Cervical radiculopathy secondary to vertebral artery dissection: clinical features and outcomes.

PURPOSE: Cervical radiculopathy due to various mechanical causes is commonly seen, however, cervical vertebral artery dissection (cVAD)-related radiculopathy is very rare with poorly characterized clinical outcomes. Thus, we conducted a systematic review of published literature and reported an institutional case to provide a better illustration of this rare entity. METHODS: We systematically reviewed the PubMed literature and queried the clinical database at our center for cVAD-related radiculopathy. We described the baseline characteristics of patients with cVAD-related radiculopathy, the involved segment, diagnostic approach and treatment options. RESULT: 14 previously published studies met the inclusion criteria and along with the case we identified in our center, our study included 17 patients total (median age: 35 years, 9 females). C5 was the most commonly affected root and ipsilateral shoulder/arm pain along with shoulder abduction weakness was most common presentation. Antiplatelet or anticoagulant therapy was the treatment of choice. Most cases managed conservatively (82%). Majority of the cases (92%) had either complete or partial resolution of their symptoms. CONCLUSION: Despite its limitations, this study show that cVAD related radiculopathy is a relatively benign entity with excellent clinical outcomes when managed medically.

Acute intracranial stenting in acute ischemic stroke with underlying atherosclerosis: A two-center retrospective study.

OBJECTIVE: In patients with large vessel occlusion, successful reperfusion is a predictor of favorable outcome. However, patients with underlying intracranial atherosclerotic disease (ICAD) show higher rates of immediate reocclusion, frequently requiring rescue stenting. We aimed to investigate the safety, efficacy, and outcome of acute stenting in acute stroke patients with underlying ICAD. METHODS: Prospective databases from two centers between 2012 and 2021 were reviewed. Adult patients who underwent ICAD-related acute intracranial stenting, after mechanical thrombectomy (MT) were included. Clinical and procedural data, technical success measured by Modified Thrombolysis in Cerebral Infarction score, periprocedural complications, stent restenosis, and follow up mRS at three months were evaluated. RESULTS: During a 10-year period, a total of 96 patients with acute stroke and intracranial atherosclerotic steno-occlusive lesions underwent stenting after MT. Mean age was 63 (SD 14) and 54 patients were male (56.3%). Successful reperfusion (TICI ≥ 2b) was achieved in 86 patients (89.6%) following rescue stenting; favorable clinical outcome (mRS < 3) was observed in 32 patients (37.6%). Symptomatic intracranial hemorrhage and mortality were observed in 9.5% and 22.4% of patients, respectively. Multivariate regression yielded older age (OR: 0.477, 95% CI: 0.933-0.999, p=0.046) as an independent negative predictor of favorable functional outcome after acute intracranial stenting. CONCLUSION: Our results suggest that acute intracranial stenting is safe and effective as a rescue treatment after MT in acute stroke patients with underlying ICAD. Younger age was found as an independent predictor of good outcome. Nevertheless, ICAD still carries a high mortality and poor functional clinical outcome.

Management of intracranial arterial stenosis during mechanical thrombectomy: Survey of neuro-interventionalists.

BACKGROUND: The optimal management of emergent large vessel occlusion due to underlying intracranial stenosis (intracranial stenosis related large vessel occlusion) remains unknown. The primary aim of this survey analysis was to measure variation in the clinical management of intracranial stenosis related large vessel occlusion during mechanical thrombectomy. METHODS: A survey was designed using a web-based survey-building platform and distributed via the Society of NeuroInterventional Surgery (SNIS) and the Society of Vascular and Interventional Neurology (SVIN) websites for a response. Predictors of respondents' level of comfortability stenting were estimated using a binomial logistic regression model. RESULTS: We received 105 responses to the survey. Most respondents (54.3%) practiced at an academic Stroke Center. Nearly half of the respondents (49%) had been practicing for 5 or more years independently after fellowship. An average of 54 mechanical thrombectomies were performed by each respondent annually. There was variation in the definition of intracranial stenosis related large vessel occlusion, number of passes performed before pursuing rescue stenting, as well as intra and post-procedural antiplatelet management. Of respondents, 58% felt rescue stenting was very risky, and 55.7% agreed that there was equipoise regarding emergent angioplasty and/or stenting versus medical therapy for intracranial stenosis related large vessel occlusion. Respondents who encountered intracranial stenosis related large vessel occlusion more frequently thought that rescue stenting was less risky. CONCLUSION: There is notable variability in the diagnosis and management of intracranial stenosis related large vessel occlusion during mechanical thrombectomy. While most respondents felt rescue stenting was risky, the majority believed the benefit could outweigh the risk. The majority of respondents agreed that equipoise exists regarding the management of intracranial stenosis related large vessel occlusion, highlighting the need for clinical trials in this rare patient population.

Predictors and outcomes of first pass efficacy in posterior circulation strokes: Insights from STAR collaboration.

Background: First-pass efficacy (FPE) has been established as an important predictor of favorable functional outcomes after endovascular thrombectomy (ET) in anterior circulation strokes. In this retrospective cohort study, we investigate predictors and clinical outcomes of FPE in posterior circulation strokes (pcAIS). Methods: The Stroke Thrombectomy and Aneurysm Registry database was used to identify pcAIS patients who achieved FPE. Their baseline characteristics and outcomes were compared with the non-FPE group. The primary outcome was a 90-day modified Rankin Scale (mRS) of 0-3. Univariate (UVA) and multivariate (MVA) analyses were done to evaluate predictors of FPE. Safety outcomes included distal emboli, vessel rupture, symptomatic intracranial hemorrhage, and mortality. Results: Of 359 patients, 179 (50%) achieved FPE. Clot burden, occlusion site, and ET technique-related variables were similar between the two groups except for shorter procedure time with FPE. The primary outcome was significantly better with FPE (56.4% vs. 32.8%, p < 0.001). Complications were similar except for a higher rate of distal emboli in non-FPE group (11.1% vs. 3.2%, p = 0.032). Atrial fibrillation (Afib) had increased odds (aOR: 2.06, 95% CI; 1.24, 3.4, p = 0.005) and prior ischemic stroke had decreased odds (aOR: 0.524, 95% CI; 0.28, 0.97, p = 0.04) of FPE. Afib was the only independent predictor of FPE on MVA (1.94, 95% CI; 1.1, 3.43, p = 0.022). Conclusions: Higher rate of FPE in Afib-related pcAIS could possibly be explained by the differences in clot composition and degree of in-situ atherosclerotic disease burden. Future studies are warranted to explore the relationship of clot composition with ET outcomes.

Carotid artery revascularization: endarterectomy versus endovascular therapy.

Carotid endarterectomy is considered the gold standard for primary and secondary stroke prevention in patients with asymptomatic and symptomatic carotid artery stenosis. The role of CEA has been defined by multiple randomized multicenter trials and CEA is the most studied surgical procedure. In recent years, with advances in endovascular techniques, carotid angioplasty, and stenting (CAS) has been proposed as an alternative to CEA especially in high-risk patients. In this article, we review some of the most important trials on the invasive treatment of carotid artery stenosis and summarized the most recent treatment recommendations based on current evidence. The data overwhelmingly supports revascularization of patients with symptomatic stenosis between 70-90%, with a clear preference for CEA over CAS to be done within 14 days of symptom onset is possible. However, CAS is an acceptable alternative to CEA in certain symptomatic patients such as those with severe medical comorbidities, high riding plaques, contralateral occlusion, restenosis after prior CEA, and radiation-induced stenosis. Treatment of asymptomatic patients remains controversial because of advanced of modern medical therapy and large trials are underway to define the role of invasive revascularization in these patients.