Initial Experience Performing Mechanical Thrombectomy With the CatchView Mini Device for Distal M2 Segment Middle Cerebral Artery Occlusions.

Background: Mechanical thrombectomy (MT) has become the standard of care for acute ischemic stroke due to large vessel occlusion; however, its safety and efficacy in patients with distal strokes remains unclear. In this study, we investigated the safety and efficacy of MT for distal middle cerebral artery (MCA) occlusions using the CatchView Mini (CVM; Balt, Montmorency, France). Methods: This was a prospective single-center analysis of patients with a single MCA-M2 occlusion treated with the CVM device. Consecutive patients were prospectively enrolled from October 2018 to March 2020. Efficacy outcomes included successful recanalization [modified Thrombolysis in Cerebral Infarction (mTICI) 2b/3], procedure times, and number of device passes. Clinical outcomes included National Institutes of Health Stroke Scale Score (NIHSS) at discharge, 90-day functional independence (modified Rankin Scale 0-2) and safety outcomes included hemorrhagic complications, and 90-day mortality. Results: A total of 45 patients (mean age: 74.0 ± 12.6; 53.3% [24/45] female) were included in the study. Upon admission, 33.3% (15/45) of patients were mRS 3-5; and mean NIHSS was 13.2 ± 4.2 Mean time from symptom onset to final angiography was 250.0 ± 83.4 min with a mean intervention duration of 34.0 ± 12.6 min. The mean number of device passes was 1.8 ± 1.5 final mTICI 2b/3 was achieved in 91.1% (41/45) of patients. Eight hemorrhagic complications (17.8%, 8/34) occurred, none of which were symptomatic. At 90-days, 57.8% (26/45) patients were functionally independent and the rate of mortality was 15.6% (7/45). Conclusions: The present analysis demonstrates a low risk profile and high recanalization success for patients with distal M2 occlusions treated with the CVM device.

Efficacy and Safety of Endovascular Treatment in Acute Tandem Carotid Occlusions: Analysis of a Single-Center Cohort.

INTRODUCTION: Acute ischemic strokes with tandem occlusions, which represent 10-20% of all ischemic strokes, have a particularly poor prognosis. Since emergent treatment of tandem lesions has not been specifically addressed in randomized trials, there is an absence of standardized management. OBJECTIVE: We sought to assess the efficacy and safety of acute endovascular treatment in stroke due to tandem occlusions in our center and compare the results with previous reports. METHODS: From a prospective registry we analyzed data of 99 consecutive patients (males: 77.7%, mean age ± SD: 67.5 ± 9.5 years) with stroke due to tandem occlusions who underwent treatment with emergent carotid stenting and intracranial mechanical thrombectomy. Successful recanalization was defined as a TICI score of 2b-3 and a good functional outcome was defined as a modified Rankin scale score ≤2 at 90 days. Symptomatic intracranial hemorrhage (sICH) was considered when associated with worsening on the National Institutes of Health Stroke Scale (≥4 points). RESULTS: A successful recanalization rate was achieved in 87.8 and 48.5% of the patients had a good functional outcome. sICH and mortality rates were 12.1 and 20.2%, respectively, and 21.2% of the patients received combined treatment with intravenous thrombolysis, which did not affect neither the prognosis nor the recanalization or sICH rates. The time from symptom onset to recanalization and the degree of recanalization were the main factors associated with prognosis and the occurrence of sICH. CONCLUSIONS: Our results suggest that endovascular treatment with emergent carotid stenting and intracranial thrombectomy in patients with acute stroke due to tandem occlusions is an effective and safe procedure.

Clinical Predictors of Hyperperfusion Syndrome Following Carotid Stenting: Results From a National Prospective Multicenter Study.

OBJECTIVES: The aim of the HISPANIAS (HyperperfusIon Syndrome Post-carotid ANgIoplasty And Stenting) study was to define CHS rates and develop a clinical predictive model for cerebral hyperperfusion syndrome (CHS) after carotid artery stenting (CAS). BACKGROUND: CHS is a severe complication following CAS. The presence of clinical manifestations is estimated on the basis of retrospective reviews and is still uncertain. METHODS: The HISPANIAS study was a national prospective multicenter study with 14 recruiting hospitals. CHS was classified as mild (headache only) and moderate-severe (seizure, impaired level of consciousness, or development of focal neurological signs). RESULTS: A total of 757 CAS procedures were performed. CHS occurred in 22 (2.9%) patients, in which 16 (2.1%) had moderate-severe CHS and 6 (0.8%) had mild CHS (only headache). The rate of hemorrhages was 0.7% and was associated with high mortality (20%). Pre-operative predictors of moderate-severe CHS in multivariate analysis were female sex (odds ratio [OR]: 3.24; 95% confidence interval [CI]: 1.11 to 9.47; p = 0.03), older patients (OR: 1.09; 95% CI: 1.01 to 1.17; p = 0.02), left carotid artery treated (OR: 4.13; 95% CI: 1.11 to 15.40; p = 0.03), and chronic renal failure (OR: 6.29; 95% CI: 1.75 to 22.57; p = 0.005). The area under the curve of this clinical and radiological model was 0.86 (95% CI: 0.81 to 0.92; p = 0.001). CONCLUSIONS: The rate of CHS in the HISPANIAS study was 2.9%, with moderate-severe CHS of 2.1%. CHS was independently associated with female sex, older age, history of chronic kidney disease, and a treated left carotid artery. Although further investigations are needed, the authors propose a model to identify high-risk patients and develop strategies to decrease CHS morbidity and mortality in the future.

Réplica: Valoración de la atrofia cerebral en la esclerosis múltiple mediante el índice de cuerpo calloso / Reply: Appraisal of cerebral atrophy in multiple sclerosis by means of the corpus callosum index

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Análisis de los costes directos asociados a la trombectomía mecánica y a la fibrinólisis intravenosa en el Hospital Universitario Central de Asturias / Analysis of the direct costs associated with mechanical thrombectomy and intravenous fibrinolysis in the Hospital Universitario Central de Asturias

Introducción. La ampliación de las indicaciones de la trombectomía mecánica y su implementación en los hospitales españoles hacen necesario conocer los costes relacionados con este tratamiento para racionalizar los recursos económicos y permitir una adecuada distribución de éstos. Objetivos. Analizar los costes directos asociados a los pacientes con ictus isquémico agudo tratados con fibrinólisis intravenosa y con trombectomía mecánica, y valorar la efectividad y seguridad de ambos tratamientos durante los primeros 90 días de evolución en el Hospital Universitario Central de Asturias. Pacientes y métodos. Se realizó un análisis retrospectivo en el que se incluyó a 44 pacientes que recibieron fibrinólisis intravenosa y a 61 pacientes tratados con trombectomía mecánica, en los que se analizaron una serie de variables clínicas y económicas. Resultados. El coste total final medio por paciente fue de 16.059 euros en los tratados con trombectomía y de 8.169 euros en los que se administró fibrinólisis intravenosa. El porcentaje de pacientes con buen pronóstico funcional a los 90 días fue del 63,93% en los tratados de forma endovascular y del 56,82% en los que recibieron fibrinólisis intravenosa. Las tasas de mortalidad fueron del 18,03% y 11,36%, respectivamente. Conclusiones. El coste medio del tratamiento con trombectomía mecánica, así como el coste medio total por paciente durante la fase aguda de la enfermedad asociado a esta técnica, es mayor que en el caso de la fibrinólisis intravenosa. Tanto la fibrinólisis intravenosa como la trombectomía mecánica se configuran en nuestro medio como tratamientos efectivos y seguros (AU)

Introduction. The increase in the indications for mechanical thrombectomy and its implementation in Spanish hospitals makes it necessary to determine the costs related to this treatment so as to be able to streamline economic resources and allow them to be distributed in an appropriate manner. Aims. To analyse the direct costs associated with patients with acute ischaemic stroke who are treated with intravenous fibrinolysis and with mechanical thrombectomy, and to assess the effectiveness and safety of both treatments during the first 90 days of progression in the Hospital Universitario Central de Asturias. Patients and methods. A retrospective analysis was performed that included 44 patients who received intravenous fibrinolysis and 61 patients treated with mechanical thrombectomy, in whom a series of clinical and economic variables were analysed. Results. The mean final total cost per patient was 16,059 euros in treatments with thrombectomy and 8,169 euros in those in which intravenous fibrinolysis was administered. The percentage of patients with a good functional prognosis at 90 days was 63.93% in those treated by endovascular means and 56.82% in those who received intravenous fibrinolysis. Mortality rates were 18.03 and 11.36%, respectively. Conclusions. The mean cost of treatment with mechanical thrombectomy, as well as the total mean cost per patient during the acute phase of the disease associated with this technique, is higher than in the case of intravenous fibrinolysis. In our setting, both intravenous fibrinolysis and mechanical thrombectomy are considered to be effective and safe (AU)

Valoración de la atrofia cerebral en la esclerosis múltiple mediante el índice de cuerpo calloso / Appraisal of cerebral atrophy in multiple sclerosis by means of the corpus callosum index

Introducción. La esclerosis múltiple se caracteriza en su evolución por el desarrollo de atrofia cerebral. Su monitorización resulta de interés para evaluar la respuesta al tratamiento, y son de elección los análisis volumétricos cerebrales, actualmente confinados al ámbito de la investigación. Objetivo. Analizar el índice de cuerpo calloso (ICC) como una posible alternativa a los métodos basados en la segmentación cerebral. Sujetos y métodos. Se reúne a 109 pacientes con enfermedades desmielinizantes de reciente diagnóstico (90 con esclerosis múltiple remitente recurrente, 7 con formas primarias progresivas y 12 con síndrome desmielinizante aislado) y se calcula el ICC en su primer estudio de resonancia magnética cerebral, así como en 101 controles sanos. Las secuencias de los pacientes se someten a análisis volumétrico mediante el programa MSmetrix. Resultados. El valor medio del ICC es de 0,377 en los pacientes y 0,411 en los controles, y la diferencia es estadísticamente significativa (p < 0,001). El ICC muestra una correlación estadísticamente significativa con el volumen encefálico (p < 0,001; r = 0,444) y con el volumen lesional en secuencia FLAIR (p < 0,001; r = -0,521), mientras que no se demuestra asociación con el volumen de la sustancia gris (p = 0,058). Conclusiones. El ICC se relaciona con el volumen encefálico global obtenido mediante técnicas volumétricas y puede reflejar la presencia de atrofia ya en los estadios iniciales de las enfermedades desmielinizantes, por lo que se presenta como una alternativa de rápido y sencillo cálculo

Introduction. The course of multiple sclerosis is characterised by the development of cerebral atrophy. It is of interest to monitor it in order to evaluate the treatment response, and the preferred technique consists in performing brain volume analyses, which are currently restricted to the field of research. Aim. To analyse the corpus callosum index (CCI) as a possible alternative to the methods based on brain segmentation. Subjects and methods. Our sample was made up of 109 patients with recently diagnosed demyelinating diseases (90 relapsing-remitting multiple sclerosis, 7 primary progressive forms and 12 isolated demyelinating syndromes), and the CCI was calculated in their first magnetic resonance brain scan, together with 101 healthy controls. The sequences of the patients were submitted to a volumetric analysis using the software package MSmetrix. Results. The mean value of the CCI was 0.377 in patients and 0.411 in the controls, and the difference was statistically significant (p < 0.001). The CCI also showed a statistically significant correlation with the brain volume (p < 0.001; r = 0.444) and with the lesional volume in the FLAIR sequence (p < 0.001; r = -0.521), while no association was observed with the volume of grey matter (p = 0.058). Conclusions. The CCI is related to the overall brain volume obtained by volumetric techniques and may reflect the presence of atrophy in the initial stages of demyelinating diseases, which makes it a fast and easy to calculate alternative

Superficial middle cerebral artery territory infarction.

The superficial middle cerebral artery (MCA) territory includes the greater part of the lateral surface of the cerebral hemisphere. It is the most frequent infarct in MCA ischemic cerebrovascular pathology. It is divided into 12 areas supplied by 12 different arteries referred to as the irrigated areas; however, anatomical variations should be considered in these infarcts. Clinical symptomatology depends on the artery affected (changes in personality, judgment or motor synchronization disturbances, disorientation, hemianopia or hemineglect), but more frequently there is an overlapping of artery infarcts (insular syndrome and sensitive, motor or language disturbances). Embolic mechanism remains the main etiology of these infarcts, but due to different etiological mechanisms of ischemic stroke, an extensive neurovascular and cardiological assessment is essential for the correct treatment of the patient.

[Endovascular treatment of carotid stenosis: an experience in the Hospital Universitario Central de Asturias]. / Tratamiento endovascular de la estenosis carotídea: experiencia en el Hospital Universitario Central de Asturias.

INTRODUCTION: Carotid stenosis accounts for about 25% of all ischaemic cerebrovascular events. Carotid angioplasty and stenting (CAS) is a minimally invasive procedure used as an alternative to carotid endarterectomy, especially in high surgical risk patients. AIM: To analyse the effectiveness and safety of the endovascular treatment of carotid stenosis in the Hospital Universitario Central de Asturias. PATIENTS AND METHODS: The study consisted in a retrospective analysis of the carotid stenoses treated by means of CAS between February 2005 and April 2010, and the following information was recorded: demographic data, clinical diagnosis, indication of treatment, time between the onset of symptoms and beginning of treatment, angiographic findings, complications and long-term follow-up (including the rate of restenosis). RESULTS: Altogether 121 patients were treated (77.8% males and 22.2% females), with a mean age of 70.8 ± 10.7 years. The main vascular risk factors were arterial hypertension (65.3%), smoking (61.2%) and dyslipidaemia (42.1%). In 86% of cases the stenoses were symptomatic and in the remaining 14% they were asymptomatic. In 60.3% of cases they were stenoses > 70%, in 30.6% they were preocclusive stenoses and in 9.1% they were recanalisations of unstable carotid occlusions. The mean treatment time was 17.0 ± 8.3 days after the ischaemic event. The residual stenosis was less than 30% in all cases. The morbidity and mortality rate at 30 days was 4.1% and the rate of restenosis throughout a mean follow-up of 31.2 ± 10.8 months was 2.4%. CONCLUSIONS: In our hospital CAS is considered an effective and safe technique, with a rate of complications that is within the parameters that justify its indication.

¿Es poco eficaz la prevención secundaria en los infartos cerebrales? / Is secondary prevention inefficient in cerebral infarcts?

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¿Cuál es el futuro de los infartos isquémicos de la arteria cerebral media? / What is the future of medium cerebral artery is chemic strokes?

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