Detection of microemboli in patients with acute ischaemic stroke and atrial fibrillation suggests poor functional outcome.

INTRODUCTION: We investigated the burden of microembolic signals (MES) in patients with acute ischaemic stroke (AIS) and atrial fibrillation (AF), assessing their impact on functional outcomes. PATIENTS AND METHODS: This multicentre international prospective cohort study involved patients with AIS and either a known or newly diagnosed anticoagulant-naïve AF. All centres utilised the same transcranial Doppler machine for 1-h monitoring with bilateral 2 MHz probes within 24 h of symptom onset. Recordings underwent MES analysis by a blinded central reader. The primary objectives were to ascertain the MES proportion and its association with functional outcomes assessed by the modified Rankin scale (mRS) score at 90 days. RESULTS: Between September 2019 and May 2021, we enrolled 61 patients, with a median age of 78 years (interquartile range 73-83) and a median stroke severity score of 11 (interquartile range 4-18). MES were observed in 14 patients (23%), predominantly unilateral (12/14, 86%), with a median rate of 6 counts/hour (interquartile range 4-18). MES occurrence was higher post-thrombectomy and among those with elevated brain natriuretic peptide levels (p < 0.05). A worse mRS score of 3-6 was more frequent in patients with MES, occurring in 11/14 (79%), compared to those without MES, 20/47 (43%), with an adjusted odds ratio of 5.04 (95% CI, 1.15-39.4), p = 0.04. CONCLUSIONS: Nearly a quarter of patients with AIS and AF exhibited silent microembolization after the index event. Detecting MES within 24 h post-stroke (using transcranial Doppler) could signify a marker of poor functional outcomes. Subsequent trials will assess if very early antithrombotic treatment might enhance outcomes in this highly selective group of cardioembolic stroke patients. (Clinicaltrials.gov ID: NCT06018090).

Mechanical Thrombectomy in Cervical Artery Dissection-Related Stroke.

BACKGROUND: Cervical artery dissection (CeAD) causing a large vessel occlusion (LVO) stroke might represent a procedural challenge for mechanical thrombectomy (MT) impacting on its effects. The aim of the present study was to analyze safety, reperfusion rates, and clinical outcome of patients with CeAD treated by MT and compare these results with those obtained in non-CeAD patients. METHODS: All consecutive LVO stroke patients undergoing MT between June 2015 and June 2021 at our University Stroke Center were analyzed. Baseline and procedural characteristics, recanalization rates, adverse events, and functional outcome of patients with CeAD were compared with non-CeAD patients. RESULTS: MT was performed on 375 patients, 20 (5.3%) were diagnosed with CeAD. These patients were younger (52.9 ± 7.8 vs. 72.5 ± 12.9 years, P < 0.001), and showed lower rates of cardiovascular risk factors. In patients with CeAD, tandem occlusions were more frequent (65.0% vs. 14.4%, P < 0.001), groin to reperfusion time was longer (93.6 ± 34.9 vs. 68.3 ± 50.2 minutes, P = 0.01), and general anesthesia was more frequently utilized (70.0% vs. 27.9%, P < 0.001). Recanalization rates (Treatment in Cerebral Infarction 2b-3: 100.0% vs. 88.5%) and MT-related adverse events (10.0% vs. 10.7%) did not differ between the groups, while functional outcome was better in patients with CeAD (modified Rankin Scale 0-2 at 3 months: 85.0% vs. 62.0%, P = 0.038). CONCLUSIONS: Although CeAD represents a procedural challenge, MT constitutes a safe and effective treatment for patients with CeAD with LVO stroke.

Relationship between hemoglobin, hemolysis, and transcranial Doppler velocities in children with sickle cell disease: Results from a long-term natural history study in Italy in the era of multimodal therapy.

BACKGROUND: Stroke and cerebral vasculopathy are leading causes of morbidity and mortality in patients with sickle cell disease (SCD). Transcranial Doppler (TCD) is a reliable and validated predictor of stroke risk. Children with conditional or abnormal TCD are at an increased risk for stroke, which can be mitigated by red blood cell transfusion or hydroxyurea. Elucidating the relationship between cerebral hemodynamics and hemolytic anemia can help identify novel therapeutic approaches to reduce stroke risk and transfusion dependence. METHODS: This long-term, real-world study was designed to evaluate the prevalence of TCD imaging (TCDi)-assessed flow velocities in children and to interrogate their relationship with markers of anemia and hemolysis. RESULTS: In total, 155 children (median follow-up 79.8 months, 1358.44 patient-years) had 583 evaluable TCDi results. Only patients with HbSS or HbSß0 had abnormal (1.6%) or conditional (10.9%) TCDi. Children with abnormal or conditional TCDi had lower hemoglobin (Hb) and higher hemolysis markers. A linear correlation was detected between TCD velocity and Hb: an Hb increase of 1 g/dL corresponded to decreases in velocity in the internal carotid and middle cerebral arteries (6.137 cm/s and 7.243 cm/s). Moreover, patients with Hb >9 g/dL presented a lower risk of TCDi-associated events. CONCLUSION: These results support the need to optimize disease-modifying treatments that increase Hb and reduce hemolysis for stroke prevention in young children with SCD.

The Combination of Natural Molecules Naringenin, Hesperetin, Curcumin, Polydatin and Quercetin Synergistically Decreases SEMA3E Expression Levels and DPPIV Activity in In Vitro Models of Insulin Resistance.

Type 2 diabetes mellitus (T2DM) is a disease characterized by a prolonged hyperglycemic condition caused by insulin resistance mechanisms in muscle and liver, reduced insulin production by pancreatic ß cells, and a chronic inflammatory state with increased levels of the pro-inflammatory marker semaphorin 3E. Phytochemicals present in several foods have been used to complement oral hypoglycemic drugs for the management of T2DM. Notably, dipeptidyl peptidase IV (DPPIV) inhibitors have demonstrated efficacy in the treatment of T2DM. Our study aimed to investigate, in in vitro models of insulin resistance, the ability of the flavanones naringenin and hesperetin, used alone and in combination with the anti-inflammatory natural molecules curcumin, polydatin, and quercetin, to counteract the insulin resistance and pro-inflammatory molecular mechanisms that are involved in T2DM development. Our results show for the first time that the combination of naringenin, hesperetin, curcumin, polydatin, and quercetin (that mirror the nutraceutical formulation GliceFen®, Mivell, Italy) synergistically decreases expression levels of the pro-inflammatory gene SEMA3E in insulin-resistant HepG2 cells and synergistically decreases DPPIV activity in insulin-resistant Hep3B cells, indicating that the combination of these five phytochemicals is able to inhibit pro-inflammatory and insulin resistance molecular mechanisms and could represent an effective innovative complementary approach to T2DM pharmacological treatment.

Systemic Neoplastic Cryoglobulinemic Vasculitis Mimics Large Vessel Occlusion: A Case Report.

INTRODUCTION: We describe a systemic neoplastic cryoglobulinemic vasculitis presenting as a large vessel occlusion (LVO) syndrome. We focus on a rare presentation of a rare condition. CASE REPORT: A 68-year-old man was admitted to the Stroke Unit of Padova with a right middle cerebral artery syndrome. A cerebrovascular event was suspected and protocol for revascularization treatment was performed. Neuroimaging provided no evidence for infarcted tissue or medium-large vascular occlusion but hypothesized a vasculitic involvement of the small vessels of the right hemisphere. Further diagnostics demonstrated a microangiopathic involvement of the heart, kidneys, and lungs. Blood tests showed circulating cryoglobulins and further hematological investigation identified a chronic lymphatic leukemia-like lymphoproliferative disorder. High-dose steroid therapy improved the patient's clinical status and no neurological symptoms remained at discharge. CONCLUSION: We discuss the clinical-radiologic presentation of a small vessel vasculitis that mimics an LVO stroke. This case focuses on the relevance of concomitant multiorgan manifestations in the hyper-acute evaluation of LVO stroke, suggesting the clinical neurologist should consider alternative etiologies as these could provide important clinical implications.

The "SALPARE study" of spontaneous intracerebral hemorrhage: part 1.

BACKGROUND: Spontaneous intracerebral hemorrhage (ICH) is a devastating type of stroke with a huge impact on patients and families. Expanded use of oral anticoagulants and ageing population might contribute to an epidemiological change. In view of these trends, we planned a study to obtain a contemporary picture and identify early prognostic factors to improve secondary prevention. METHODS: This multicenter prospective cohort study included consecutive adult patients with non-traumatic ICH admitted to three academic Italian hospitals (Salerno, Padova, Reggio Emilia) over a 2-year period. Demographic characteristics, vascular risk profile, clinical data and main radiological characteristics were correlated to 90-day clinical outcome. RESULTS: Out of 682 patients [mean age: 73 ± 14 years; 316 (46.3%) females] enrolled in this study, 40% died [86/180 (47.8%) in Salerno, 120/320 (37.5%) in Padova, 67/182 (36.8%) in Reggio Emilia; p < 0.05)] and 36% were severely disabled at 90 days. Several factors were associated with a higher risk of poor functional outcome such as antithrombotic drug use, hyperglycemia, previous cerebrovascular accident, low platelet count, and pontine/massive/intraventricular hemorrhage. However, at multivariate analysis only pre-ICH mRS score (OR 30.84), GCS score at presentation (OR 11.88), initial hematoma volume (OR 29.71), and NIHSS score at presentation (OR 25.89) were independent predictors of death and poor functional outcome. CONCLUSION: Despite the heterogeneity among centers, this study on ICH has identified four simple prognostic factors that can independently predict patients outcome, stratify their risk, and guide their management.

The "SALPARE study" of spontaneous intracerebral haemorrhage-part 2-early CT predictors of outcome in ICH: keeping it simple.

BACKGROUND: The aim of this study was to investigate the prognostic role of hematoma characteristics and hematoma expansion (HE) in patients with spontaneous intracerebral hemorrhage (ICH). METHODS: This multicenter prospective cohort study enrolled consecutive adult patients with non-traumatic ICH admitted to three Italian academic hospitals (Salerno, Padova, Reggio Emilia) over a 2-year period. Early noncontrast CT (NCCT) features of the hematoma, including markers of HE, and 3-month outcome were recorded. Multivariable logistic regression analysis was performed to identify predictors of poor outcome. RESULTS: A total of 682 patients were included in the study [mean age: 73 ± 14 years; 316 (46.3%) females]. Pontine and massive hemorrhage, intraventricular bleeding, baseline hematoma volume > 15 mL, blend sign, swirl sign, margin irregularity ≥ 4, density heterogeneity ≥ 3, hypodensity ≥ 1, island sign, satellite sign, and black hole sign were associated with a higher risk of mortality and disability. However, at multivariate analysis only initial hematoma volume (OR 29.71) proved to be an independent predictor of poor functional outcome at 3 months. CONCLUSION: Simple hematoma volume measured on baseline CT best identifies patients with a worse outcome, while early NCCT markers of HE do not seem to add any clinically significant information.

Multiparametric identification of subclinical atrial fibrillation after an embolic stroke of undetermined source.

BACKGROUND: Subclinical atrial fibrillation (SCAF) may represent a cause of embolic stroke of undetermined source (ESUS) and its detection has important implications for secondary prevention with anticoagulation. Indications to implantable cardiac monitors (ICM) include SCAF detection. The aims of this study were to (1) evaluate the frequency of ICM-detected SCAF; (2) determine predictors of SCAF; and (3) identify patients who would benefit most from ICM implantation. METHODS: Between February 2017 and November 2020, all consecutive patients referred for ICM implantation after a diagnosis of ESUS and without previous history of atrial fibrillation or atrial flutter were included in this study. SCAF was diagnosed if the ICM electrogram demonstrated an episode of irregularly irregular rhythm without distinct P waves lasting > 2 min. RESULTS: We enrolled 109 patients (age 66, SD = 13 years; 36% females). During a median follow-up of 19.2 (IQR 11.0-27.5) months, SCAF episodes were detected in 36 (33%) patients. Only abnormal P wave terminal force in lead V1, left atrial end-systolic indexed volume > 34 ml/m2, and BMI > 25 kg/m2 were independently associated with an increased risk of SCAF (HR 2.44, 95% CI 1.14-5.21, p = 0.021; HR 2.39, 95% CI 1.11-5.13, p = 0.026; and HR 2.64, 95% CI 1.06-6.49, p = 0.036 respectively). The ROC curve showed that the presence of all three parameters had the best accuracy (74%) to predict SCAF detection (sensitivity 39%, specificity 91%). CONCLUSION: A multiparametric evaluation has the best accuracy to predict SCAF in ESUS patients and may help identifying those who would benefit most from ICM.

SOFIA Nonwire Advancement techniKE 35 Technique: A Minimalist Approach to Stroke Thrombectomy.

BACKGROUND: The Soft Torqueable Catheter Optimized for Intracranial Access (SOFIA) is a catheter designed to enable intracranial access, allowing for advancement, at least partially, without a microcatheter by a technique called SOFIA Nonwire Advancement techniKE (SNAKE). We propose a variation of this technique, called SOFIA Nonwire Advancement techniKE 35 (SNAKE35), in which the catheter is navigated by the intracatheter support of a 0.035-inch guidewire, allowing for rapid, distal intracranial access through a biaxial technique. OBJECTIVE: To assess the performance of a modified navigation technique in the setting of acute stroke thrombectomy. METHODS: Consecutive patients who underwent a thrombectomy procedure between January 2017 and February 2019 were retrospectively identified at our institution. The primary end point was defined as successful positioning of the catheter at the proximal end of the occlusion with the sole use of the SNAKE35 technique. Secondary end points were defined as complications, reperfusion times, and thrombolysis in cerebral infarction scores. RESULTS: Among 140 patients, SNAKE35 was attempted in 79 patients (SNAKE35 group), while traditional navigation was used in the remaining 61 patients (conventional group). Of the total 79 cases, SNAKE35 was successful in positioning the catheter at the proximal end of the occlusion in 66 cases (84%). Of these, 54 cases were completed solely with aspiration techniques. Groin puncture to revascularization time averaged 26 minutes in the SNAKE35 group and 37 minutes in the conventional group ( P < .05), despite older age ( P < .001) and increased use of conscious sedation ( P < .001) in the SNAKE35 group. CONCLUSION: SNAKE35 is an effective and safe technique for SOFIA navigation up to the site of intracranial occlusion in the anterior circulation leading to significant decrease of procedural times.

Risk Factors for General Anesthesia Conversion in Anterior Circulation Stroke Patients Undergoing Endovascular Treatment.

BACKGROUND AND PURPOSE: No current consensus exists on the best anesthetic management of ischemic stroke patients undergoing mechanical thrombectomy. Both conscious sedation (CS) and general anesthesia (GA) are currently considered valid anesthetic strategies, yet patients managed under CS may require emergent conversion to GA, which has been associated with worse outcomes. The aim of this study was to analyze the conversion rate and potential risk factors for GA conversion during mechanical thrombectomy. METHODS: Two-hundred and twenty-seven patients with consecutive acute anterior circulation ischemic stroke treated with mechanical thrombectomy and initiated under CS or local anesthesia were included in this retrospective analysis. Conversion rate to GA was calculated, while univariate and multivariate analysis were used to identify risk factors. RESULTS: Twenty patients (8.8%) were switched to GA. Multivariate analysis identified procedure duration (odds ratio [OR] 1.01, 95% confidence interval [CI] 1.00-1.02, p value 0.028), tandem stroke (OR 8.57, 95% CI 2.06-35.7, p value 0.003), Sequential Organ Failure Assessment (SOFA) (OR 1.76, 95% CI 1.19-2.61, p value 0.005), and number of pharmacological agents used (OR 5.76, 95% CI 2.49-13.3, p value <0.001) as independently associated with conversion to GA. CONCLUSION: In our study, tandem occlusion, longer endovascular procedures, SOFA, and number of pharmacological agents used predicted the risk of emergent conversion to GA in stroke patients undergoing endovascular treatment. Prospective studies investigating optimal CS strategies are deemed necessary.

Stroke management during the coronavirus disease 2019 (COVID-19) pandemic: experience from three regions of the north east of Italy (Veneto, Friuli-Venezia-Giulia, Trentino-Alto-Adige).

BACKGROUND: Efficiency of care chain response and hospital reactivity were and are challenged for stroke acute care management during the pandemic period of coronavirus disease 2019 (COVID-19) in North-Eastern Italy (Veneto, Friuli-Venezia-Giulia, Trentino-Alto-Adige), counting 7,193,880 inhabitants (ISTAT), with consequences in acute treatment for patients with ischemic stroke. METHODS: We conducted a retrospective data collection of patients admitted to stroke units eventually treated with thrombolysis and thrombectomy, ranging from January to May 2020 from the beginning to the end of the main first pandemic period of COVID-19 in Italy. The primary endpoint was the number of patients arriving to these stroke units, and secondary endpoints were the number of thrombolysis and/or thrombectomy. Chi-square analysis was used on all patients; furthermore, patients were divided into two cohorts (pre-lockdown and lockdown periods) and the Kruskal-Wallis test was used to test differences on admission and reperfusive therapies. RESULTS: In total, 2536 patients were included in 22 centers. There was a significant decrease of admissions in April compared to January. Furthermore, we observed a significant decrease of thrombectomy during the lockdown period, while thrombolysis rate was unaffected in the same interval across all centers. CONCLUSIONS: Our study confirmed a decrease in admission rate of stroke patients in a large area of northern Italy during the lockdown period, especially during the first dramatic phase. Overall, there was no decrease in thrombolysis rate, confirming an effect of emergency care system for stroke patients. Instead, the significant decrease in thrombectomy rate during lockdown addresses some considerations of local and regional stroke networks during COVID-19 pandemic evolution.

Acute revascularization treatments for ischemic stroke in the Stroke Units of Triveneto, northeast Italy: time to treatment and functional outcomes.

It is not known whether the current territorial organization for acute revascularization treatments in ischemic stroke patients guarantees similar time to treatment and functional outcomes among different levels of institutional stroke care. We aimed to assess the impact of time to treatment on functional outcomes in ischemic stroke patients who received intravenous thrombolysis (IVT) alone, bridging (IVT plus thrombectomy), or primary thrombectomy in level 1 and level 2 Stroke Units (SUs) in Triveneto, a geographical macroarea in Northeast of Italy. We conducted an analysis of data prospectively collected from 512 consecutive ischemic stroke patients who received IVT and/or mechanical thrombectomy in 25 SUs from September 17th to December 9th 2018. The favorable outcome measures were mRS score 0-1 and 0-2 at 3 months. The unfavorable outcome measures were mRS score 3-5 and death at 3 months. We estimated separately the possible association of each variable for time to treatment (onset-to-door, door-to-needle, onset-to-needle, door-to-groin puncture, needle-to-groin puncture, and onset-to-groin puncture) with 3-month outcome measures by calculating the odds ratios (ORs) with two-sided 95% confidence intervals (CI) after adjustment for pre-defined variables and variables with a probability value ≤ 0.10 in the univariate analysis for each outcome measure. Distribution of acute revascularization treatments was different between level 1 and level 2 SUs (p < 0.001). Among 182 patients admitted to level 1 SUs (n = 16), treatments were IVT alone in 164 (90.1%), bridging in 12 (6.6%), and primary thrombectomy in 6 (3.3%) patients. Among 330 patients admitted to level 2 SUs (n = 9), treatments were IVT alone in 219 (66.4%), bridging in 74 (22.4%), and primary thrombectomy in 37 (11.2%) patients. Rates of excellent outcome (51.4% vs 45.9%), favorable outcome (60.1% vs 58.7%), unfavorable outcome (33.3% vs 33.8%), and death (9.8% vs 11.3%) at 3 months were similar between level 1 and 2 SUs. No significant association was found between time to IVT alone (onset-to-door, door-to-needle, and onset-to-needle) and functional outcomes. After adjustment, door-to-needle time ≤ 60 min (OR 4.005, 95% CI 1.232-13.016), shorter door-to-groin time (OR 0.991, 95% CI 0.983-0.999), shorter needle-to-groin time (OR 0.986, 95% CI 0.975-0.997), and shorter onset-to-groin time (OR 0.994, 95% CI 0.988-1.000) were associated with mRS 0-1. Shorter door-to-groin time (OR 0.991, 95% CI 0.984-0.998), door-to-groin time ≤ 90 min (OR 12.146, 95% CI 2.193-67.280), shorter needle-to-groin time (OR 0.983, 95% CI 0.972-0.995), and shorter onset-to-groin time (OR 0.993, 95% CI 0.987-0.999) were associated with mRS 0-2. Longer door-to-groin time (OR 1.007, 95% CI 1.001-1.014) and longer needle-to-groin time (OR 1.019, 95% CI 1.005-1.034) were associated with mRS 3-5, while door-to-groin time ≤ 90 min (OR 0.229, 95% CI 0.065-0.808) was inversely associated with mRS 3-5. Longer onset-to-needle time (OR 1.025, 95% CI 1.002-1.048) was associated with death. Times to treatment influenced the 3-month outcomes in patients treated with thrombectomy (bridging or primary). A revision of the current territorial organization for acute stroke treatments in Triveneto is needed to reduce transfer time and to increase the proportion of patients transferred from a level 1 SU to a level 2 SU to perform thrombectomy.

Acute stroke treatment during coronavirus disease 2019 pandemic.

PURPOSE OF REVIEW: The coronavirus disease 2019 (COVID-19) pandemic has caused a major impact on stroke care. This review synthesizes the available data and provides a framework for optimal management of stroke patients with confirmed or suspected COVID-19 infection and eligible to reperfusion treatments. RECENT FINDINGS: Reorganization of health services has led to the conversion of stroke units and relocation of stroke staff to COVID units. During the pandemic surge, there has been a general decline of stroke presentations, increased time delays, and reduced activity across all areas of stroke care, specifically the delivery of acute treatment. Moreover, COVID-19 patients seem to have a worse outcome despite prompt recanalization. Periprocedural monitoring studies are needed in these patients to target a more adequate therapy. SUMMARY: The COVID-19 pandemic has jeopardized the ability of stroke centers to provide timely assessment and acute therapies such as reperfusive treatments. Yet, as stroke remains a medical emergency, efforts to maintain stroke teams and safe provision of highly effective stroke treatments should be prioritized despite healthcare systems reorganization. This can be accomplished through the activation of telestroke networks, protected stroke pathways, 24/7 open-access high-quality stroke centers, and stroke awareness programs.

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.

Acute stroke management pathway during Coronavirus-19 pandemic.

Since the outbreak of the COVID-19 epidemic which in our region, Veneto (Italy), dates back to February, we were confronted with several challenges, but with a constant aim of keeping our Stroke Unit COVID-free. For this reason, in addition to creating a dedicated hot-spot as a pre-triage just outside the Emergency Department, together with the Neuroradiology Unit we obtained a mobile CT unit that could be used by COVID-positive or COVID-suspected patients. Furthermore, thanks to the collaboration with colleagues from different specialties (Infectious Disease, Internal Medicine, Intensive Care, Emergency Medicine), dedicated areas for COVID patients were activated. This led to a substantial change of our acute stoke management pathway. As the number of COVID patients increased, and the WHO declared a state of pandemic, this new stroke pathway has been fully tested. We would like to share our experience and send a clear message to keep a high attention on stroke as an emergency condition, because we have observed a decreased number of patients with minor strokes and TIAs, longer onset-to-door and door-to-treatment times for major strokes, and a reduced number of transfers from spokes. We strongly believe that the general population and family doctors are rightly focused on COVID. However, to remain at home with stroke symptoms does not mean to "stay safe at home".

Early hemodynamic predictors of good outcome and reperfusion injury after endovascular treatment.

OBJECTIVE: To find early hemodynamic predictors of outcome and reperfusion injury in patients with acute ischemic stroke due to anterior circulation large artery occlusion (LAO) after endovascular treatment (EVT). METHODS: Serial transcranial color-coded sonography examinations assessed the vessel status and cerebral hemodynamics of 185 (109 [58.9%] men, mean age 69.5 ± 12.3 years) consecutive patients with acute anterior circulation LAO soon after, at 48 hours after, and 1 week after EVT. RESULTS: Successful recanalization (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.11-0.61) and normal peak systolic velocity (PSV) ratio (PSV of recanalized middle cerebral artery/PSV of contralateral middle cerebral artery) at 48 hours (OR 0.22, 95% CI 0.15-0.64) and after 1 week (OR 0.11, 95% CI 0.07-0.31) from EVT were independent predictors of good outcome at 3 months. Thrombectomy failure (OR 10.22, 95% CI 1.47-45.53) and pathologic PSV ratio at 1 week from EVT (OR 15.23, 95% CI 4.54-46.72) were associated with a worse 90-day outcome. Patients who subsequently developed postinterventional intracranial hemorrhage (ICH) showed a higher mean PSV ratio (3.5 ± 0.2 vs 2.4 ± 0.1, p < 0.0001) soon after successful recanalization. In multivariate analysis, early PSV ratio was independently associated with postprocedural ICH (OR 8.474, 95% CI 3.066-45.122, p < 0.01]. At 1 week from EVT, 15 of 21 (71.4%) patients with ICH who resumed normal PSV values had a better 90-day outcome (modified Rankin Scale score 0-2: 40% vs 0%). CONCLUSION: Post-EVT ultrasound monitoring of stroke patients might be an effective bedside method for assessing treatment efficacy, shedding light on outcome variability and identifying patients at increased risk of ICH.

Ultrasound Identification of Patients at Increased Risk of Intracranial Hemorrhage After Successful Endovascular Recanalization for Acute Ischemic Stroke.

BACKGROUND: Intracranial hemorrhage (ICH) is the most feared complication of endovascular treatment (EVT) for acute ischemic stroke because of anterior circulation large vessel occlusion (LVO). The purpose of this study was to identify cerebral hemodynamic predictors of ICH and poor outcome in patients with successful recanalization. METHODS: Serial transcranial color-coded sonography (TCCS) examinations assessed vessel status and cerebral hemodynamics of 226 (mean age, 69.8 ± 12.5 years; 130 men [57.5%]) consecutive patients with acute anterior circulation LVO at 48 hours and 1 week after EVT. Middle cerebral artery peak systolic velocity (PSVMCA) and PSVMCA ratio (recanalized PSVMCA/contralateral PSVMCA) were recorded. RESULTS: Out of 180 successfully recanalized patients (79.6%), 28 patients (15.5%) had ICH. They more often had arterial hypertension (25/28 [89.3%] vs. 106/152 [69.7%], P = 0.04), a more severe stroke syndrome (18 [range, 10-23] vs. 16 [range, 5-26], P = 0.01), a worse clinical outcome (90-day modified Rankin Scale [mRS] score 3-5: 16/28 [57.1%] vs. 42/152 [27.6%], P = 0.004), and soon after EVT showed a significantly higher mean PSVMCA ratio (3.4 ± 0.1 vs. 2.4 ± 0.1, P < 0.0001) than patients without ICH, respectively. In multivariate analysis, early PSVMCA ratio was independently associated with postinterventional ICH (odds ratio, 13.379; 95% confidence interval, 2.466-50.372; P < 0.01). The patients with ICH (19/28 [67.9%]) who resumed normal PSVMCA values at 1 week after EVT had a better outcome (90-day mRS score 0-2: 8/19 [42.1%] vs. 0/9 [0%], respectively). CONCLUSIONS: Early TCCS detection of a high PSVMCA ratio in successfully recanalized stroke patients indicates an increased risk of ICH, whereas cerebral hemodynamics normalization at 1 week in patients with postinterventional ICH predicts a relatively better 3-month outcome.

Treatment of stroke with early imaging and revascularization: when to be aggressive?

Neuroimaging has a key role in the assessment and treatment of acute stroke. Cerebral computer tomography is the first step to differentiate hemorragic from ischemic stroke and to detect, in the latter, early signs representative of the lesion severity and predicting a possible hemorrhagic infarction after thrombolytic treatment.Advanced neuroimaging techniques are relevant in the assessment of the ischemic and/or hypo-perfused area, being an essential tool in uncertain situations or when the time of symptoms onset is unavailable, increasing the efficacy and safety of endovenous thrombolysis by enlarging its therapeutic window and leading to more accurate selection of patients to be treated.Moreover, advanced neuroimaging may be of help in choosing the patients to be submitted to endovascular treatment when occlusion of an intracranial artery is documented, either after intravenous thrombolysis or as a primary approach.Here we describe the impact of neuroimaging in the decisional process in acute ischemic stroke, presenting the literature evidence on the topic, especially regarding the recent trials on endovascular treatment.