Prevalence, clinical features, and radiological pattern of artery of Percheron infarction: a challenging diagnosis.

PURPOSE: Occlusion of artery of Percheron (AOP), a rare variant of paramedian branches of posterior cerebral artery, results in a characteristic pattern of ischemic lesions in bilateral paramedian thalami with or without midbrain and anterior thalami involvement. AIM: To evaluate the prevalence, the clinical, and the imaging features of AOP infarction in a single comprehensive stroke center experience. METHODS: We retrospectively search in our stroke center database, patients with ischemic lesions in the AOP distribution. We collected clinical features and time between hospital admission and diagnosis. Imaging findings were categorized following a pre-selected classification. RESULTS: Of 2830 ischemic stroke admitted in our center, we identified 15 patients with AOP infarction (0.53%). Clinical manifestations were variable, but oculomotor disturbances, particularly vertical gaze palsy, were the most observed, followed by consciousness impairment, varying from drowsiness to coma. The most frequent imaging pattern was bilateral paramedian thalamic infarction with midbrain infarction, and the V-sign was recognized in 6 cases from this group. In 8 patients a fetal origin of the PCA was observed. The average time from first hospital admission to diagnosis was 28.09 h. CONCLUSIONS: The prevalence of AOP infarction in our center was 0.53%. Diagnosis of AOP infarction can be challenging and should be suspected in case of sudden altered consciousness.

Repeated reperfusion treatment in recurrent ischemic stroke: A retrospective single-center case series.

Data regarding repeated reperfusion therapy (rRT) in acute ischemic stroke (AIS), including intravenous thrombolysis and endovascular treatment (EVT), are quite poor. To date, there are only few case reports and five larger studies on repeated EVT. We aimed to report our single-center experience and describe different clinical scenarios of recurrent AIS with emergent large vessel occlusion (LVO), for which the decision-making process could be challenging in the emergency setting. We retrospectively reviewed 765 consecutive AIS patients with LVO, who underwent reperfusion procedures at our comprehensive stroke center, from 2014 to 2020, and identified rRT patients. We identified and reviewed the medical records of eight patients (1.05%), who repeated reperfusive treatment for recurrent stroke within 30 days (early arterial reocclusion, EAR) and after 30 days (late arterial reocclusion, LAR). We assigned collected data to three clinical scenarios, each divided into EAR and LAR cases. All patients had recurrent emergent LVO in the same vessel territory previously affected, both in EAR and LAR patients. A good clinical outcome has been achieved in EAR patients (modified Rankin Score ≤ 2). Artery-to-artery embolic mechanism was more common in the EAR group, while LAR was more frequently associated with cardioembolic source. RRT appears to be an effective treatment option for recurrent LVO, and it should not be withheld in carefully selected patients. EVT should be considered, including aspiration-only and stenting procedures in patients with AIS and recurrent LVO after previous reperfusive treatments, even after a very short time.

Vascular pattern and radiological follow up in a case of pontine warning syndrome.

Pontine warning syndrome (PWS) is a condition characterized by crescendo transient ischemic attacks due to pontine ischemia. The reported case described a 72-year-old woman who presented repetitive sudden episodes of double vision, impaired balance, slurred speech and right-sided weakness. Neurological deficits lasted a few minutes-hours and disappeared during the first seven days after onset. On the 1st day, MRI revealed acute left paramedian pontine infarction with focal swelling. Supra-aortic vessel imagining revealed bilateral internal carotid stenosis of 50%; hypoplasia of the left vertebral artery. On the 7th day, MRI showed a tissue swelling reduction, and from that day, she had no symptoms. These clinical and radiological features were suggestive of PWS. Our patient presented a particular vascular pattern that could favour symptoms fluctuation. We performed a close MRI follow up and it allowed us to observe a clinical stabilization in association with edema reduction.

Variants of the circle of Willis in ischemic stroke patients.

PURPOSE: We aim to provide prevalence and pattern of anatomical variants of circle of Willis in over one thousand ischemic stroke patients compared to an age- and sex-matched control group, and to determine their role in the severity and in-hospital prognosis. METHODS: Two groups of neuroradiologists evaluated all vascular images of ischemic stroke patients and controls to identify anatomical variants using a preexisted classification. We collected data concerning patient characteristics, stroke severity on admission and discharge, in-hospital mortality, hemorrhagic transformation, acute treatment performed, and etiology. RESULTS: We included 1131 patients with acute ischemic stroke and 562 controls. Among stroke patients, 702 (62.1%) had one or more vascular variants, compared to 308 (54.8%) of the control group (p < 0.01), 165/702 (23.5%) had an anterior circulation variant only, 384/702 (54.7%) had a posterior circulation variant only, and 153/702 (21.8%) patients had variants in both anterior and posterior circulation. Patients with variants were older (69.7 ± 13.9 years vs 72.0 ± 12.9 years; p = 0.039). The most prevalent variant was the agenesis/hypoplasia of the ACA (201/1131; 17.8%) followed by the unilateral fetal type of the PCA (137/1131; 12.11%). CONCLUSIONS: We provided the prevalence and the pattern of the brain vascular variants of the circle of Willis in a cohort of patients with ischemic stroke. The prevalence of variants was higher in stroke patients compared to controls. Patients with variants were older but had no differences in sex, neurological admission severity, hemorrhagic transformation, etiology, and in-hospital outcome compared to patients with a typical circle of Willis.

Mechanical Thrombectomy for Acute Intracranial Carotid Occlusion with Patent Intracranial Arteries : The Italian Registry of Endovascular Treatment in Acute Stroke.

PURPOSE: Intracranial carotid artery occlusion represents an underinvestigated cause of acute ischemic stroke as well as an indication for mechanical thrombectomy. We investigated baseline and procedural characteristics, outcomes and predictors of outcome in patients with acute ischemic stroke secondary to intracranial carotid artery occlusion. METHODS: A retrospective analysis of the Italian Registry of Endovascular Treatment in Acute Stroke was performed. Patients with intracranial carotid artery occlusion (infraclinoid and supraclinoid) with or without cervical artery occlusion but with patent intracranial arteries were included. The 3­month functional independence, mortality, successful reperfusion and symptomatic intracranial hemorrhage were evaluated. RESULTS: Intracranial carotid artery occlusion with patent intracranial arteries was diagnosed in 387 out of 4940 (7.8%) patients. The median age was 74 years and median baseline National Institute of Health Stroke Scale (NIHSS) was 18. Functional independence was achieved in 130 (34%) patients, successful reperfusion in 289 (75%) and symptomatic intracranial hemorrhage in 33 (9%), whereas mortality occurred in 111 (29%) patients. In univariate analysis functional independence was associated with lower age, lower NIHSS at presentation, higher rate of successful reperfusion and lower rate of symptomatic intracranial hemorrhage. Multivariable regression analysis found age (odds ratio, OR:1.03; P = 0.006), NIHSS at presentation (OR: 1.07; P < 0.001), diabetes (OR: 2.60; P = 0.002), successful reperfusion (OR:0.20; P < 0.001) and symptomatic intracranial hemorrhage (OR: 4.17; P < 0.001) as the best independent predictors of outcome. CONCLUSION: Our study showed a not negligible rate of intracranial carotid artery occlusion with patent intracranial arteries, presenting mostly as severe stroke, with an acceptable rate of 3­month functional independence. Age, NIHSS at presentation and successful reperfusion were the best independent predictors of outcome.

Complications of mechanical thrombectomy for acute ischemic stroke: Incidence, risk factors, and clinical relevance in the Italian Registry of Endovascular Treatment in acute stroke.

BACKGROUND: There are limited data concerning procedure-related complications of endovascular thrombectomy for large vessel occlusion strokes. AIMS: We evaluated the cumulative incidence, the clinical relevance in terms of increased disability and mortality, and risk factors for complications. METHODS: From January 2011 to December 2017, 4799 patients were enrolled by 36 centers in the Italian Registry of Endovascular Stroke Treatment. Data on demographic and procedural characteristics, complications, and clinical outcome at three months were prospectively collected. RESULTS: The complications cumulative incidence was 201 per 1000 patients undergoing endovascular thrombectomy. Ongoing antiplatelet therapy (p < 0.01; OR 1.82, 95% CI: 1.21-2.73) and large vessel occlusion site (carotid-T, p < 0.03; OR 3.05, 95% CI: 1.13-8.19; M2-segment-MCA, p < 0.01; OR 4.54, 95% CI: 1.66-12.44) were associated with a higher risk of subarachnoid hemorrhage/arterial perforation. Thrombectomy alone (p < 0.01; OR 0.50, 95% CI: 0.31-0.83) and younger age (p < 0.04; OR 0.98, 95% CI: 0.97-0.99) revealed a lower risk of developing dissection. M2-segment-MCA occlusion (p < 0.01; OR 0.35, 95% CI: 0.19-0.64) and hypertension (p < 0.04; OR 0.77, 95% CI: 0.6-0.98) were less related to clot embolization. Higher NIHSS at onset (p < 0.01; OR 1.04, 95% CI: 1.02-1.06), longer groin-to-reperfusion time (p < 0.01; OR 1.05, 95% CI: 1.02-1.07), diabetes (p < 0.01; OR 1.67, 95% CI: 1.25-2.23), and LVO site (carotid-T, p < 0.01; OR 1.96, 95% CI: 1.26-3.05; M2-segment-MCA, p < 0.02; OR 1.62, 95% CI: 1.08-2.42) were associated with a higher risk of developing symptomatic intracerebral hemorrhage compared to no/asymptomatic intracerebral hemorrhage. The subgroup of patients treated with thrombectomy alone presented a lower risk of symptomatic intracerebral hemorrhage (p < 0.01; OR 0.70; 95% CI: 0.55-0.90). Subarachnoid hemorrhage/arterial perforation and symptomatic intracerebral hemorrhage after endovascular thrombectomy worsen both functional independence and mortality at three-month follow-up (p < 0.01). Distal embolization is associated with neurological deterioration (p < 0.01), while arterial dissection did not affect clinical outcome at follow-up. CONCLUSIONS: Complications globally considered are not uncommon and may result in poor clinical outcome. Early recognition of risk factors might help to prevent complications and manage them appropriately in order to maximize endovascular thrombectomy benefits.

Endovascular Thrombectomy for Acute Ischemic Stroke Beyond 6 Hours From Onset: A Real-World Experience.

BACKGROUND AND PURPOSE: To evaluate outcome and safety of endovascular treatment beyond 6 hours of onset of ischemic stroke due to large vessel occlusion in the anterior circulation, in routine clinical practice. METHODS: From the Italian Registry of Endovascular Thrombectomy, we extracted clinical and outcome data of patients treated for stroke of known onset beyond 6 hours. Additional inclusion criteria were prestroke modified Rankin Scale score ≤2 and ASPECTS score ≥6. Patients were selected on individual basis by a combination of CT perfusion mismatch (difference between total hypoperfusion and infarct core sizes) and CT collateral score. The primary outcome measure was the score on modified Rankin Scale at 90 days. Safety outcomes were 90-day mortality and the occurrence of symptomatic intracranial hemorrhage. Data were compared with those from patients treated within 6 hours. RESULTS: Out of 3057 patients, 327 were treated beyond 6 hours. Their mean age was 66.8±14.9 years, the median baseline National Institutes of Health Stroke Scale 16, and the median onset to groin puncture time 430 minutes. The most frequent site of occlusion was middle cerebral artery (45.1%). Functional independence (90-day modified Rankin Scale score, 0-2) was achieved by 41.3% of cases. Symptomatic intracranial hemorrhage occurred in 6.7% of patients, and 3-month case fatality rate was 17.1%. The probability of surviving with modified Rankin Scale score, 0-2 (odds ratio, 0.58 [95% CI, 0.43-0.77]) was significantly lower in patients treated beyond 6 hours as compared with patients treated earlier No differences were found regarding recanalization rates and safety outcomes between patients treated within and beyond 6 hours. There were no differences in outcome between people treated 6-12 hours from onset (278 patients) and those treated 12 to 24 hours from onset (49 patients). CONCLUSIONS: This real-world study suggests that in patients with large vessel occlusion selected on the basis of CT perfusion and collateral circulation assessment, endovascular treatment beyond 6 hours is feasible and safe with no increase in symptomatic intracranial hemorrhage.

Recurrent intracranial hemorrhage and cerebral venous sinus thrombosis: an atypical case of Neuro-Behçet's Syndrome.

We report the case of a 22-year-old man with an history of headaches, seizures, cognitive impairment associated with recurrent intracranial hemorrhage (ICH), acute ischemic stroke (AIS), worsened over the last eighteen months for a new onset of uveitis and cerebral venous sinus thrombosis (CVST). After excluding common causes of lobar ICH, and some rare ones according to the diagnostic protocol proposed by Beuker et al, in the suspicion of Primary Angiitis of the Central Nervous System (PACNS), the gradual development of a low-grade fever, a cutaneous rash, and a papulopustular manifestation on lower back after rachicentesis (pathergy phenomenon), allowed us to make a diagnosis of Neuro-Behçet's Syndrome (NBS) without oral/genital aphthous ulcerations, according to the International Study Group for Behçet's Disease classification criteria for BD (ICBD).

Acute Stroke Treatment in Patients with Basilar Artery Occlusion: A Single-Center Observational Study.

BACKGROUND: Acute ischemic stroke (AIS) due to basilar artery occlusion (BAO) represents 1-4% of all ischemic strokes. BAO results in strokes associated with a high risk of a poor functional outcome and, in 86-95% of the untreated cases, it results in death because of the vital cerebral structures involved. Diagnosis can be delayed because of the variability in presenting symptoms, and acute treatment is often attempted even beyond 6 h from symptoms onset because of the high risk of a fatal prognosis. OBJECTIVE: In this observational study, we retrospectively analyzed patients with AIS due to BAO referred to the stroke center of the University Hospital of Messina. We aimed to assess prognostic factors and to evaluate the association between clinical outcome and posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) and collateral status. METHOD: BAO was confirmed by cerebral computed tomography (CT) angiography or cerebral angiography. All patients underwent CT scan and magnetic resonance imaging (MRI). We assessed the pc-ASPECTS on diffusion-weighted imaging (DWI) MR images and the Posterior Circulation Collateral Score (PC-CS) for every patient. Functional outcome was assessed at 3 months using the modified Rankin Scale (mRS). RESULTS: The study population consisted of 27 patients; 16 males and 11 females. The mean age was 66 (±14) years. We observed a favorable outcome (mRS 0-3) in 40.7% of cases, 25.9% reached mRS 0-2, and 29.6% had a poor clinical outcome (mRS 4-5). Patient survival was 70.4%, whereas 8 patients died (29.6%). In 7 patients, pc-ASPECTS was ≥7. According to the PC-CS, 33.3% had moderate collaterals and 63.0% had good collateral status prior to receiving the treatment. Favorable outcome was significantly associated with age, NIHSS score at admission, pc-ASPECTS, hypercholesterolemia, and female sex but not with the other risk factors. CONCLUSIONS: In our study, we found that younger age, low NIHSS score at admission, and high pc-ASPECTS, but not onset to treatment time, are associated with a favorable clinical outcome. Transferred patients did not have a significantly poorer outcome. These findings confirm that acute stroke treatment improves clinical outcome in BAO patients, in spite of a delayed diagnosis and an extended therapeutic window, considering lesion volume and localization in DWI MRI.