs 16%, P<0.05), as well as an excellent outcome (12% vs 4%, P<0.01). Significantly fewer patients in the ET group than in the IVT group died (14% vs 22%, P<0.05) or had a poor outcome (35% vs 52%, P<001). The SICH rates were lower after ET than after IVT (1% vs 6%, P<0.01), and the infarct sizes were smaller after ET than after IVT. CONCLUSIONS: Compared with IVT, the routine use of ET significantly improved the early clinical and radiological outcome in patients with anterior circulation large vessel occlusions aged ≥80 years. Nevertheless, poor outcome rates were high so the role of ET needs to be defined further in this population.

The P300 in middle cerebral artery strokes or hemorrhages: Outcome predictions and source localization.

OBJECTIVES: There are no reliable outcome predictors for severely impaired patients suffering from large infarctions or hemorrhages within the territory of the middle cerebral artery. This study investigated whether the amplitude of the event-related potential (ERP) component P300 predicts if a patient will be transferred to the next stage of rehabilitation (positive outcome) or to a nursing home (negative outcome). The second goal was to look for lesion locations determining the generation of the P300 amplitude. METHODS: Forty-seven patients performed an auditory oddball task to elicit the P300 and were assessed with different scores for activities of daily living (ADL). Patients were divided in two groups according to their outcome. P300 amplitudes were compared between these groups controlling for age and gender. Post-hoc analyses were performed to analyse the relationship between P300 amplitude and neurological outcome scores. In addition, lesion overlaps were created to detect which lesion pattern affects P300 generation. RESULTS: Patients with a positive outcome showed higher P300 amplitudes at frontal electrode sites than those with a negative outcome. P300 amplitude correlated with ADL score difference. Lesions in the superior temporal gyrus, middle and inferior frontal and prefrontal regions led to visibly diminished P300 amplitudes. CONCLUSIONS: The findings suggest that an impairment of attention (P300 amplitude reduction) negatively influences successful neurological rehabilitation. Left superior temporal lobe and the left premotor/prefrontal areas are essential brain areas for the generation of the P300. SIGNIFICANCE: P300 amplitude may be used as an outcome predictor for severely impaired patients suffering from middle cerebral artery strokes or hemorrhages.

Cognition after malignant media infarction and decompressive hemicraniectomy--a retrospective observational study.

BACKGROUND: Decompressive hemicraniectomy is a life-saving procedure for patients with malignant middle cerebral artery infarctions. However, the neuropsychological sequelae in such patients have up to now received little attention. In this study we not only describe neuropsychological deficits but also the quality of life and the extent of depression and other psychiatric symptoms in patients after complete media infarction of the non-speech dominant hemisphere. METHODS: 20 patients from two different university hospitals (mean ± standard deviation: 52 ± 14 years of age) who had undergone hemicraniectomy with duraplasty above the non-speech dominant hemisphere at least one year previously were examined using a thorough neurological and neuropsychological work-up. The quality of life and the extent of psychiatric problems were determined on the basis of self-estimation questionnaires. The patients were asked whether they would again opt for the surgical treatment when considering their own outcome. 20 healthy persons matched for age, gender and education served as a control group. RESULTS: All patients but one were neurologically handicapped, half of them severely. Age was significantly correlated with poorer values on the Rankin scale and Barthel index. All cognitive domain z values were significantly lower than in the control group. Upon re-examination, 18 of 20 patients were found to be cognitively impaired to a degree that fulfilled the formal DSM IV criteria for dementia. CONCLUSIONS: Patients with non-speech dominant hemispheric infarctions and decompressive hemicraniectomy are at high risk of depression and severe cognitive impairment.

New brain lesions after carotid revascularization are not associated with cognitive performance.

PURPOSE: Carotid angioplasty and stenting (CAS) is increasingly being used as a treatment alternative to endarterectomy (CEA) for patients with significant carotid stenosis. However, diffusion-weighted imaging (DWI) has indicated that CAS is associated with a significantly higher burden of microemboli. This study evaluated the potential effect on intellectual functions of new DWI lesions after CEA or CAS. METHODS: This prospective study analyzed the neuropsychologic outcomes after revascularization in 24 CAS and 31 CEA patients with severe carotid stenosis compared with a control group of 27 healthy individuals. All patients underwent clinical examinations, magnetic resonance imaging scans, and a neuropsychologic test battery that assessed six major cognitive domains performed immediately before CEA or CAS, ≤ 72 hours after, and at 3 months. RESULTS: New DWI lesions were detected among 15 of 21 (71%) of the CAS patients immediately after treatment but in only 1 of the 28 CEA patients (4%; P < .01). As a group, patients with new DWI lesions showed a decline in their performance in the cognitive domains, attention, and visuoconstructive functions within 72 hours of carotid revascularization. Individually, however, in none of the cognitive domains did the decreases reach a clinically relevant threshold of z < -1.5. Moreover, the cognitive performance was not significantly different between patients with and without new DWI lesions 3 months after treatment. The cognitive performance was similar between CEA and CAS patients at all points. CONCLUSIONS: The findings support the assumption that new brain lesions, as detected with DWI after CAS or CEA, do not affect cognitive performance in a manner that is long-lasting or clinically relevant. Despite the higher embolic load detected by DWI, CAS is not associated with a greater cognitive decline than CEA.

Recombinant human erythropoietin in the treatment of acute ischemic stroke.

BACKGROUND AND PURPOSE: Numerous preclinical findings and a clinical pilot study suggest that recombinant human erythropoietin (EPO) provides neuroprotection that may be beneficial for the treatment of patients with ischemic stroke. Although EPO has been considered to be a safe and well-tolerated drug over 2 decades, recent studies have identified increased thromboembolic complications and/or mortality risks on EPO administration to patients with cancer or chronic kidney disease. Accordingly, the double-blind, placebo-controlled, randomized German Multicenter EPO Stroke Trial (Phase II/III; ClinicalTrials.gov Identifier: NCT00604630) was designed to evaluate efficacy and safety of EPO in stroke. METHODS: This clinical trial enrolled 522 patients with acute ischemic stroke in the middle cerebral artery territory (intent-to-treat population) with 460 patients treated as planned (per-protocol population). Within 6 hours of symptom onset, at 24 and 48 hours, EPO was infused intravenously (40,000 IU each). Systemic thrombolysis with recombinant tissue plasminogen activator was allowed and stratified for. RESULTS: Unexpectedly, a very high number of patients received recombinant tissue plasminogen activator (63.4%). On analysis of total intent-to-treat and per-protocol populations, neither primary outcome Barthel Index on Day 90 (P=0.45) nor any of the other outcome parameters showed favorable effects of EPO. There was an overall death rate of 16.4% (n=42 of 256) in the EPO and 9.0% (n=24 of 266) in the placebo group (OR, 1.98; 95% CI, 1.16 to 3.38; P=0.01) without any particular mechanism of death unexpected after stroke. CONCLUSIONS: Based on analysis of total intent-to-treat and per-protocol populations only, this is a negative trial that also raises safety concerns, particularly in patients receiving systemic thrombolysis.

Target lesion ulceration and arch calcification are associated with increased incidence of carotid stenting-associated ischemic lesions in octogenarians.

PURPOSE: Although evidence is accumulating that advanced age is a risk factor for carotid angioplasty and stenting (CAS), the reason for this finding is incompletely understood. The aims of this study were to compare the prevalence of anatomic risk factors in patients <80 years with those in patients > or =80 years and to determine the effect of these risk factors on the incidence of new lesions seen on diffusion-weighted imaging (DWI) after protected CAS as surrogate markers for stroke. METHODS: Various potential anatomic risk factors for CAS were analyzed in 62 symptomatic patients (49 aged <80 years; 13 aged > or =80 years) by using preprocedural digital subtraction angiograms and extracranial contrast-enhanced magnetic resonance angiographies. DWI was performed immediately before and or =80 years) were not significant, the proportion of patients with any new ipsilateral DWI lesions, as well as the total number of these lesions, was higher in octogenarians than in patients aged <80 years (85% vs 47%, P < .05), with a median of 2 (interquartile range [IQR], 1 to 5) vs 0 (IQR, 0 to 3; P = .07). Similarly, the proportion of patients with any new DWI lesions outside the vascular territory of the target vessel as well as the total number of these lesions was significantly higher in octogenarians compared with patients aged <80 years (54% vs 10%, P < .01), with a median of 1.5 (IQR, 0.25 to 10.75) vs 0 (IQR, 0 to 1; P < .05). The presence of an ulcerated lesion was an independent predictor of any new ipsilateral DWI lesion (odds ratio [OR], 4.3; 95% confidence interval [CI], 1.06 to 17.1; P < .05), whereas a severe aortic arch calcification tended to be a predictor of new DWI lesions outside the territory of the treated artery (OR, 1.8; 95% CI, 0.99 to 3335; P = .05). CONCLUSIONS: Increased prevalences of severe aortic arch calcifications and target lesion ulceration are associated with an increased risk for magnetic resonance DWI-detected embolic events during CAS. Because in our study arch calcification and target lesion ulceration were more prevalent in octogenarians, this association may explain the increased risk of CAS in the elderly.

Dropped-head syndrome due to steroid responsive focal myositis: a case report and review of the literature.

Isolated severe weakness of the paraspinal musculature, either at the cervical level leading to a "dropped head syndrome" or at the thoracic level leading to a "bent-spine syndrome", is a rare disorder. Etiologically it may be present in a variety of neurological diseases including Parkinson's disease, multiple system atrophy, neuromuscular or motor neuron diseases, as well as non-inflammatory, inflammatory, dystrophic or metabolic myopathies. We present a previously healthy 74-year-old man with a 2-month history of progressive difficulty in lifting his chin off his chest. Magnetic resonance imaging and skeletal muscle biopsy revealed an isolated myositis of the neck extensor and trapezius muscles, which responded well to steroid therapy. This case and other rare reports obtained from a systematic review of the literature indicate that in a subgroup of patients "dropped head syndrome" or "bent spine syndrome" is caused by a myositis, which emphasizes the necessity to obtain a MRI examination, as well as a muscle biopsy to diagnose this potentially treatable disease.

Risk factors for periprocedural complications in carotid artery stenting without filter protection: A serial diffusion-weighted MRI study.

INTRODUCTION: In high-grade stenosis, carotid artery stenting (CAS) may be chosen as an alternative to carotid surgery. Ischemic periprocedural complications may be documented best with diffusion-weighted MRI (DWMRI). In this prospective study serial DW-MRI and color-coded duplex sonography (CCDS) were used to identify carotid stenosis, which is associated with an increased risk of ischemic events due to CAS. METHODS: High resolution DW-MRI were performed in 74 out of 77 patients before and after CAS. All MRI scans were analyzed in a blinded manner. With CCDS each carotid stenosis was evaluated according to the grade, length, echo properties and plaque surface. RESULTS: In 42 out of 74 patients (56.8 %) a total of 188 new procedure- related DWI-lesions could be detected, while in 32 patients MRI-controls remained normal. Of the lesions 79.25 % had a size < 1 cm. In one major and two minor strokes due to CAS (total complication rate 3.9 %) corresponding territorial infarcts could be demonstrated. A highly significant correlation was found between the length of the stenosis and the incidence of new DWI-lesions (p = 0.0141). In contrast, neither the grade of ICA stenosis nor the sonographic plaque morphology or plaque surface correlated with the number of DWI-lesion in postinterventional scans. CONCLUSIONS: The length-and not the degree-of an ICA stenosis seems to be the most decisive sonographic factor for estimating the periprocedural risk of embolism. DWI-lesions are much more frequent than clinical complications and may represent an important surrogate marker for improving the techniques of carotid artery stenting, especially comparing the benefit of different mechanical protection devices.

Incidence and risk factors for medical complications after carotid artery stenting.

OBJECTIVE: Carotid angioplasty and stenting (CAS) is being evaluated as an alternative to carotid endarterectomy for the treatment of carotid artery stenosis; however, to date little is known about the incidence of medical complications after CAS. The goal of this study was to determine the frequency of, and to identify potential clinical risk factors for, the development of medical complications after CAS. METHODS: Medical complications that occurred < or = 30 days after CAS in 327 consecutive patients (241 men, 86 women; mean age, 69 +/- 9 years; range, 45 to 90 years) treated for symptomatic (n = 182, 56%) or asymptomatic (n = 145, 44%) carotid artery stenosis were recorded. The effect of clinical characteristics on the subsequent development of medical complications was analyzed by logistic regression. RESULTS: Fifty-one patients (15%) had 62 medical complications: 3 (0.9%) myocardial infarctions, 3 (0.9%) cardiac arrhythmias, 4 (1.2%) episodes of angina pectoris, 3 (0.9%) episodes of symptomatic hypertension, 16 (4.9%) episodes of symptomatic hypotension, 10 (3.1%) chest infections, 9 (2.7%) had periods of confusion, 5 (1.5%) had urinary retention, and 9 (2.7%) urinary tract infections. One chest infection was fatal and 16 complications prolonged the intensive care unit monitoring period > 24 hours. Advanced age (odds ratio [OR], 1.1; 95% confidence interval [CI], 1.05 to 1.14) and a symptomatic carotid stenosis (OR, 2.1; 95% CI, 1.07 to 4.1) independently predicted the occurrence of medical complications. CONCLUSION: Although life-threatening or fatal non-neurologic events were uncommon in this series, the overall incidence of medical complications after CAS might be higher than currently anticipated. Older and symptomatic patients are at the highest risk, and these subgroups should be monitored closely.