Device size selection can enhance Y-stentrieving efficacy and safety as a rescue strategy in stroke thrombectomy.

BACKGROUND: Despite advancements in stroke treatment, refractory clots are relatively common, prompting the exploration of alternative techniques. Bifurcation occlusions pose specific intraprocedural challenges, occasionally dealt with by two stentrievers deployed in Y-configuration. Previous studies have portrayed this strategy as feasible, yet little is known about its safety and efficacy, and how to best select retrievers. OBJECTIVE: To determine whether device selection influences the efficacy and safety of Y-stentrieving. METHODS: We performed a multicentric, retrospective analysis of patients undergoing Y-stentrieving rescue for bifurcation occlusions. Demographics, devices, procedural metrics, neurological severity, reperfusion, disability, and safety were assessed. RESULTS: Y-configuration stents were used as a rescue maneuver after 2.16±1.5 failed attempts with other techniques in 20 patients. Successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2b-3) was achieved in 70% of patients after the first Y-stentrieving attempt. The first stentriever more often had a larger diameter (5.15±0.92 vs 3.67±0.57 mm, p=0.017) and longer length (33.12±5.78 vs 20.67±1.15 mm, p=0.002) in successfully reperfused cases. Also, the diameter of the first device was associated with both any parenchymal (6.0 vs 4.71±0.99 mm, p=0.045) and symptomatic (6.0 vs 4.86±1.02 mm, p<0.001) hemorrhages. Exact logistic regression demonstrated that a longer length first stentriever independently predicted better angiographic outcomes (OR=1.26, p=0.036), and a 6 mm diameter first stentriever independently predicted more intracranial hemorrhages (OR=15.28, p=0.044). No periprocedural mortality was recorded. CONCLUSION: Y-stentrieving is an effective and safe bail-out strategy for refractory bifurcation clots. Longer stents may promote better angiographic outcomes, whereas avoidance of disproportionately large retrievers may mitigate intracranial hemorrhage. Future studies should account for these factors when evaluating alternative stentriever techniques.

Cost-effectiveness of mechanical thrombectomy for acute ischemic stroke in Brazil: Results from the RESILIENT trial.

BACKGROUND: The RESILIENT trial demonstrated the clinical benefit of mechanical thrombectomy in patients presenting acute ischemic stroke secondary to anterior circulation large vessel occlusion in Brazil. AIMS: This economic evaluation aims to assess the cost-utility of mechanical thrombectomy in the RESILIENT trial from a public healthcare perspective. METHODS: A cost-utility analysis was applied to compare mechanical thrombectomy plus standard medical care (n = 78) vs. standard medical care alone (n = 73), from a subset sample of the RESILIENT trial (151 of 221 patients). Real-world direct costs were considered, and utilities were imputed according to the Utility-Weighted modified Rankin Score. A Markov model was structured, and probabilistic and deterministic sensitivity analyses were performed to evaluate the robustness of results. RESULTS: The incremental costs and quality-adjusted life years gained with mechanical thrombectomy plus standard medical care were estimated at Int$ 7440 and 1.04, respectively, compared to standard medical care alone, yielding an incremental cost-effectiveness ratio of Int$ 7153 per quality-adjusted life year. The deterministic sensitivity analysis demonstrated that mRS-6 costs of the first year most affected the incremental cost-effectiveness ratio. After 1000 simulations, most of results were below the cost-effective threshold. CONCLUSIONS: The intervention's clear long-term benefits offset the initially higher costs of mechanical thrombectomy in the Brazilian public healthcare system. Such therapy is likely to be cost-effective and these results were crucial to incorporate mechanical thrombectomy in the Brazilian public stroke centers.

Diagnostic Yield and Accuracy of Different Metabolic Syndrome Criteria in Adult Patients with Epilepsy.

INTRODUCTION: Metabolic syndrome (MetS) is an emergent problem among patients with epilepsy. Here, we evaluate and compare the diagnostic yield and accuracy of different MetS criteria among adult patients with epilepsy to further explore the best strategy for diagnosis of MetS among patients with epilepsy. MATERIALS AND METHODS: Ninety-five epileptic adults from a tertiary epilepsy reference center were prospectively recruited over 22 weeks in a cross-sectional study. MetS was defined according to five international criteria used for the diagnosis of the condition [ATP3, American Association of Clinical Endocrinologists (AACE), International Diabetes Federation (IDF), AHA/NHLBI, and harmonized criteria]. Sensitivity, specificity, positive and negative predictive values (NPVs), and area under the receiver operating characteristic curve (ROC) curve were estimated for each criterion. RESULTS: In our sample, adult patients with epilepsy showed a high prevalence of obesity, hypertension, and diabetes. However, the prevalence of MetS was significantly different according to each criterion used, ranging from 33.7%, as defined by AACE, to 49.4%, as defined by the harmonized criteria (p < 0.005). IDF criteria showed the highest sensitivity [S = 95.5% (95% CI 84.5-99.4), p < 0.05] and AACE criteria showed the lowest sensitivity and NPV [S = 68.2% (95% CI 52.4-81.4), p < 0.05; NPV = 75.8% (95% CI 62.3-86.1), p < 0.05]. ROC curve for all criteria studied showed that area under curve (AUC) for IDF criterion was 0.966, and it was not different from AUC of harmonized criterion (p = 0.092) that was used as reference. On the other hand, the use of the other three criteria for MetS resulted in significantly lower performance, with AUC for AHA/NHLBI = 0.920 (p = 0.0147), NCEP/ATP3 = 0.898 (p = 0.0067), AACE = 0.830 (p = 0.00059). CONCLUSION: Our findings suggest that MetS might be highly prevalent among adult patients with epilepsy. Despite significant variations in the yield of different criteria, the harmonized definition produced the highest prevalence rates and perhaps should be preferred. Correct evaluation of these patients might improve the rates of detection of MetS and foster primary prevention of cardiovascular events in this population.

The rare association of leukoencephalopathy, cerebral calcifications, and cysts: case report / A associação rara de leucoencefalopatia, calcificações cerebrais e cistos: relato de caso

Although basal ganglia calcifications were described a long time ago,1,3,11 the association of leukoencephalopathy, cerebral calcifications, and cysts (LCC) is a very rare entity described in 1996.5 We present a new case of LCC and discuss clinical, neuroradiologic, and histopathologic findings regarding this association.

Mesmo que as calcificaçãoes dos núcleos da base tenham sido descritas há muito tempo atrás1,3,11 a associação com leucoencefalopatia, calcificações cerebrais e cistos (LCC) é uma entidade muito rara descrita em 1996.5 Nós apresentamos um caso novo de LCC e discutimos os achados clínicos, neurorradiológicos e histopatológicos relacionados a essa entidade.