Treatment of Cerebral Vasospasm Following Aneurysmal Subarachnoid Hemorrhage using the Neurospeed Semi-compliant Balloon.

BACKGROUND AND PURPOSE: Cerebral vasospasm (CV) following aneurysmal subarachnoid hemorrhage (aSAH) may lead to morbidity and mortality. Endovascular mechanical angioplasty may be performed if symptomatic CV is refractory to noninvasive medical management. Off-label compliant remodelling balloons tend to conform to the course of the vessel, contrary to noncompliant or semi-compliant balloons. Our objective is to describe our initial experience with the semi-compliant Neurospeed balloon (approved for intracranial stenosis) in cerebral vasospasm treatment following aSAH. METHODS: All patients included in the prospective observational SAVEBRAIN PWI (NCT05276934 on clinicaltrial.gov) study who underwent cerebral angioplasty using the Neurospeed balloon for the treatment of medically refractory and symptomatic CV after aSAH were identified. Patient demographic information, procedural details and outcomes were obtained from electronic medical records. RESULTS: Between February 2022 and June 2023, 8 consecutive patients underwent CV treatment with the Neurospeed balloon. Angioplasty of 48 arterial segments (supraclinoid internal carotid artery, A1 and A2 segments of the anterior cerebral artery, M1 and M2 segments of the middle cerebral artery) was attempted and 44/48 (92%) were performed. The vessel diameter significantly improved following angioplasty (+81%), while brain hypoperfusion decreased (-81% of the mean TMax). There was no long-term clinical complication, 4% periprocedural complications occurred. CONCLUSION: The semi-compliant Neurospeed balloon is effective in the treatment of cerebral vasospasm following aSAH, bringing a new device into the armamentarium of the neurointerventionalist to perform intracranial angioplasty.

Prognostic value of early electrographic biomarkers of epileptogenesis in high-risk ischaemic stroke patients.

BACKGROUND AND PURPOSE: Post-stroke epilepsy (PSE) is frequent. Better prediction of PSE would enable individualized management and improve trial design for epilepsy prevention. The aim was to assess the complementary value of continuous electroencephalography (EEG) data during the acute phase compared with clinical risk factors currently used to predict PSE. METHODS: A prospective cohort of 81 patients with ischaemic stroke who received early continuous EEG monitoring was studied to assess the association of early EEG seizures, other highly epileptogenic rhythmic and periodic patterns, and regional attenuation without delta (RAWOD, an EEG pattern of stroke severity) with PSE. Clinical risk factors were investigated using the SeLECT (stroke severity; large-artery atherosclerosis; early clinical seizures; cortical involvement; territory of middle cerebral artery) scores. RESULTS: Twelve (15%) patients developed PSE. The presence of any of the investigated patterns was associated with a risk of epilepsy of 46%, with a sensitivity and specificity of 83% and 78%. The association remained significant after adjusting for the SeLECT score (odds ratio 18.8, interquartile range 3.8-72.7). CONCLUSIONS: It was found that highly epileptogenic rhythmic and periodic patterns and RAWOD were associated with the development of PSE and complemented clinical risk factors. These findings indicate that continuous EEG provides useful information to determine patients at higher risk of developing PSE and could help individualize care.

Severely Hypoperfused Brain Tissue Correlates with Final Infarct Volume Despite Recanalization in DMVO Stroke.

Objectives: We sought to assess whether there were any parameter(s) on baseline computed-tomography-perfusion (CTP) strongly correlating with final-infarct-volume, and infarct volume progression after endovascular recanalization of acute ischemic stroke (AIS) with primary distal, medium vessel occlusion (DMVO). Materials and Methods: We performed a retrospective analysis of consecutive AIS patients who were successfully recanalized by thrombectomy for DMVO. By comparing baseline CTP and follow-up MRI, we evaluated the correlation between baseline infarct and hypoperfusion volumes, and final infarct volume and infarct volume progression. We also examined their effect on good clinical outcome at 3 months (defined as an mRS score of 0 to 2). Results: Between January 2018 and January 2021, 38 patients met the inclusion criteria (76% [29/38] female, median age 75 [66-86] years). Median final infarct volume and infarct volume progression were 8.4 mL [IQR: 5.2-44.4] and 7.2 mL [IQR: 4.3-29.1] respectively. TMax > 10 sec volume was strongly correlated with both (r = 0.831 and r = 0.771 respectively, p < 0.0001), as well as with good clinical outcome (-0.5, p = 0.001). A higher baseline TMax > 10 sec volume increased the probability of a higher final-infarct-volume (r2 = 0.690, coefficient = 0.83 [0.64-1.00], p < 0.0001), whereas it decreased the probability of good clinical outcome at 3 months (odds ratio = -0.67 [-1.17 to -0.18], p = 0.008). Conclusion: TMax > 10 sec volume on baseline CTP correlates strongly with final infarct volume as well as with clinical outcome after mechanical thrombectomy for an AIS with DMVO.

Diagnosis and endovascular management of vasospasm after aneurysmal subarachnoid hemorrhage - survey of real-life practices.

BACKGROUND: Vasospasm and delayed cerebral ischemia (DCI) are the leading causes of morbidity and mortality after intracranial aneurysmal subarachnoid hemorrhage (aSAH). Vasospasm detection, prevention and management, especially endovascular management varies from center to center and lacks standardization. We aimed to evaluate this variability via an international survey of how neurointerventionalists approach vasospasm diagnosis and endovascular management. METHODS: We designed an anonymous online survey with 100 questions to evaluate practice patterns between December 2021 and September 2022. We contacted endovascular neurosurgeons, neuroradiologists and neurologists via email and via two professional societies - the Society of NeuroInterventional Surgery (SNIS) and the European Society of Minimally Invasive Neurological Therapy (ESMINT). We recorded the physicians' responses to the survey questions. RESULTS: A total of 201 physicians (25% [50/201] USA and 75% non-USA) completed the survey over 10 months, 42% had >7 years of experience, 92% were male, median age was 40 (IQR 35-46). Both high-volume and low-volume centers were represented. Daily transcranial Doppler was the most common screening method (75%) for vasospasm. In cases of symptomatic vasospasm despite optimal medical management, endovascular treatment was directly considered by 58% of physicians. The most common reason to initiate endovascular treatment was clinical deficits associated with proven vasospasm/DCI in 89%. The choice of endovascular treatment and its efficacy was highly variable. Nimodipine was the most common first-line intra-arterial therapy (40%). Mechanical angioplasty was considered the most effective endovascular treatment by 65% of neurointerventionalists. CONCLUSION: Our study highlights the considerable heterogeneity among the neurointerventional community regarding vasospasm diagnosis and endovascular management. Randomized trials and guidelines are needed to improve standard of care, determine optimal management approaches and track outcomes.

Crossed Cerebellar Diaschisis Worsens the Clinical Presentation in Acute Large Vessel Occlusion.

INTRODUCTION: Initial NIHSS in anterior large vessel occlusion (LVO) correlates partially with the hypoperfusion volume. We aimed at assessing the contribution of crossed cerebellar diaschisis (CCD) from the hypoperfused territory on LVO initial clinical deficit. METHODS: CCD was retrospectively identified by brain CT perfusion imaging (CTP) in patients with anterior LVO treated by mechanical thrombectomy from January 2017 to July 2021. CCD was defined by CTP parameter alteration in the contralateral cerebellar hemisphere to the LVO. NIHSS, clinical/perfusion variables, and CCD were included in regression models to assess their interrelationships. RESULTS: 206 patients were included. CCD was present in 90 patients (69%). NIHSS scores were higher on admission and at stroke discharge among patients with CCD (17.90 ± 6.1 vs. 11.4 ± 8.4, p < 0.001; 9.6 ± 7.7 vs. 6.6 ± 7.9, p = 0.049; respectively). Patients with a CCD had higher stroke volumes (118.2 ± 60.3 vs. 69.3 ± 59.7, p < 0.001) and lower rate of known atrial fibrillation (22% vs. 41%, p = 0.021). On multivariable logistic regression, CCD independently worsened the initial NIHSS (OR 4.85 [2.37-7.33]; p < 0.001). CONCLUSION: CCD is found in 69% of LVO on admission CTP, correlates with stroke volumes, and independently worsens initial NIHSS.

Global Impact of the COVID-19 Pandemic on Stroke Volumes and Cerebrovascular Events: A 1-Year Follow-up.

BACKGROUND AND OBJECTIVES: Declines in stroke admission, IV thrombolysis (IVT), and mechanical thrombectomy volumes were reported during the first wave of the COVID-19 pandemic. There is a paucity of data on the longer-term effect of the pandemic on stroke volumes over the course of a year and through the second wave of the pandemic. We sought to measure the effect of the COVID-19 pandemic on the volumes of stroke admissions, intracranial hemorrhage (ICH), IVT, and mechanical thrombectomy over a 1-year period at the onset of the pandemic (March 1, 2020, to February 28, 2021) compared with the immediately preceding year (March 1, 2019, to February 29, 2020). METHODS: We conducted a longitudinal retrospective study across 6 continents, 56 countries, and 275 stroke centers. We collected volume data for COVID-19 admissions and 4 stroke metrics: ischemic stroke admissions, ICH admissions, IVT treatments, and mechanical thrombectomy procedures. Diagnoses were identified by their ICD-10 codes or classifications in stroke databases. RESULTS: There were 148,895 stroke admissions in the 1 year immediately before compared with 138,453 admissions during the 1-year pandemic, representing a 7% decline (95% CI [95% CI 7.1-6.9]; p < 0.0001). ICH volumes declined from 29,585 to 28,156 (4.8% [5.1-4.6]; p < 0.0001) and IVT volume from 24,584 to 23,077 (6.1% [6.4-5.8]; p < 0.0001). Larger declines were observed at high-volume compared with low-volume centers (all p < 0.0001). There was no significant change in mechanical thrombectomy volumes (0.7% [0.6-0.9]; p = 0.49). Stroke was diagnosed in 1.3% [1.31-1.38] of 406,792 COVID-19 hospitalizations. SARS-CoV-2 infection was present in 2.9% ([2.82-2.97], 5,656/195,539) of all stroke hospitalizations. DISCUSSION: There was a global decline and shift to lower-volume centers of stroke admission volumes, ICH volumes, and IVT volumes during the 1st year of the COVID-19 pandemic compared with the prior year. Mechanical thrombectomy volumes were preserved. These results suggest preservation in the stroke care of higher severity of disease through the first pandemic year. TRIAL REGISTRATION INFORMATION: This study is registered under NCT04934020.

First-Pass Effect Predicts Clinical Outcome and Infarct Growth After Thrombectomy for Distal Medium Vessel Occlusions.

BACKGROUND: The first-pass effect in endovascular thrombectomy (EVT) has been associated with better clinical outcomes and decreased stroke progression in large vessel occlusion but has not been evaluated in distal, medium vessel occlusions (DMVOs). OBJECTIVE: To assess the impact on clinical outcome and stroke progression of the modified first-pass effect (defined as a successful first-pass [modified Thrombolysis In Cerebral Infarction 2b/2c/3] revascularization) in patients who underwent EVT for a primary DMVOs. METHODS: We collected data from consecutive patients who underwent EVT for a primary DMVO at a single large academic center. We compared the rate of good clinical outcome (modified Rankin Scale of 0-2 at 3 months) and stroke progression between patients who demonstrated modified first-pass effect (mFPE) vs those who did not (no-mFPE). RESULTS: Between January 2018 and January 2021, we included 60 patients who underwent EVT for an acute ischemic stroke with a primary DMVO. Overall, mFPE was achieved in 32% (19/60) of EVTs. The mFPE was associated with a higher rate of good clinical outcome compared with no-mFPE (89% vs 46%, odds ratio = 16.04 [2.23-115.39], P = .006 in multivariate analysis). Final stroke volume was less among mFPE patients (6.9 mL [4.7-13.6] vs 23 mL [14.6-47], P = .001) as was stroke progression (6.8 mL [4-12.1] vs 17.8 mL [8.1-34.9], P = .016). The mFPE was still associated with higher rates of good clinical outcome when compared with patients reaching an modified Thrombolysis In Cerebral Infarction score ≥2b in more than 1 pass (89% vs 53%; odds ratio = 7.37 [1.43-38.08], P = .017). CONCLUSION: The mFPE may be associated with better clinical outcomes and lower stroke progression in DMVO.

Cerebellar cognitive affective syndrome after acute cerebellar stroke.

Introduction: The cerebellum modulates both motor and cognitive behaviors, and a cerebellar cognitive affective syndrome (CCAS) was described after a cerebellar stroke in 1998. Yet, a CCAS is seldom sought for, due to a lack of practical screening scales. Therefore, we aimed at assessing both the prevalence of CCAS after cerebellar acute vascular lesion and the yield of the CCAS-Scale (CCAS-S) in an acute stroke setting. Materials and methods: All patients admitted between January 2020 and January 2022 with acute onset of a cerebellar ischemic or haemorrhagic first stroke at the CUB-Hôpital Erasme and who could be evaluated by the CCAS-S within a week of symptom onset were included. Results: Cerebellar acute vascular lesion occurred in 25/1,580 patients. All patients could complete the CCAS-S. A definite CCAS was evidenced in 21/25 patients. Patients failed 5.2 ± 2.12 items out of 8 and had a mean raw score of 68.2 ± 21.3 (normal values 82-120). Most failed items of the CCAS-S were related to verbal fluency, attention, and working memory. Conclusion: A definite CCAS is present in almost all patients with acute cerebellar vascular lesions. CCAS is efficiently assessed by CCAS-S at bedside tests in acute stroke settings. The magnitude of CCAS likely reflects a cerebello-cortical diaschisis.

Global Impact of the COVID-19 Pandemic on Cerebral Venous Thrombosis and Mortality.

BACKGROUND AND PURPOSE: Recent studies suggested an increased incidence of cerebral venous thrombosis (CVT) during the coronavirus disease 2019 (COVID-19) pandemic. We evaluated the volume of CVT hospitalization and in-hospital mortality during the 1st year of the COVID-19 pandemic compared to the preceding year. METHODS: We conducted a cross-sectional retrospective study of 171 stroke centers from 49 countries. We recorded COVID-19 admission volumes, CVT hospitalization, and CVT in-hospital mortality from January 1, 2019, to May 31, 2021. CVT diagnoses were identified by International Classification of Disease-10 (ICD-10) codes or stroke databases. We additionally sought to compare the same metrics in the first 5 months of 2021 compared to the corresponding months in 2019 and 2020 (ClinicalTrials.gov Identifier: NCT04934020). RESULTS: There were 2,313 CVT admissions across the 1-year pre-pandemic (2019) and pandemic year (2020); no differences in CVT volume or CVT mortality were observed. During the first 5 months of 2021, there was an increase in CVT volumes compared to 2019 (27.5%; 95% confidence interval [CI], 24.2 to 32.0; P<0.0001) and 2020 (41.4%; 95% CI, 37.0 to 46.0; P<0.0001). A COVID-19 diagnosis was present in 7.6% (132/1,738) of CVT hospitalizations. CVT was present in 0.04% (103/292,080) of COVID-19 hospitalizations. During the first pandemic year, CVT mortality was higher in patients who were COVID positive compared to COVID negative patients (8/53 [15.0%] vs. 41/910 [4.5%], P=0.004). There was an increase in CVT mortality during the first 5 months of pandemic years 2020 and 2021 compared to the first 5 months of the pre-pandemic year 2019 (2019 vs. 2020: 2.26% vs. 4.74%, P=0.05; 2019 vs. 2021: 2.26% vs. 4.99%, P=0.03). In the first 5 months of 2021, there were 26 cases of vaccine-induced immune thrombotic thrombocytopenia (VITT), resulting in six deaths. CONCLUSIONS: During the 1st year of the COVID-19 pandemic, CVT hospitalization volume and CVT in-hospital mortality did not change compared to the prior year. COVID-19 diagnosis was associated with higher CVT in-hospital mortality. During the first 5 months of 2021, there was an increase in CVT hospitalization volume and increase in CVT-related mortality, partially attributable to VITT.

Early Neurological Improvement Predicts Clinical Outcome After Thrombectomy for Distal Medium Vessel Occlusions.

Background and Purpose: Good clinical outcome predictors have been established in mechanical thrombectomy (MT) for acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). An early neurological improvement (ENI), defined as a reduction of ≥8 on the National Institutes of Health Stroke Scale (NIHSS), compared with the baseline score or an NIHSS of 0 or 1 at 24 h after MT, is a strong predictor of favorable outcome. We aimed to study the impact of ENI after MT for distal medium vessel occlusions (DMVO). Methods: We retrospectively analyzed the data of consecutive patients who underwent MT for a primary DMVO in one large academic center. We compared clinical outcomes between patients with DMVO stratified by ENI. Multivariate analyses were performed to determine the impact of ENI on good 90-day outcome (modified Rankin scale of 0-2) and identify factors contributing to ENI. Results: Between January 2018 and January 2021, 61 patients underwent an MT for an AIS with a primary DMVO. An ENI was seen in 24 (39%) patients (ENI+). Outcomes were significantly better in ENI+ patients, with 83% achieving a good outcome at 3 months vs. 43% for patients without ENI (ENI-; p = 0.019). ENI was an independent predictive factor of good clinical outcome even after adjusting for potential confounding factors [odds ratio 12.49 (1.49-105.01), p = 0.020]. The use of intravenous tissue plasminogen activator [IVtPA; Odds-ratio 6.59 (1.82-23.89), p = 0.004] was a positive predictor of ENI. Conclusion: ENI at day 1 following MT for DMVO stroke is a strong independent predictor of good to excellent 3-month clinical outcome.

Stroke Core Volume Weighs More Than Recanalization Time for Predicting Outcome in Large Vessel Occlusion Recanalized Within 6 h of Symptoms Onset.

Introduction: Current guidelines suggest that perfusion imaging should only be performed > 6 h after symptom onset. Pathophysiologically, brain perfusion should matter whatever the elapsed time. We aimed to compare relative contribution of recanalization time and stroke core volume in predicting functional outcome in patients treated by endovascular thrombectomy within 6-h of stroke-onset. Methods: Consecutive patients presenting between January 2015 and June 2021 with (i) an acute ischaemic stroke due to an anterior proximal occlusion, (ii) a successful thrombectomy (TICI >2a) within 6-h of symptom-onset and (iii) CT perfusion imaging were included. Core stroke volume was automatically computed using RAPID software. Two linear regression models were built that included in the null hypothesis the pre-treatment NIHSS score and the hypoperfusion volume (Tmax > 6 s) as confounding variables and 24 h post-recanalization NIHSS and 90 days mRS as outcome variables. Time to recanalization was used as covariate in one model and stroke core volume as covariate in the other. Results: From a total of 377 thrombectomies, 94 matched selection criteria. The Model null hypothesis explained 37% of the variability for 24 h post-recanalization NIHSS and 42% of the variability for 90 days MRS. The core volume as covariate increased outcome variability prediction to 57 and 56%, respectively. Time to recanalization as covariate marginally increased outcome variability prediction from 37 and 34% to 40 and 42.6%, respectively. Conclusion: Core stroke volume better explains outcome variability in comparison to the time to recanalization in anterior large vessel occlusion stroke with successful thrombectomy done within 6 h of symptoms onset. Still, a large part of outcome variability prediction fails to be explained by the usual predictors.

Hypoperfusion Intensity Ratio Predicts Infarct Growth After Successful Thrombectomy for Distal Medium Vessel Occlusion.

BACKGROUND AND PURPOSE: This study evaluated whether quantitative measurement of collaterals by the hypoperfusion intensity ratio (HIR) on baseline computed tomography perfusion (CTP) correlated with infarct growth and clinical outcome after successful endovascular recanalization of acute ischemic stroke (AIS) caused by primary distal medium vessel occlusions (DMVO). METHODS: We performed a retrospective analysis of consecutive AIS patients who underwent an initial CTP and were successfully recanalized by thrombectomy (modified thrombolysis In cerebral infarction 2b or 3) for DMVO. We evaluated the association of baseline HIR with infarct growth and clinical outcome. RESULTS: Between January 2018 and January 2021, 40 patients with an AIS caused by a DMVO were successfully recanalized by MT (65%, 26/40 female, median age 72 years, range 65-83 years). Baseline HIR was strongly correlated with infarct growth after successful recanalization (r = 0.501, p = 0.001). An HIR<0.3 was the optimal threshold for good collaterals using ROC analysis. Patients with HIR ≥ 0.3 had higher infarct growth compared to HIR < 0.3 (23.8 mL, IQR: 9.1-45.1 vs. 7.2 mL, interquartile range (IQR): 4.2-11.7, relative risk 7.9, p = 0.024 in multivariate analysis); their clinical outcome was poorer in univariate analysis (75%, 21/28 patients with a 3 months modified Rankin scale of 0-2 vs. 33%,4/12, p < 0.017, odds ratio (OR) 6.0, 1.37-26.20) but it did not remain significant in multivariate analysis (p = 0.107). CONCLUSION: Good collaterals on initial CTP assessed by an HIR < 0.3 are associated with less infarct growth after successful recanalization of AIS caused by a DMVO.

Predictors of stroke favorable functional outcome in Guinea, results from the Conakry stroke registry.

Low- to middle-income countries (LMICs) now bear most of the stroke burden. In LMICs, stroke epidemiology and health care systems are different from HICs. Therefore, a high-income country (HIC)-based predictive model may not correspond to the LMIC stroke context. Identify the impact of modifiable variables in acute stroke management in Conakry, Guinea as potential predictors of favorable stroke outcome. Data were extracted from the Conakry stroke registry that includes 1018 patients. A logistic regression model was built to predict favorable stroke outcomes, defined as mRS 0-2. Age, admission NIHSS score, mean arterial blood pressure and capillary glycemia were chosen as covariates. Delay to brain CT imaging under 24 h from symptom onset, fever, presence of sores and abnormal lung auscultation were included as factors. NIHSS score on admission, age and ischemic stroke were included in the null model as nuisance parameters to determine the contribution of modifiable variables to predict stroke favorable outcome. Lower admission NIHSS, brain CT imaging within 24 h of symptoms onset and lower mean arterial blood pressure emerged as a significant positive predictors of favorable stroke outcome with respective odd ratios (OR) of 1.35 [1.28-1.43], 2.1 [1.16-3.8] and 1.01 [1.01-1.04]. The presence of fever or sores impacted negatively stroke favorable outcomes with OR of 0.3 [0.1-0.85] and 0.25 [0.14-0.45]. The area under receiver operating characteristic curves (AUC) of the model was 0.86. This model explained 44.5% of the variability of the favorable stroke outcome with 10.2% of the variability explained by the modifiable variables when admission NIHSS, and ischemic stroke were included in the null model as nuisance parameter. In the Conakry stroke registry, using a logistic regression to predict stroke favorable outcome, five variables that led to an AUC of 0.86: admission NIHSS, early brain CT imaging, fever, sores and mean blood pressure. This paves the way for future public health interventions to test whether modulating amendable variables leads to increased favorable stroke outcomes in LMICs.

Predictors of Good Clinical Outcome after Thrombectomy for Distal Medium Vessel Occlusions.

OBJECTIVE: Good clinical outcome predictors have been emphasized in mechanical thrombectomy (MT) for acute ischemic stroke (AIS) with large vessel occlusion. MT for distal, medium vessel occlusions (DMVO) is still debated. We sought to assess the factors associated with clinical outcome after MT for DMVO. METHODS: We retrospectively analyzed the data of consecutive patients who underwent MT for a primary DMVO in 1 large academic center and aimed to identify the baseline clinical, imaging, and MT factors associated with good clinical outcome (defined as modified Rankin scale score of 0-2) at 3 months. RESULTS: Between January 2018 and January 2021, 61 patients underwent a MT for an AIS with a primary DMVO. Overall, good clinical outcome was achieved in 56% (34 of 61) of our patients. In multivariate analysis, an older age (odds ratio [OR] 0.89 [95% confidence interval 0.83-0.96], P = 0.003), longer puncture to recanalization time (OR 0.97 [0.93-0.99], P = 0.033), and higher baseline core volume (OR 0.84 [0.75-0.94], P = 0.003) decreased the probability of good clinical outcomes, while a final complete (or near-) recanalization (modified Thrombolysis In Cerebral Infarction [mTICI] score 2c-3) increased the probability of good outcome (OR 14.19 [1.99-101.4], P = 0.008). CONCLUSIONS: An older age, a longer puncture to recanalization time, and a higher baseline core volume decreased the probability of good clinical outcomes, while successful recanalization (mTICI 2c-3) was associated with better outcomes after MT for DMVO.

Long-term follow-up of the pCONus device for the treatment of wide-neck bifurcation aneurysms.

PURPOSE: Wide-neck bifurcation aneurysms remain challenging for the neurointerventionist and/or neurosurgeon despite many recent advances. The pCONus (Phenox, Bochum, Germany) is an emerging device for endovascular neck protection, we report the first long-term results of this device. METHODS: We performed a retrospective analysis of all consecutive intracranial wide-neck bifurcation aneurysms treated with the pCONus. Patients' characteristics were reviewed, procedural complications, angiographic (Roy-Raymond scale) and clinical outcomes were documented. RESULTS: Between January 2016 and September 2019, 43 patients (74% female, median age 56 [49-66] years) with 43 wide-neck bifurcation aneurysms (mean width of 6.8 ± 2.1 mm, dome/neck ratio of 1.3 ± 0.2 and neck of 5.2 ± 1.3 mm) were included. A procedural angiographic complication was reported in five patients (12%), no patient presented a post-operative neurological deficit or long-term complication, mortality rate was 0%. At last follow-up (median of 46.5 months [38.3-51.7]), an adequate occlusion (complete and neck remnant) was observed in 37/43 patients (86%) and an aneurysm remnant in 6/43 (14%). Four patients (9%) needed retreatment. No in-stent stenosis or branch occlusion was depicted. CONCLUSION: pCONus device provides a safe and efficient alternative for endovascular wide-neck bifurcation aneurysms management, with long-term stability.

Thrombectomy for distal medium vessel occlusion with a new generation of Stentretriever (Tigertriever 13).

PURPOSE: To evaluate the safety and efficacy of the Tigertriever 13 (Rapid Medical, Yoqneam, Israel) stent retriever in acute ischemic stroke (AIS) patients with primary or secondary distal, medium vessel occlusions (DMVO). METHODS: We performed a retrospective analysis of all consecutive AIS patients who underwent thrombectomy with the Tigertriever13 for DMVO. Patients' characteristics were reviewed, procedural complications, angiographic (modified thrombolysis in cerebral infarction score [mTICI]) and clinical (modified Rankin Scale [mRS]) outcomes were documented. RESULTS: Between November 2019 and November 2020, 16 patients with 17 DMVO were included (40% female, median age 60 [50-65] years). The Tigertriever13 was used in 11/17 (65%, median NIHSS of 8 [6-15]) primary DMVO and in 6/17 (35%, median NIHSS of 20 [13-24]) cases of secondary DMVO after a proximal thrombectomy. The successful reperfusion rate (mTICI 2b, 2c, 3) was 94% (16/17) for the dedicated vessel. At day 1, CT imaging showed a subarachnoid hemorrhage in 29% of the cases and a parenchymal hematoma in 12%. At 3 months, 65% of the patients (11/17) had a favorable outcome (mRS 0-2). CONCLUSION: Mechanical thrombectomy using the Tigertriever13 appears to be safe and effective for DMVO. Clinical and anatomical results are in line with those of patients with proximal occlusions.

Early Venous Filling Following Thrombectomy: Association With Hemorrhagic Transformation and Functional Outcome.

Background and Purpose: Previous studies have noted the angiographic appearance of early venous filling (EVF) following recanalisation in acute ischemic stroke. However, the prognostic implications of EVF as a novel imaging biomarker remain unclear. We aimed to evaluate the correlation between EVF with (i) the risk of subsequent reperfusion hemorrhage (RPH) and (ii) the association of EVF on both the NIHSS score at 24 h and functional outcome as assessed with the Modified Rankin Scale (mRS) score at 90 days. Methods: We conducted a retrospective cohort study of patients presenting with an acute ischemic stroke due to a proximal large-vessel occlusion of the anterior circulation treated by thrombectomy. Post-reperfusion digital subtraction angiography was reviewed to look for EVF as evidenced by the contrast opacification of any cerebral vein before the late arterial phase. Results: EVF occurred in 22.4% of the 147 cases included. The presence of EVF significantly increased the risk of RPH (p = 0.0048), including the risk of symptomatic hemorrhage (p = 0.0052). The presence of EVF (p = 0.0016) and the absence of RPH (p = 0.0021) were independently associated with a better outcome as defined by the NIHSS difference at 24 h, most significantly in the EVF+RPH- group. No significant relationship was however found between either EVF or RPH and a mRS score ≤ 2 at 90 days. Conclusion: Early venous filling on angiographic imaging is a potential predictor of reperfusion hemorrhage. The absence of subsequent RPH in this sub-group is associated with better outcomes at 24 h post-thrombectomy than in those with RPH.

Can chronic anti-tumour necrosing factor therapy and colic polyps overwhelm a normal functioning mitral valve? A case report of an endocarditis complicated by a ruptured intracranial mycotic aneurysm.

BACKGROUND: Rapid identification of endocarditis is challenging but also an important opportunity to change disease course. This is especially true when immunosuppression undermines diagnosis by mitigating symptoms that commonly accompany infectious disease, sometimes in the absence of predisposing heart valve disease as in this case presented here. CASE SUMMARY: A middle-aged man with chronic etanercept treatment for ankylosing spondylitis, with previously well-documented normal cardiac valves, presented with afebrile chills, night sweating, weight loss, and a new mitral regurgitation at auscultation. This Streptococcus bovis-related endocarditis, in the presence of benign colic polyps, rapidly became complicated by a ruptured infectious intracranial mycotic aneurysm. The patient was successfully cured by endovascular embolization. Severe mitral regurgitation required an uneventful mitral annuloplasty 1 month thereafter. DISCUSSION: Immunosuppression from etanercept treatment was likely responsible for this unspecific clinical presentation and potentially devastating intracranial mycotic aneurysm. This complication is infrequently reported within 6 months of anti-tumour necrosing factor therapy initiation but occurred after more than 11 years of therapy in our patient. This case is a timely reminder of the clinical challenges of endocarditis in immunosuppressed patients and highlights a potential long-term complication of etanercept.

European Multicenter Study of ET-COVID-19.

BACKGROUND AND PURPOSE: Acute ischemic stroke and large vessel occlusion can be concurrent with the coronavirus disease 2019 (COVID-19) infection. Outcomes after mechanical thrombectomy (MT) for large vessel occlusion in patients with COVID-19 are substantially unknown. Our aim was to study early outcomes after MT in patients with COVID-19. METHODS: Multicenter, European, cohort study involving 34 stroke centers in France, Italy, Spain, and Belgium. Data were collected between March 1, 2020 and May 5, 2020. Consecutive laboratory-confirmed COVID-19 cases with large vessel occlusion, who were treated with MT, were included. Primary investigated outcome: 30-day mortality. SECONDARY OUTCOMES: early neurological improvement (National Institutes of Health Stroke Scale improvement ≥8 points or 24 hours National Institutes of Health Stroke Scale 0-1), successful reperfusion (modified Thrombolysis in Cerebral Infarction grade ≥2b), and symptomatic intracranial hemorrhage. RESULTS: We evaluated 93 patients with COVID-19 with large vessel occlusion who underwent MT (median age, 71 years [interquartile range, 59-79]; 63 men [67.7%]). Median pretreatment National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score were 17 (interquartile range, 11-21) and 8 (interquartile range, 7-9), respectively. Anterior circulation acute ischemic stroke represented 93.5% of cases. The rate modified Thrombolysis in Cerebral Infarction 2b to 3 was 79.6% (74 patients [95% CI, 71.3-87.8]). Thirty-day mortality was 29% (27 patients [95% CI, 20-39.4]). Early neurological improvement was 19.5% (17 patients [95% CI, 11.8-29.5]), and symptomatic intracranial hemorrhage was 5.4% (5 patients [95% CI, 1.7-12.1]). Patients who died at 30 days exhibited significantly lower lymphocyte count, higher levels of aspartate, and LDH (lactate dehydrogenase). After adjustment for age, initial National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, and successful reperfusion, these biological markers remained associated with increased odds of 30-day mortality (adjusted odds ratio of 2.70 [95% CI, 1.21-5.98] per SD-log decrease in lymphocyte count, 2.66 [95% CI, 1.22-5.77] per SD-log increase in aspartate, and 4.30 [95% CI, 1.43-12.91] per SD-log increase in LDH). CONCLUSIONS: The 29% rate of 30-day mortality after MT among patients with COVID-19 is not negligible. Abnormalities of lymphocyte count, LDH and aspartate may depict a patient's profiles with poorer outcomes after MT. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT04406090.