Recanalization status and temporal evolution of early ischemic changes following stroke thrombectomy.

INTRODUCTION: Present-day computer tomography (CT) scanners have excellent spatial resolution and signal-to-noise ratio and are instrumental detecting early ischemic changes (EIC) in brain. We assessed the temporal changes of EIC based on the recanalization status after thrombectomy. PATIENTS AND METHODS: The cohort comprises consecutive patients with acute ischemic stroke in anterior circulation treated with thrombectomy in tertiary referral hospital. All baseline and follow-up scans were screened for any ischemic changes and further classified using Alberta Stroke Program Early CT Score (ASPECTS). Generalized linear mixed models were used to analyze the impact of recanalization status using modified Thrombolysis in Cerebral Infarction (mTICI) on temporal evolution of ischemic changes. RESULTS: We included 614 patients with ICA, M1, or M2 occlusions. Median ASPECTS score was 9 (IQR 7-10) at baseline and 7 (5-8) at approximately 24 h. mTICI 3 was achieved in 207 (33.8%), 2B 241 (39.3%), 2A in 77 (12.6%), and 0-1 in 88 (14.3%) patients. Compared to patients with mTICI 3, those with mTICI 0-1 and 2A had less favorable temporal changes of ASPECTS (p < 0.001). Effect of recanalization was noted in the cortical regions of ICA/M1 patients, but not in their deep structures or patients with M2 occlusions. All ischemic changes detected at baseline were also present at all follow-up images, regardless of the recanalization status. CONCLUSIONS: Temporal evolution of the ischemic changes and ASPECTS are related to the success of the recanalization therapy in cortical regions of ICA/M1 patients, but not in their deep brain structures or M2 patients. In none of the patients did EIC revert in any brain region after successful recanalization.

Laboratory Assessment of Unfractionated Heparin (UFH) with Activated Clotting Time (ACT) and Anti-Xa Activity during Peripheral Arterial Angiographic Procedure.

Activated clotting time (ACT) is used in cardiac surgery for monitoring unfractionated heparin (UFH). In endovascular radiology, ACT use is less established. We aimed to test the validity of ACT in UFH monitoring in endovascular radiology. We recruited 15 patients undergoing endovascular radiologic procedure. ACT was measured with ICT Hemochron® device as point-of-care (1) before standard UFH bolus, (2) immediately after the bolus, and in some cases (3) 1 h into the procedure or a combination thereof (altogether 32 measurements). A total of two different cuvettes, ACT-LR and ACT+ were tested. A reference method of chromogenic anti-Xa was used. Blood count, APTT, thrombin time and antithrombin activity were also measured. UFH levels (anti-Xa) varied between 0.3-2.1 IU/mL (median 0.8) and correlated with ACT-LR moderately (R2 = 0.73). The corresponding ACT-LR values were 146-337 s (median 214). ACT-LR and ACT+ measurements correlated only modestly with one another at this lower UFH level, with ACT-LR being more sensitive. Thrombin time and APTT were unmeasurably high after the UFH dose, rendering them of limited use in this indication. We adopted an ACT target of >200-250 s in endovascular radiology based on this study. While ACT correlation with anti-Xa is suboptimal, the readily available point-of-care nature increases its suitability.

ErbB signaling is a potential therapeutic target for vascular lesions with fibrous component.

Background: Sporadic venous malformation (VM) and angiomatosis of soft tissue (AST) are benign, congenital vascular anomalies affecting venous vasculature. Depending on the size and location of the lesion, symptoms vary from motility disturbances to pain and disfigurement. Due to the high recurrence of the lesions, more effective therapies are needed. Methods: As targeting stromal cells has been an emerging concept in anti-angiogenic therapies, here, by using VM/AST patient samples, RNA-sequencing, cell culture techniques, and a xenograft mouse model, we investigated the crosstalk of endothelial cells (EC) and fibroblasts and its effect on vascular lesion growth. Results: We report, for the first time, the expression and secretion of transforming growth factor A (TGFA) in ECs or intervascular stromal cells in AST and VM lesions. TGFA induced secretion of vascular endothelial growth factor (VEGF-A) in paracrine fashion, and regulated EC proliferation. Oncogenic PIK3CA variant in p.H1047R, a common somatic mutation found in these lesions, increased TGFA expression, enrichment of hallmark hypoxia, and in a mouse xenograft model, lesion size, and vascularization. Treatment with afatinib, a pan-ErbB tyrosine-kinase inhibitor, decreased vascularization and lesion size in a mouse xenograft model with ECs expressing oncogenic PIK3CA p.H1047R variant and fibroblasts. Conclusions: Based on the data, we suggest that targeting of both intervascular stromal cells and ECs is a potential treatment strategy for vascular lesions having a fibrous component. Funding: Academy of Finland, Ella and Georg Ehnrooth foundation, the ERC grants, Sigrid Jusélius Foundation, Finnish Foundation for Cardiovascular Research, Jane and Aatos Erkko Foundation, GeneCellNano Flagship program, and Department of Musculoskeletal and Plastic Surgery, Helsinki University Hospital.

Endovascular Versus Medical Management of Posterior Cerebral Artery Occlusion Stroke: The PLATO Study.

BACKGROUND: The optimal management of patients with isolated posterior cerebral artery occlusion is uncertain. We compared clinical outcomes for endovascular therapy (EVT) versus medical management (MM) in patients with isolated posterior cerebral artery occlusion. METHODS: This multinational case-control study conducted at 27 sites in Europe and North America included consecutive patients with isolated posterior cerebral artery occlusion presenting within 24 hours of time last well from January 2015 to August 2022. Patients treated with EVT or MM were compared with multivariable logistic regression and inverse probability of treatment weighting. The coprimary outcomes were the 90-day modified Rankin Scale ordinal shift and ≥2-point decrease in the National Institutes of Health Stroke Scale. RESULTS: Of 1023 patients, 589 (57.6%) were male with median (interquartile range) age of 74 (64-82) years. The median (interquartile range) National Institutes of Health Stroke Scale was 6 (3-10). The occlusion segments were P1 (41.2%), P2 (49.2%), and P3 (7.1%). Overall, intravenous thrombolysis was administered in 43% and EVT in 37%. There was no difference between the EVT and MM groups in the 90-day modified Rankin Scale shift (aOR, 1.13 [95% CI, 0.85-1.50]; P=0.41). There were higher odds of a decrease in the National Institutes of Health Stroke Scale by ≥2 points with EVT (aOR, 1.84 [95% CI, 1.35-2.52]; P=0.0001). Compared with MM, EVT was associated with a higher likelihood of excellent outcome (aOR, 1.50 [95% CI, 1.07-2.09]; P=0.018), complete vision recovery, and similar rates of functional independence (modified Rankin Scale score, 0-2), despite a higher rate of SICH and mortality (symptomatic intracranial hemorrhage, 6.2% versus 1.7%; P=0.0001; mortality, 10.1% versus 5.0%; P=0.002). CONCLUSIONS: In patients with isolated posterior cerebral artery occlusion, EVT was associated with similar odds of disability by ordinal modified Rankin Scale, higher odds of early National Institutes of Health stroke scale improvement, and complete vision recovery compared with MM. There was a higher likelihood of excellent outcome in the EVT group despite a higher rate of symptomatic intracranial hemorrhage and mortality. Continued enrollment into ongoing distal vessel occlusion randomized trials is warranted.

Thrombectomy in Acute Ischemic Stroke in the Extended Time Window: Real-Life Experience in a High-Volume Center.

OBJECTIVES: Selected patients with acute ischemic stroke (AIS) caused by proximal middle cerebral artery (MCA) or internal carotid artery occlusion benefit from endovascular thrombectomy (EVT) in extended time window (6-24 h from last seen well) based on two landmark randomized controlled trials (RCTs) DAWN and DEFUSE-3. We evaluated patients' outcome in the real-life with the focus on adherence to protocol of the two RCTs. MATERIALS AND METHODS: We included consecutive patients with AIS (excluding basilar artery occlusions) referred to EVT in our stroke center in the extended time window between January 2018 and December 2019 and compared the outcome of patients who fulfilled criteria of the RCTs with those who did not. RESULTS: Of the total of 100 patients, 23 complied with RCT's criteria and 18 presented with minor non-adherence (lower NIHSS score or longer treatment delay), whereas 22 patients had large baseline ischemia (>1/3 MCA), 28 presented with M2 and more distal occlusions, and 9 patients did not undergo perfusion imaging prior to EVT. Good 3-month outcome (modified Rankin Scale 0-2) was observed in 54% of those who either met the RCT criteria or presented with lower NIHSS score or longer treatment delay, but only in 30% of M2 occlusions, and in none of the patients with large baseline ischemia. CONCLUSIONS: Our findings highlight the impact of mostly large baseline ischemia but also vessel status when selecting patients for EVT in the extended time window and emphasize the need for further data in these patient subgroups.

Recanalization treatment for acute ischemic stroke: 3-month outcome before and after implementation of routine endovascular treatment.

Background and purpose: Endovascular treatment for acute ischemic stroke has become a recommended treatment option for selected patients after several randomized controlled trials have shown the effectiveness of endovascular treatment. Due to the nature of randomized clinical trials, the generalizability to population based real life settings and the resulting benefits remain difficult to estimate. Methods: We included 896 consecutive patients treated with intravenous thrombolysis (IVT) within 4.5 h of stroke onset between January 2016 and December 2018, who were treated with additional endovascular treatment according to the new evidence when indicated (new-IVT-cohort). This cohort was compared to 913 intravenous thrombolysis patients treated in the 4.5 h time-window between January 2011 and December 2013 before the era of endovascular treatment (old-IVT-cohort). Results: In the new-IVT-cohort there were 253 intravenous thrombolysis + endovascular treatment treated patients. The new-IVT-cohort was associated with a better outcome on the modified Rankin Scale at 3 months in univariable ordinal regression (OR 1.27; 95% CI 1.08-1.49). The association remained significant (OR 1.65; 95% CI 1.27-2.14) also after adjustment for following confounding factors: sex, NIHSS, diabetes, atrial fibrillation, hypertension, coronary artery disease, hypercholesterolemia, myocardial infarction, heart failure, history of ischemic stroke, history of TIA, and use of antithrombotic, statins, antihypertensive, anticoagulation treatment, or endovascular treatment (Fig. 1). Conclusion: We were able to verify the efficacy of endovascular treatment in a real life cohort of intravenous thrombolysis patients even when only 28% of the patients are eligible for endovascular treatment on top of intravenous thrombolysis treatment.

EndoVAscular treatment and ThRombolysis for Ischemic Stroke Patients (EVA-TRISP) registry: basis and methodology of a pan-European prospective ischaemic stroke revascularisation treatment registry.

PURPOSE: The Thrombolysis in Ischemic Stroke Patients (TRISP) collaboration was a concerted effort initiated in 2010 with the purpose to address relevant research questions about the effectiveness and safety of intravenous thrombolysis (IVT). The collaboration also aims to prospectively collect data on patients undergoing endovascular treatment (EVT) and hence the name of the collaboration was changed from TRISP to EVA-TRISP. The methodology of the former TRISP registry for patients treated with IVT has already been published. This paper focuses on describing the EVT part of the registry. PARTICIPANTS: All centres committed to collecting predefined variables on consecutive patients prospectively. We aim for accuracy and completeness of the data and to adapt local databases to investigate novel research questions. Herein, we introduce the methodology of a recently constructed academic investigator-initiated open collaboration EVT registry built as an extension of an existing IVT registry in patients with acute ischaemic stroke (AIS). FINDINGS TO DATE: Currently, the EVA-TRISP network includes 20 stroke centres with considerable expertise in EVT and maintenance of high-quality hospital-based registries. Following several successful randomised controlled trials (RCTs), many important clinical questions remain unanswered in the (EVT) field and some of them will unlikely be investigated in future RCTs. Prospective registries with high-quality data on EVT-treated patients may help answering some of these unanswered issues, especially on safety and efficacy of EVT in specific patient subgroups. FUTURE PLANS: This collaborative effort aims at addressing clinically important questions on safety and efficacy of EVT in conditions not covered by RCTs. The TRISP registry generated substantial novel data supporting stroke physicians in their daily decision making considering IVT candidate patients. While providing observational data on EVT in daily clinical practice, our future findings may likewise be hypothesis generating for future research as well as for quality improvement (on EVT). The collaboration welcomes participation of further centres willing to fulfill the commitment and the outlined requirements.

Microsurgical removal of a misplaced intraspinal venous stent in a patient with inferior vena cava atresia.

Inferior vena cava atresia (IVCA) is a rare vascular condition that may be treated by venous stenting. The authors report on the microsurgical removal of an intraspinally misplaced stent causing nerve root compression and neurological deficits.A 42-year-old patient with IVCA and painful cutaneous collaterals had been scheduled for treatment by stenting of the iliocaval confluence and associated venous collaterals. Initial stenting of the right iliac vein was successful; however, during recanalization of the left paravertebral plexus, the stent entered the spinal canal via extraspinal-to-intraspinal venous collaterals. Because of the use of monoplanar angiography, the stent misplacement was not seen during the procedure. Postinterventionally, the patient experienced a foot elevation weakness (grade 1/5) as well as pain and hypesthesia corresponding to the L5 dermatome. Ultrasonography ruled out a lumbosacral plexus hematoma. CT angiography showed that a stent had entered the spinal canal through the left S1 neuroforamen causing nerve root compression. The intraspinal portion of the stent was removed piecemeal via a left-sided hemilaminectomy. Venous bleeding due to the patient's anticoagulation therapy, the stent's sharp mesh wire architecture, and the proximity to nerve roots complicated the surgery. Postoperatively, the foot elevation improved to grade 4/5.

Catheter-Directed Thrombolysis Versus Pharmacomechanical Thrombectomy for Upper Extremity Deep Venous Thrombosis: A Cost-Effectiveness Analysis.

BACKGROUND: Upper extremity deep vein thrombosis represents (UEDVT) 2-3% of all deep vein thrombosis. Catheter directed thrombolysis (CDT) was replaced largely by pharmacomechanical thrombolysis (PMT) in our institution. In this study we compared the immediate and 1-year results as well as the total hospital costs between CDT and PMT in the treatment of UEDVT. METHODS: From 2006 to 2013, 55 patients with UEDVT were treated with either CDT or PMT at Helsinki University Hospital. Of them, 43 underwent thoracoscopic rib resection later to relieve phlebography-confirmed vein compression. This patient cohort was prospectively followed up with repeated phlebographies. CDT was performed to 24 patients, and 19 had PMT with a Trellis™ device. Clinical evaluation and vein patency assessment were performed with either phlebography or ultrasound 1 year after the thrombolysis. Primary outcomes were immediate technical success, 1-year vein patency, and costs of the initial treatment. RESULTS: The immediate overall technical success rate, defined as recanalization of the occluded vein and removal of the fresh thrombus, was 91.7% in the CDT group and 100% in the PMT group (n.s.). The median thrombolytic time was significantly longer in CDT patients than that in PMT patients (21.1 vs. 0.33 hr, P < 0.00001). There were no procedure-related complications. The 1-year primary assisted patency rate was similar in both the groups (91.7% and 94.7%). There were no recurrences of clinical DVT. The hospital costs for the acute period were significantly lower in the PMT group than those in the CDT group (medians: 11,476 € and 5,975 € in the CDT and PMT groups, respectively [P < 0.00001]). CONCLUSIONS: The clinical results of the treatment of UEDVT with CDT or PMT were similar. However, PMT required shorter hospital stay and less intensive surveillance, leading to lower total costs.

The evolution of the Helsinki frostbite management protocol.

BACKGROUND: Severe frostbite can result in devastating injuries leading to significant morbidity and loss of function from distal extremity amputation. The modern day management approach to frostbite injuries is evolving from a historically very conservative approach to the increasingly reported use of early interventional angiography and fibrinolysis with tPA. The aim of this study was to evaluate the results of our frostbite treatment protocol introduced 3 years ago. METHODS: All frostbite patients underwent first clinical and then Doppler ultrasound examination. Angiography was conducted if certain clinical criteria indicated a severe frostbite injury and if there were no contraindications to fibrinolysis. Intra-arterial tissue plasminogen activator (tPA) was then administered at 0.5-1mg/h proximal to the antecubital fossa (brachial artery) or popliteal fossa (femoral artery) if angiography confirmed thrombosis, as well as unfractionated intravenous heparin at 500 units/h. The vasodilator iloprost was administered intravenously (0.5-2.0ng/kg/min) in selected cases. RESULTS: 20 patients with frostbite were diagnosed between 2013-2016. Fourteen patients had a severe injury and angiography was performed in 10 cases. The total number of digits at risk was 111. Nine patients underwent fibrinolytic treatment with tPA (including one patient who received iloprost after initial non response to tPA), 3 patients were treated with iloprost alone and 2 patients received neither treatment modality (due to contraindications). The overall digital salvage rate was 74.8% and the Hennepin tissue salvage rate was 81.1%. One patient developed a catheter-site pseudoaneurysm that resolved after conservative treatment. CONCLUSIONS: Prompt referral to a facility where interventional radiology and 24/7 laboratory services are available, and the combined use of tPA and iloprost, may improve outcome after severe frostbite.

Actual and Potential Radiation Exposures in Digital Radiology: Analysis of Cumulative Data, Implications to Worker Classification and Occupational Exposure Monitoring.

Radiation worker categorization and exposure monitoring are principal functions of occupational radiation safety. The aim of this study was to use the actual occupational exposure data in a large university hospital to estimate the frequency and magnitude of potential exposures in radiology. The additional aim was to propose a revised categorization and exposure monitoring practice based on the potential exposures. The cumulative probability distribution was calculated from the normalized integral of the probability density function fitted to the exposure data. Conformity of the probabilistic model was checked against 16 years of national monitoring data. The estimated probabilities to exceed annual effective dose limits of 1 mSv, 6 mSv and 20 mSv were 1:1000, 1:20 000 and 1:200 000, respectively. Thus, it is very unlikely that the class A categorization limit of 6 mSv could be exceeded, even in interventional procedures, with modern equipment and appropriate working methods. Therefore, all workers in diagnostic and interventional radiology could be systematically categorized into class B. Furthermore, current personal monitoring practice could be replaced by use of active personal dosemeters that offer more effective and flexible means to optimize working methods.

Angiomatosis of soft tissue as an important differential diagnosis for intramuscular venous malformations.

Background We aimed to improve management of extremity low-flow vascular malformations by analyzing the histology and imaging of venous malformations (VMs) not responsive to sclerotherapy. Method We reviewed patient records of 102 consecutive patients treated with sclerotherapy for extremity VM in our institution to identify patients who had undergone surgery due to insufficient response. We semi-quantitatively analysed the tissue specimens and compared histological findings to those in preoperative imaging. Result The number of patients operated on was 19 (18.6%); 15 of them had lower-extremity intramuscular lesions. The histological pattern of 13 of these 15 lesions corresponded to angiomatosis of soft tissue (AST). All other lesions treated surgically were VMs. The histology of AST was distinctive but magnetic resonance imaging findings often overlapped with those of VM. Conclusion AST is easily mixed with intramuscular VM. The differentiation of these two entities has therapeutic importance. We emphasize the role of histology in the differential diagnostics of intramuscular slow-flow vascular malformations.

Efficacy of endovascular treatment for pelvic congestion syndrome.

BACKGROUND: Chronic pelvic pain is not a rare health problem among women. One of the most common causes of chronic pelvic pain is pelvic congestion syndrome (PCS). We have reviewed all medical literature on the endovascular treatment of PCS and hereby provide a brief overview of the anatomy, pathophysiology, and clinical aspects of ovarian and pelvic varices. We describe the technique of transcatheter embolization, the complications thereof and the clinical results of the treatment. METHODS: A literature search was performed using PubMed, Science Direct, Google Scholar, and Scopus to identify case series on the endovascular treatment of PCS up until the end of November 2014. RESULTS: Twenty studies with a total of 1081 patients were included in the review. There were no randomized trials, and only one study included a control group. The immediate technical success rate in the occlusion of the affected veins was 99%. Seventeen studies reported the 1- to 3-month clinical success of 641 patients. Of these, 88.1% reported moderate to significant relief in the symptoms and 11.9% reported little or no relief. In 17 studies, long-term results were reported, and the follow-up varied between 7.3 months and 5 years. In late follow-up, 86.6% reported relief of the symptoms and 13.6% experienced little or no relief. CONCLUSIONS: The immediate success rate for the endovascular treatment of PCS is good and the complication rate low. Most patients report relief in the symptoms for up to 5 years after the procedure. However, there are no randomized or high-quality controlled trials, and the level of evidence therefore remains at C.

Sclerotherapy complications of peripheral venous malformations.

Background Sclerotherapy is often the primary treatment for peripheral venous malformations. It is mostly sufficient alone, but can be combined with other endovascular techniques. Despite its mini-invasiveness, it is not without potentially severe complications. Here, we systematically report sclerotherapy complications in trunk and extremity venous malformations. Methods We retrospectively assessed the complications of 127 consecutive patients who had received sclerotherapy for peripheral venous malformation in our tertiary care unit (January 2007-August 2013). We applied the Clavien-Dindo classification to grade the severity of complications. We mostly used detergent sclerosants (85.7%), and less often ethanol (5.7%) or bleomycin (4.2%). In 4.2% of the procedures, we combined glue, coils, endovascular laser or particles to sclerotherapy. Results The overall complication rate per procedure was 12.5%. Most complications (83.3%) were local and managed conservatively. We encountered four severe complications, all related to blood coagulopathy. Subcutaneous lesion location and use of ethanol significantly increased the risk of local complications. Conclusion Sclerotherapy alone or combined with other endovascular techniques is a safe method for local venous malformations with moderate risk for conservatively manageable complications. Blood coagulopathy constitutes a risk for, otherwise rare, severe complications.

Complications of sclerotherapy for 75 head and neck venous malformations.

Sclerotherapy is one treatment option for head and neck venous malformations (VMs). Evaluation of complication risks is, however, essential to improve its safety. We aimed to systematically report sclerotherapy complications by means of the Clavien-Dindo classification and to distinguish factors predisposing to complications. We identified our institution's head and neck VM patients who received sclerotherapy between 1 January 2007 and 31 August 2013, analyzed patient reports retrospectively, and applied to them the Clavien-Dindo classification. Our 75 VM patients underwent a total of 150 sclerotherapy sessions. The most common sclerosants were 3 % sodium tetradecyl sulfate and polidocanol. Complications occurred in 13 patients (17.3 %) and in 15 sessions (10.0 %); 3 complications required extensive postprocedural treatment and caused permanent morbidity, whereas 12 received conservative treatment. Patients with sclerotherapy complications underwent more treatments (p = 0.009) and more often needed further surgery (p = 0.007). We thus consider sclerotherapy a relatively safe treatment modality for head and neck VMs. To avoid complications, evaluation of VM characteristics and optimal treatment technique in a multidisciplinary team is vital.

An interdisciplinary specialist team leads to improved diagnostics and treatment for paediatric patients with vascular anomalies.

AIM: Patients with vascular anomalies are often misdiagnosed, leading to delayed or improper treatment. The aim of this study was to evaluate the impact of an interdisciplinary team on the diagnosis and treatment of paediatric patients with vascular anomalies. METHODS: We reviewed the paediatric patients evaluated by our interdisciplinary team between 2002 and 2012, analysing the referral diagnosis, final diagnosis, patient age, sex, clinical history, laboratory tests, imaging studies and treatments. RESULTS: Of the 480 patients who were evaluated, 435 (90.6%) had a vascular anomaly: 30.7% of all patients had a tumour and 55.2% had a malformation. Haemangiomas comprised 93.2% of all tumours, while malformations included capillary (9.8%), lymphatic (30.1%), venous (36.8%), arteriovenous (3.8%) and combined slow-flow (7.9%) malformations. Tumours were initially diagnosed correctly in 89.2% of the patients, but only 38.0% of the malformations were diagnosed correctly. Improper treatment was given to 1.4%, due to incorrect diagnoses. CONCLUSION: This study showed that haemangiomas were likely to be diagnosed correctly, but other tumours and vascular malformations were likely to be misdiagnosed. Misdiagnosis seldom led to improper treatment, but probably led to delayed treatment in many cases. The interdisciplinary approach led to improved diagnostics and treatment.

Intravenous alteplase versus rescue endovascular procedure in patients with proximal middle cerebral artery occlusion.

OBJECTIVES: To compare outcome of ischaemic stroke patients undergoing rescue endovascular procedure for proximal middle cerebral artery occlusion with matched patients without endovascular procedure after unsuccessful intravenous thrombolysis. METHODS: Endovascularly treated patients with middle cerebral artery occlusion (n = 41) were matched by propensity score with similar patients treated by intravenous thrombolysis and having a considerable post-thrombolysis neurological deficit (n = 82). We compared their three-month outcome (modified Rankin Scale) and frequency of symptomatic intracerebral haemorrhage. For the endovascular group, we report onset-to-puncture time, onset-to-recanalization time, and recanalization rates. RESULTS: In age, gender, time from onset, admission National Institutes of Health Stroke Scale, systolic and diastolic blood pressure, blood glucose, history of hypertension, diabetes mellitus, hyperlipidaemia, atrial fibrillation, and congestive heart failure, and in aetiology, the groups were similar. Endovascular group patients had a recanalization rate of 90%, and more often reached three-month modified Rankin Scale 0-2 (36.6% vs. 18.3%, P = 0.03). Mortality was equally common (19.5%) in both groups, and frequency of symptomatic intracerebral haemorrhage was 9.8% vs. 14.6% (P = 0.45). The endovascular group's median onset-to-puncture time was four-hours and six-minutes and onset-to-recanalization time was five-hours and 12 min. The latter time was more than one-hour longer in patients treated under general anaesthesia compared with patients treated under conscious sedation (median four-hours 50 min vs. five-hours 58 min; P < 0.01). CONCLUSIONS: Rescue endovascular approach increases likelihood of recanalization and may improve functional outcome in acute ischaemic stroke patients with proximal middle cerebral artery occlusion who did not respond to intravenous thrombolysis.

[Renal denervation in the treatment of hypertension]. / Munuaisten denervaatio hypertension hoidossa.

Therapy resistant hypertension is common in hypertensive patients. The kidneys play an important role in the sympathetic nervous system overactivity associated with hypertension. Percutaneous transluminal ablation of renal nerves is a novel treatment strategy for resistant hypertension decreasing both renal and systemic sympathetic activity. Renal denervation resulted in significant blood pressure reduction within 6 months in a multicentre, prospective, randomized trial. The treatment has proved safe and blood pressure reduction appears sustained up to 2 years. It also improves glycemic control. Further studies are needed to evaluate the mortality and morbidity impact of this promising therapy of resistant hypertension.

Angiosome-targeted infrapopliteal endovascular revascularization for treatment of diabetic foot ulcers.

OBJECTIVE: Because of the prolonged healing time of diabetic foot ulcers, methods for identifying ways to expedite the ulcer healing process are needed. The angiosome concept delineates the body into three-dimensional blocks of tissue fed by specific source arteries. The aim of this study was to evaluate the benefit of infrapopliteal endovascular revascularization guided by an angiosome model of perfusion in the healing process of diabetic foot ulcers. METHODS: A total of 250 consecutive legs with diabetic foot ulcers in 226 patients who had undergone infrapopliteal endovascular revascularization in a single center were evaluated. Patient records and periprocedural leg angiograms were reviewed. The legs were divided into two groups depending on whether direct arterial flow to the site of the foot ulcer based on the angiosome concept was achieved (direct group) or not achieved (indirect group). Ulcer healing time was compared between the two groups. A propensity score was used for adjustment of differences in pretreatment covariables in multivariate analysis and for 1:1 matching. RESULTS: Direct flow to the angiosome feeding the ulcer area was achieved in 121 legs (48%) compared with indirect revascularization in 129 legs. Foot ulcers treated with angiosome-targeted infrapopliteal percutaneous transluminal angioplasty healed better. The ulcer healing rate was mean (standard deviation) 72% (5%) at 12 months for the direct group compared with 45% (6%) for the indirect group (P < .001). When adjusted for propensity score, the direct group still had a significantly better ulcer healing rate than the indirect group (hazard ratio, 1.97; 95% confidence interval, 1.34-2.90; P = .001). CONCLUSIONS: Attaining a direct arterial flow based on the angiosome model of perfusion to the foot ulcer appears to be important for ulcer healing in diabetic patients.

IV Thrombolysis-Bridging and Endovascular Treatment for Occlusive Internal Carotid Artery Dissection with Tandem Occlusion.

Compared to other etiologies of ischemic stroke, occlusive internal carotid artery dissection responds worse to intravenous (IV) thrombolysis. Intracranial tandem occlusion is a predictor of poor outcome. A direct endovascular approach has been proposed as a safe and probably superior alternative to IV thrombolysis. However, it may lead to considerable treatment delays. We used rapidly initiated IV thrombolysis-bridging and subsequent endovascular treatment in two patients with severe hemispheric ischemia due to occlusive internal carotid artery dissection with tandem occlusion and achieved good outcomes. Minimizing recanalization times likely improves patient outcome and IV thrombolysis-bridging may be a reasonable strategy to achieve this. The positive initial results obtained with endovascular approaches and IV thrombolysis-bridging in this patient group deserve further scientific exploration.