IV thrombolysis plus thrombectomy versus IV thrombolysis alone for minor stroke with anterior circulation large vessel occlusion from the IRETAS and Italian SITS-ISTR cohorts.

INTRODUCTION: The aim of this study was to compare the outcomes of patients treated with intravenous thrombolysis (IVT) <4.5 h after symptom onset plus mechanical thrombectomy (MT) <6 h with those treated with IVT alone <4.5 h for minor stroke (NIHSS ≤5) with large vessel occlusion (LVO) in the anterior circulation. PATIENTS AND METHODS: Patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) and in the Italian centers included in the SITS-ISTR were analyzed. RESULTS: Among the patients with complete data on 24-h ICH type, 236 received IVT plus MT and 382 received IVT alone. IVT plus MT was significantly associated with unfavorable shift on 24-h ICH types (from no ICH to PH-2) (OR, 2.130; 95% CI, 1.173-3.868; p=0.013) and higher rate of PH (OR, 4.363; 95% CI, 1.579-12.055; p=0.005), sICH per ECASS II definition (OR, 5.527; 95% CI, 1.378-22.167; p=0.016), and sICH per NINDS definition (OR, 3.805; 95% CI, 1.310-11.046; p=0.014). Among the patients with complete data on 3-month mRS score, 226 received IVT plus MT and 262 received IVT alone. No significant difference was reported between IVT plus MT and IVT alone on mRS score 0-1 (72.1% versus 69.1%), mRS score 0-2 (79.6% versus 79%), and death (6.2% versus 6.1%). CONCLUSIONS: Compared with IVT alone, IVT plus MT was associated with unfavorable shift on 24-h ICH types and higher rate of 24-h PH and sICH in patients with minor stroke and LVO in the anterior circulation. However, no difference was reported between the groups on 3-month functional outcome measures.

Stroke with large vessel occlusion in the posterior circulation: IV thrombolysis plus thrombectomy versus IV thrombolysis alone.

Efficacy and safety of mechanical thrombectomy (MT) for stroke with posterior circulation large vessel occlusion (LVO) is still under debate. We aimed to compare the outcomes of stroke patients with posterior circulation LVO treated with intravenous thrombolysis (IVT) (< 4.5 h after symptom onset) plus MT < 6 h after symptom onset with those treated with IVT alone (< 4.5 h after symptom onset). Patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) and in the Italian centers included in the SITS-ISTR were analysed. We identified 409 IRETAS patients treated with IVT plus MT and 384 SITS-ISTR patients treated with IVT alone. IVT plus MT was significantly associated with higher rate of sICH (ECASS II) compared with IVT alone (3.1 vs 1.9%; OR 3.984, 95% CI 1.014-15.815), while the two treatments did not differ significantly in 3-month mRS score ≤ 3 (64.3 vs 74.1%; OR 0.829, 95% CI 0.524-1.311). In 389 patients with isolated basilar artery (BA) occlusion, IVT plus MT was significantly associated with higher rate of any ICH compared with IVT alone (9.4 vs 7.4%; OR 4.131, 95% CI 1.215-14.040), while two treatments did not differ significantly in 3-month mRS score ≤ 3 and sICH per ECASS II definition. IVT plus MT was significantly associated with higher rate mRS score ≤ 2 (69.1 vs 52.1%; OR 2.692, 95% CI 1.064-6.811) and lower rate of death (13.8 vs 27.1%; OR 0.299, 95% CI 0.095-0.942) in patients with distal-segment BA occlusion, while two treatments did not differ significantly in 3-month mRS score ≤ 3 and sICH per ECASS II definition. IVT plus MT was significantly associated with lower rate of mRS score ≤ 3 (37.1 vs 53.3%; OR 0.137, 0.009-0.987), mRS score ≤ 1 (22.9 vs 53.3%; OR 0.066, 95% CI 0.006-0.764), mRS score ≤ 2 (34.3 vs 53.3%; OR 0.102, 95% CI 0.011-0.935), and higher rate of death (51.4 vs 40%; OR 16.244, 1.395-89.209) in patients with proximal-segment BA occlusion. Compared with IVT alone, IVT plus MT was significantly associated with higher rate of sICH per ECASS II definition in patients with stroke and posterior circulation LVO, while two treatment groups did not differ significantly in 3-month mRS score ≤ 3. IVT plus MT was associated with lower rate of mRS score ≤ 3 compared with IVT alone in patients with proximal-segment BA occlusion, whereas no significant difference was found between the two treatments in primary endpoints in patients isolated BA occlusion and in the other subgroups based on site occlusion.

Mechanical thrombectomy in patients with heart failure: the Italian registry of Endovascular Treatment in Acute Stroke.

BACKGROUND: Heart failure (HF) is the second most important cardiac risk factor for stroke after atrial fibrillation (AF). Few data are available on mechanical thrombectomy (MT) in acute ischemic stroke (AIS) patients with HF. METHODS: The source of data is the multicentre Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS). All AIS patients ≥ 18 years receiving MT were categorised in two groups: HF and no-HF. Baseline clinical and neuroradiological findings on admission were analysed. RESULTS: Of 8924 patients, 642 (7.2%) had HF. Compared to the no-HF group, HF patients had higher prevalence of cardiovascular risk factors. Rate of complete recanalisation (TICI 2b-3) was 76.9% in HF vs 78.1% in no-HF group (p = 0.481). Rate of symptomatic intracerebral haemorrhage at 24-h non-contrast computed tomography (NCCT) was 7.6% in HF vs 8.3% in no-HF patients (p = 0.520). At 3 months, 36.4% of HF patients and 48.2% of no-HF patients (p < 0.001) had mRS 0-2, and mortality was, respectively, 30.7% and 18.5% (p < 0.001). In multivariate logistic regression, HF was independently associated with mortality at 3 months (OR 1.53, 1.24-1.88 95% CI, p < 0.001). In multivariate ordinal regression, HF patients had a probability of transitioning to a higher mRS level of 1.23 (1.05-1.44 95% CI, p = 0.012). The propensity score analysis of two groups matched for age, sex, and NIHSS at admission yielded the same results. CONCLUSION: MT is safe and effective in HF patients with AIS. Patients with HF and AIS suffered from higher 3-month mortality and unfavourable outcome regardless of acute treatments.

Spinal Dural Arteriovenous Fistulas: Clinical Results and Quality of Life Assessment with Surgical Treatment as a Crucial Therapy. The Joint Experience of Two Centers.

OBJECTIVE: Dorsal intradural arteriovenous fistulas (AVFs) consist of a direct connection between a radicular feeding artery and the coronal venous plexus; this direct connection leads to arterialization of the venous plexus, venous congestion, and myelopathy. Controversy still exists regarding the best treatment modality of spinal dural AVFs. Surgical disconnection of spinal dural AVFs is a straightforward procedure with a high success rate and virtually no risk of recurrence or incomplete treatment. To identify factors associated with the clinical progression of dorsal intradural AVFs and quantify the range of surgical outcomes in terms of neurologic improvement as well as patients' perception of quality of life (QOL). METHODS: A retrospective observational study of 19 consecutive patients treated with surgery over a 10-year period was carried out. We analyzed surgical results and clinical outcomes. We also evaluated the impact of this disease and its sequelae on the patients' postoperative health-related QOL. RESULTS: The surgical procedure showed good results in terms of neurologic improvement as well as patients' perception of QOL. CONCLUSIONS: Our series confirmed that surgical obliteration of dorsal intradural AVFs is an effective and safe procedure. The results of this retrospective analysis make us believe that surgery, given its low morbidity and high success rate, represents a safe and effective first therapeutic option for these spinal vascular malformations. It could be considered to avoid unsuccessful endovascular attempts that could delay the definitive treatment of this disease. The surgical procedure showed good results in terms of neurologic improvement as well as patients' perception of QOL.

Traumatic subarachnoid hemorrhage related to ophthalmic artery avulsion: a case report.

We present a case of ophthalmic artery (OA) traumatic avulsion, leading to a post-traumatic subarachnoid hemorrhage (SAH) with ventricular blood invasion and hydrocephalus, mimicking an internal carotid aneurysm rupture. This is the third case of such an event reported in literature and the first without orbital fractures and optic nerve avulsion. Conservative treatment was sufficient for the avulsion, but surgery was needed for the coexisting eye luxation. Traumatic OA avulsion is a rare but possible event and should be suspected in case of basal cisterns SAH, evidence of orbital trauma and CT angiogram or angiographic absence of opacification of the OA.

Pituitary image: pituicytoma.

INTRODUCTION: Pituicytoma is a rare tumor arising from the neurohypophysis or pars intermedia of the adenohypophysis. CASE REPORT: A 36 year old male came to our observation presenting polydipsia, polyuria, polyphagia, decreased libido and altered sleep-wake rhythm. The biochemical tests showed hypotonic urine, mild hyperprolactinemia, hypogonadotropic hypogonadism, central hypothyroidism. Magnetic resonance revealed an expansive lesion of the suprasellar region (slightly isointense on T1, hyperintense on T2, impregnating contrast medium), that was partially removed by trans-cranial neurosurgical approach. The histopathological diagnosis was pituicytoma. After surgery, in addition to endocrine disorders, the patient presented severe neurological sequelae and hyperthermia, likely due to damage of the hypothalamus, followed by a progressive metabolic syndrome. The residual tumor was monitored by MRI, and, due to the early gradual increase in volume, was treated by stereotactic radiosurgery. DISCUSSION/CONCLUSIONS: Pituicytomas are often difficult to distinguish from other hypothalamic or pituitary lesions. However, their identification would be preferable in a pre-operative setting in order to optimize the work-up and to initiate a proactive management of the expected complications.

Intra-operative vertebroplasty combined with posterior cord decompression. A report of twelve cases.

Percutaneous vertebroplasty (VP) is a minimally invasive technique for the treatment of vertebral pathology providing early vertebral stabilization and pain relief. In cases of vertebral pathology complicated by spinal cord compression with associated neurological deficits, VP alone cannot be performed free of risks. We describe a combined approach in which decompressive laminectomy and intra-operative vertebroplasty (IVP) are performed during a single session. Among the 252 VP performed in our centre in the past three years, 12 patients (12 vertebral levels) with different pathologies (six symptomatic haemangiomas, two metastatic fractures, four osteoporotic fractures) were treated with an open procedure combined with surgery. All cases were treated with decompressive laminectomy and IVP (mono/bipeduncular or median-posterior trans-somatic access). Five patients with symptomatic haemangiomas were treated with endovascular embolization prior to the combined approach. A visual analogue scale (VAS) was applied to assess pain intensity before and after surgery. The neurological deficits were evaluated with an ASIA impairment scale. In all cases benefit from pain and neurological deficits was observed. The mean VAS score decreased from 7.8 to 2.5 after surgery. The ASIA score improved in all cases (five cases from D to E and five cases from C to D). No clinical complications were observed. In one case a CT scan performed after the procedure showed a foraminal accumulation of PMMA, but the patient referred no symptoms. IVP can be successfully applied in different pathologies affecting the vertebrae. In our limited series this approach proved safe and efficient to provide decompression of spinal cord and dural sac and vertebral body stabilization in a single session.