Embolic Stroke of Undetermined Source: Role of Implantable Loop Recorder in Secondary Prevention.

BACKGROUND AND AIMS: Atrial fibrillation (AF) is the most important cause of embolic stroke of undetermined source (ESUS). Implantable loop recorder (ILR) demonstrated the highest sensitivity for detecting it. This register was created to confirm the high prevalence of AF in patients after ESUS and to verify possible benefits on clinical outcomes such as TIA (Transient Ischaemic Attack)/stroke recurrence and death using ILR. METHODS: A total of 278 patients admitted to "Molinette" Hospital in Stroke Unit department between 2011 and 2016, diagnosed with ESUS, underwent ILR implantation if they had at least one risk factor for AF. A total of 165 patients admitted to other departments in the same center for the same pathology, without ILR, represent the control group. We used propensity score to select 132 patients from each group (matching age, sex, CHADS-VASC, and HAS-BLEED baseline characteristics). RESULTS: The detection rate of AF episodes was significantly higher in the ILR group (p < 0.001). No significant protective role of ILR for clinical endpoints was found on univariate analysis, although a trend towards significance has been pointed for the composite outcome of death and ischemic events recurrence (OR 0.52, CI 0.26-1.04, p = 0.06). A protective role of ILR was found for deaths (OR 0.4, CI 0.17-0.94, p 0.03) and for the composite outcome (OR 0.41, CI 0.19-0.87, p 0.02) on multivariate analysis in the best subsets. CONCLUSION: With our statistical models, we identified a significant clinical benefit from ILR monitoring, evidenced by a trend of less death and TIA/stroke recurrence and relevant ILR protection for prediction of TIA/stroke recurrence.

Silk Vista Baby flow diverter stent for ruptured intracranial aneurysms: a retrospective observational study.

PURPOSE: Flow diversion changed the approach to complex intracranial aneurysms, leading to a widespread use and a rapid technological evolution. Indeed, indications continued to expand, including ruptured intracranial aneurysms in selected cases. Recently, new devices have been designed specifically to target smaller vessels. Therefore, we conducted a multicenter study to evaluate clinical outcome, complications, and occlusion rate of patients with ruptured aneurysms treated with new generation low profile Silk Vista Baby (SVB) flow diverter stent (FD). METHODS: We performed a retrospective observational study on consecutive patients who underwent treatment with SVB for ruptured aneurysms at 12 Italian centers. Primary end point was favorable clinical outcome rate, defined as modified ranking score (mRS) of 0-2 at the 3 months. Secondary outcomes were complication rate, aneurysm re-rupture, and complete aneurysm occlusion at last radiological follow-up. RESULTS: Twenty-five patients were included; at 3 months' follow-up, 19 patients (79.1%) had favorable clinical outcome (mRS 0-2). Three patients (12.5%) died during follow-up. In-stent thrombosis occurred in two cases (8.3%), managed with glycoprotein IIb/IIIA and intra-stent angioplasty, without clinical consequences. In 18 (85.7%) patients, complete occlusion at 3 months was demonstrated. No rebleeding occurred during follow-up. Presentation with unfavorable World Federation of Neurosurgical Societies grading system (WFNS) and posterior circulation location were both significantly correlated with unfavorable clinical outcome (p = 0.005 and p = 0.02). CONCLUSIONS: Our data suggests that low profile FD treatment of ruptured intracranial aneurysms located distally of the circle of Willis is feasible. New generation low profile FD may represent an alternative option in carefully selected cases.

Flow Diversion for Acutely Ruptured Intracranial Aneurysms Treatment: A Retrospective Study and Literature Review.

OBJECTIVE: Flow diversion is becoming an increasingly established practice for the treatment of acutely ruptured intracranial aneurysms. In this study the authors present a literature review and meta-analysis, adding a retrospective review of institutional registry on emergency treatment of aRIA with flow diverter stent. MATERIALS AND METHODS: A systematic search of PubMed, SCOPUS, Ovid MEDLINE, and Ovid EMBASE was performed on April 20th, 2021, extrapolating 35 articles. R language 'meta' and 'metafor' packages were used for data pooling. The DerSimonian-Laird model was used to calculate the pooled effect. The I2 value and Q statistic evaluated study heterogeneity. Additionally, the authors retrospectively reviewed their institutional database for the treatment and outcomes of all patients with acutely ruptured intracranial aneurysms treated with flow diverter stent placement from May 2010 to November 2020 was performed. RESULTS: From the systematic literature review and meta-analysis, the pooled proportion of complete aneurysm occlusion was 78%, with a pooled rate of 79%, 71%, 80%, and 50% for dissecting, saccular, fusiform, and mycotic aneurysms, respectively. The pooled proportion of aneurysm rebleeding and intrastent stenosis was 12% and 15% respectively, for a total of 27% rate. The analysis of authors retrospective register showed an overall mortality rate of 16.7% (3/18), with a low but not negligible postprocedural rebleeding and intrastent thrombosis rates (5.6% and 11.1% respectively). CONCLUSION: Although increasingly utilized in the management of selected patients with acutely ruptured intracranial aneurysms, flow diversion for acutely ruptured intracranial aneurysms treatment presents rebleeding and intrastent stenosis rates not negligible.

Cineangiography versus standard digital subtraction angiography in mechanical thrombectomy: lowering the radiation exposure without sacrificing the outcome.

BACKGROUND: Endovascular thrombectomy has become a standard procedure for the treatment of acute ischemic stroke caused by large vessel occlusion. Radiation exposure to the patient and operators during mechanical thrombectomy procedures is a concern. METHODS: The use of a high frames per second unmasked protocol-cineangiography (CINE)-derived from cardiac intervention could mitigate radiation exposure without sacrificing procedural and clinical outcomes. RESULTS: The analysis of a prospective-maintained monocentric database of 131 patients who underwent mechanical thrombectomy (65 with the CINE protocol and 66 with the conventional digital subtraction angiography (DSA) protocol) showed a significant reduction in radiation exposure for both air kerma (AK) and dose-area product (DAP) indicators (AK 463.7 mGy vs 772 mGy, P<0.01; DAP 41.35 Gy/cm2 CINE vs 83.77 Gy/cm2 DSA, P<0.01), with no differences regarding both safety and efficacy outcomes (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2b 78.4% CINE and 81.5% DSA, P=0.79; overall complications rate both intracranial and extracranial 23% CINE and 19.6% DSA, P=0.65). There were no significant differences in post-thrombectomy radiographic hemorrhagic conversion rate (P=0.77) or functional independence on discharge defined as modified Rankin Scale score ≤2 (P=0.39). A post-hoc image assessment of vessel point occlusion and recanalization mTICI score performed by three experienced interventional neuroradiologists not involved in the procedure showed a non-significant difference between the two groups regarding occlusion point (0.928 vs 0.953, P=0.31) and recanalization grade (0.814 vs 0.847, P=0.62). CONCLUSIONS: Our initial experience demonstrated that reduction of the quality of CINE images caused no modifications in safety and efficacy and should fit within the context of diagnostic requests in an intracranial revascularization procedure.

A "Radial Ready" Tricoaxial Setup for Anterior Circulation Mechanical Thrombectomy: Technical Aspects and Preliminary Results.

PURPOSE: Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke (AIS) due to large vessel occlusion (LVO). The choice of a transradial approach (TRA) for anterior circulation LVOs is still debatable; the use of a specific tricoaxial system could help mitigate numerous issues related to transradial MT. MATERIALS AND METHODS: From November 2022 to November 2023, 22 patients underwent TRA-MT for anterior circulation LVOs, both as first-line and rescue from transfemoral approach (TFA) failure, with the same triaxial setup consisting of a 7F introducer sheath, 7F guide catheter, and aspiration catheters ranging from 5.5F to 5F in relation to the occlusion site. Choice of thrombectomy technique was at operator discretion. Patients' demographic data, clinical presentation, treatment details, complications, rate of crossover to TFA, successful revascularization (modified thrombolysis in cerebral infarction [mTICI] score ≥2b), and good clinical outcome at 3 months (modified Rankin scale [mRS] 0-2) were reported. RESULTS: Of 20 patients selected, 10 (50%) had occlusion of M1 segment of middle cerebral artery (MCA), 6 (30%) of internal carotid artery (ICA) terminus, and 4 (20%) with M2 MCA occlusions; 12/20 (60%) were right-sided occlusions and 8/20 (40%) were left-sided. The mean National Institutes of Health Stroke Scale score was 9.25 at admission. Successful revascularization to mTICI 2b-3 was achieved in 18/20 patients (90%). Intracranial complications were reported in 2 (10%) patients. Rate of radial artery occlusion at 24 hours was 10,6%; no access-site haemorrhagic complications were reported. Symptomatic intracranial hemorrhage occurred in 2 (10%) patients. mRS score 0-2 at 3 months was 50%. CONCLUSION: The high technical effectiveness and good safety profile of this specific tricoaxial setup for TRA-MT in AIS, even for large proximal LVOs, could constitute a viable alternative to TFA-MT in selected cases.

5F SOFIA intermediate catheter in the treatment of acute ischemic stroke: A retrospective observational study.

BACKGROUND: We herein report our experience with the 5F SOFIA (Soft Torqueable catheter Optimized for Intracranial Access) intermediate catheter for endovascular treatment of patients with acute ischemic stroke (AIS) both in distal middle vessel occlusions (DMVOs) and in large vessel occlusions (LVOs) with unfavorable anatomy. METHODS: Records of forty-seven patients undergoing endovascular thrombectomy with 5F SOFIA between September 2020 and March 2022 were retrospectively reviewed. Patients' demographic data, clinical presentation, treatment details, and complications were recorded from the medical record. The primary outcomes were successful revascularization (modified treatment in cerebral ischemia, mTICI ≥2b) and good clinical outcome at 3 months (modified rankin scale, mRS 0-2). Secondary outcomes were complication rates and switch to alternative techniques. Our institutional review board approved this study. RESULTS: Forty-seven patients with AIS treated with 5F SOFIA were examined. In eighteen (38%) cases the occlusion was located on a large vessel while in 29 (61.7%) on a distal-medium vessels. Median national institutes of health strokes scale (NIHSS) score was 16 at admission. Successful revascularization to mTICI 2b-3 was achieved in 14 of 18 patients (77.7%) with LVOs and in 24/29 cases with DMVOs (82.7%) respectively. mRS score 0-2 at three months (3 months-mRS 0-2) was 66.6% for LVOs and 68.9% in DMVOs respectively. Symptomatic intracranial hemorrhage (SICH) occurred in 2 (4.2%) patients. CONCLUSION: 5F SOFIA intermediate catheter could be a safe and effective treatment for AIS and a viable alternative to 6 F conventional intermediate catheters in selected cases.

Single-stage endovascular treatment in aneurysmal subarachnoid haemorrhage with multiple intracranial aneurysms: Systematic review of the literature and multicentric retrospective experience.

OBJECTIVES: The presence of multiple intracranial aneurysms in patients with acute subarachnoid haemorrhage is a condition with no evidence of optimal treatment strategy, especially in case of uncertain haemorrhage patterns on cumputed tomography. The aim of this study was to analyse the safety and efficacy profile of single-stage endovascular treatment of multiple intracranial aneurysms with aneurysmal subarachnoid haemorrhage in the literature and in a retrospective case series. MATERIALS AND METHODS: A systematic review of the present literature was conducted to identify studies related to single-stage endovascular treatment for ≥2 aneurysms; in addition, a retrospective multicentric review was performed. Data on clinical presentation, aneurysm size and location, occlusion rates, intracranial complications and clinical outcome were recorded. RESULTS: Thirteen articles were identified (all little case series) reporting 189 patients harbouring 389 aneurysms. And 85.6% presented with a Hunt-Hess scale 1-3, and 14.4% 4-5. Intracranial complications rate was 11.5%. Baseline and follow-up (20.5 months) occlusion rates were adequate (Raymond-Roy occlusion scale I-II) in 93% and 96.2%, respectively. 81% of patients had favourable clinical outcomes (modified Rankin Scale (mRS) ≤2; Glasgow outcome scale (GOS) 5-4) and 19% poor (mRS 3-6; GOS 3-1). The retrospective database identified 53 patients with 115 aneurysms. Clinical presentation was Hunt-Hess (HH) 1-3/WNFS 1-2 75% and HH 4-5/WNFS 3-5 25%. Intracranial complication rate was 24.5%. Occlusion rate RROC I-II was 78.7% at baseline and 15 months and 90.2% at follow up. Clinical outcome at 3 months was mRS ≤2 68.6% and mRS 3-6 31.4%. CONCLUSIONS: Single-staged endovascular treatment can be feasible, although a higher risk of intraprocedural complications, with clinical presentation being the major factor to influence the outcome.

Overview of Spontaneous Intracranial Hypotension and Differential Diagnosis with Chiari I Malformation.

Spontaneous intracranial hypotension (SIH) occurs due to a leakage of the cerebrospinal fluid (CSF) lowering the pressure of subarachnoid space, mostly caused by a dural breach or discogenic microspur. As a result of less support provided by CSF pressure, intracranial structures are stretched downward, leading to a constellation of more or less typical MRI findings, including venous congestion, subdural effusions, brainstem sagging and low-lying cerebellar tonsils. Clinic examination and an MRI are usually enough to allow for the diagnosis; however, finding the location of the dural tear is challenging. SIH shares some MRI features with Chiari malformation type I (CM1), especially low-lying cerebellar tonsils. Since SIH is likely underdiagnosed, these findings could be interpreted as signs of CM1, leading to a misdiagnosis and an incorrect treatment pathway. Medical treatment, including steroids, bed rest, hydration caffeine, and a blind epidural blood patch, have been used in this condition with variable success rates. For some years, CSF venous fistulas have been described as the cause of SIH, and a specific diagnostic and therapeutic pathway have been proposed. The current literature on SIH with a focus on diagnosis, treatment, and differential diagnosis with CM1, is reviewed and discussed.

CSF-venous leak responsible for spontaneous intracranial hypotension treated by endovascular venous route: First cases in Italy.

Spontaneous intracranial hypotension (SIH) is due to a leakage of CSF lowering the pressure of subarachnoid space, mostly caused by a dural breach or discogenic microspur. Clinical and MRI are usually typical enough to allow diagnosis, while finding the location of the dural breach is challenging. Since some years, CSF venous fistulas have been described as the cause of SIH, and a specific diagnostic and therapeutic path has been proposed. Here we report the first two successfully treated patients in Italy. Both had chronic and non specific symptoms, with severe reduction of quality of life; clinical symptoms improved after endovascular occlusion of the responsible vein.

Ruptured Proximal Anterior Cerebral Artery Aneurysm Treated with Flow Diverter.

AIM: To discuss the use of flow modulation in treating ruptured aneurysms of the proximal segment of the anterior cerebral artery (A1 aneurysms). A1 aneurysms are rare, constituting approximately 1% of all intracranial aneurysms. CASE REPORT: We report a left A1 aneurysm with a wide neck and small sac (3 × 1.8 mm). In order to treat the lesion, a flow diverter (4 × 12?18 mm, FRED, Microvention) was placed from M1 to the proximal end of the paraophthalmic internal carotid artery, without directly covering the neck of the aneurysm. No procedural bleeding occurred. During stent deployment, abciximab was infused. A day after the procedure, double antiplatelet therapy was initiated for 1 month, followed by single antiplatelet therapy for another 3 months. Due to the aneurysm morphology, we opted for a competitive flow diversion, covering the parent artery origin and leaving the A1A neck uncovered. A decreased flow into the aneurysmal parent artery gradually promoted aneurysm sac thrombosis. Both digital subtraction angiography at a 12-month follow-up and computed tomography angiography 24-month follow-up confirmed the regular patency of the stent and resolution of the aneurysm. In addition, the competitive modulation of flow in the ipsilateral anterior cerebral artery results in the narrowing of the vessel. CONCLUSION: A1 aneurysm endovascular treatment is often challenging. Coiling or assisted coiling is the most frequently employed. Although flow diverter stent (FDS) is a consolidated technique for treating ruptured intracranial blister-like and dissecting aneurysms, its role in treating intracranial saccular ruptured aneurysms has to be elucidated. However, more number of case studies is needed to confirm the efficacy and safety of an FDS in treating ruptured A1 aneurysms.

Juvenile Angiofibroma: What Is on Stage?

OBJECTIVES/HYPOTHESIS: The aim of the present study is to validate and compare four of the most widely used staging systems for juvenile angiofibroma on a homogeneous cohort of patients. STUDY DESIGN: Retrospective case series. METHODS: A retrospective review of patients treated with endoscopic or endoscopic-assisted surgical resection between 1999 and 2020 was carried out. Each case was classified according to the following staging systems: Andrews-Fisch (1989), Radkowski (1996), University of Pittsburgh Medical Center (2010), and Janakiram (2017). Spearman's rank correlation test and areas under the curve of receiver operator curves were used to assess the correlation between outcomes of interests (blood loss, surgical time, need for transfusion, and persistence of disease) and stage of disease. RESULTS: Seventy-nine patients were included, with a median follow-up time of 25 months (range 12-127 months). Median surgical time was 217 minutes (range 52-625). Median blood loss was 500 mL (range 40-5200) and 27 patients (34.2%) required blood transfusions. Seven patients (8.9%) showed persistence of disease. All classification systems showed a similar association with blood loss, surgical time, persistence of disease, and need for transfusion. CONCLUSIONS: Involvement of the infratemporal fossa and intracranial extension was identified as red flags for surgical planning and preoperative counseling, as associated with increased risk for transfusion and persistent/recurrent disease, respectively. No classification system was found to be better than the others in predicting the most important outcomes. Therefore, the simplest and most easily applicable system would be the preferred one to be used in clinical practice. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:1160-1165, 2022.

Twenty Years of Experience in Juvenile Nasopharyngeal Angiofibroma (JNA) Preoperative Endovascular Embolization: An Effective Procedure with a Low Complications Rate.

Juvenile nasopharyngeal angiofibroma (JNA) is a benign tumor of the nasal cavity that predominantly affects young boys. Surgical removal remains the gold standard for the management of this disease. Preoperative intra-arterial embolization (PIAE) is useful for reductions in intraoperative blood loss and surgical complications. In our series of 79 patients who underwent preoperative embolization from 1999 to 2020, demographics, procedural aspects, surgical management and follow-up outcome were analyzed. Embolization was performed in a similar fashion for all patients, with a superselective microcatheterization of external carotid artery (ECA) feeders and an injection of polyvinyl alcohol (PVA) particles, followed, in some cases, by the deployment of coils . Procedural success was reached in 100% of cases, with no complications such as bleeding or thromboembolic occlusion, and surgical intraoperative blood loss was significantly decreased. In conclusion, PIAE is a safe and effective technique in JNA treatment, minimizing intraoperative bleeding.

The beneficial effect of extracorporeal shockwave myocardial revascularization in patients with refractory angina.

OBJECTIVES: The incidence of patients with refractory angina (RA) is increasing. Medical therapy for RA is limited and prognosis is poor. Experimental data suggest that the use of Extracorporeal shockwave myocardial revascularization (ESMR) may contribute to angiogenesis and improve symptoms of angina in patients with RA. Purpose of our study is to determine the efficacy of cardiac shock wave therapy (ESMR) in the management of patients with nonrevascolarized coronary artery disease (CAD). METHODS: We performed a prospective cohort study to examine the efficacy of ESMR applcation in patients with RA despite optimal medical therapy, not suitable for further PCI or CABG. Characteristics such as angina class scores (CCS class score), nitroglycerin consumption and hospitalization rate among cases (patients with RA who received ESMR) and controls (patients with RA who did not receive ESMR) were compared at baseline and 6 months after ESMR therapy. In patients receiveing d ESMR the effect of on cardiac perfusion was assessed. RESULTS: There were 43 patients in the case group and 29 patients in the control group. The mean age of the patients was 70 ± 9.5 years in the case group and 71 ± 5.3 years in the control group. Other characteristics (diabetes, coronary artery bypass graft, percutaneus coronary intervention, baseline CCS class score) were similar in both groups. There was a significant improvement in CCS class score (1.33 ± 0.57 in cases and 1.92 ± 0.69 in controls; p = 0.0002), nitroglycerin consumption (20% in case cases, and 44.8% in controls; P < 0.03) and hospitalization rate significantly reduced (13.9% in case cases, and 37.9% in controls; P < 0.03). The patients who received ESMR, there was a significantly improvement in myocardial perfusion after 6 months with a 33% relative reduction of summed stress score (SSS) (p = 0.002). CONCLUSION: This case control study demonstrates the beneficial effect of ESMR therapy on cardiac symptoms, myocardial perfusion and reduced hospitalization in patients with refractory angina. Ther current study supports a role for ESMR as a non-invasive therapuetic option for patients with RA.