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Purpose: Intravenous thrombolysis and mechanical thrombectomy (MT) are standard of care in patients with acute ischemic stroke due to large vessel occlusion. Data on MT in patients with intracranial hemorrhage prior to intervention is limited to anecdotal reports, as these patients were excluded from thrombectomy trials. Methods: We analyzed patients from an observational multicenter cohort with acute ischemic stroke and endovascular treatment, the German Stroke Registry—Endovascular Treatment trial, with intracranial hemorrhage before MT. Baseline characteristics, procedural parameters and functional outcome at 90 days were analyzed and compared to a propensity score matched cohort. Results: Out of 6635 patients, we identified 32 patients (0.5%) with acute ischemic stroke due to large vessel occlusion and preinterventional intracranial hemorrhage who underwent MT. Risk factors of intracranial hemorrhage were head trauma, oral anticoagulation and intravenous thrombolysis. Overall mortality was high (50%) but among patients with a premorbid modified Rankin scale (mRS) of 0–2 (n = 15), good clinical outcome (mRS 0–2) at 90 days was achieved in 40% of patients. Periprocedural and outcome results did not differ between patients with and without preinterventional intracranial hemorrhage. Conclusion: Preinterventional intracranial hemorrhage in acute ischemic stroke patients with large vessel occlusion is rare. The use of MT is technically feasible and a substantial number of patients achieve good clinical outcome, indicating that MT should not be withheld in patients with preinterventional intracranial hemorrhage. [ABSTRACT FROM AUTHOR]

Purpose: Infections with Enterohaemorrhagic Escherichia coli typically occur in children causing haemolytic uraemic syndrome (HUS) and neurological symptoms in 20-50 %. Little information is available on the morphology of brain manifestations in adults. The purpose of this study was to identify a characteristic magnetic resonance imaging (MRI) pattern during the outbreak of a novel mutation of Escherichia coli O104:H4. Methods: Patients were recruited from two hospitals between May and July 2011. The MRI protocol included standard anatomical, diffusion-weighted, and susceptibility-sensitive sequences. Results: A total of 104 MRIs of 57 (32 female, 25 male) patients (mean 45.5 ± 18.4 years) showed abnormal signal intensity on 51 MRIs (49 %). Bilateral thalamus (39 %), bilateral pons (35 %), centrum semiovale and splenium of corpus callosum (33 %) were most often involved. Acute lesions were reversible in 81 % of cases. There was no statistically significant association between symptom onset and the MRI findings ( P = 0.2). Conclusions: Neuroimaging findings in this adult patient cohort were non-specific and similar to previous findings in children. A characteristic neuroimaging pattern of an infection with Escherichia coli O104:H4 was not identified. However, bilateral symmetric T2 hyperintense lesions of the thalami and dorsal pons characterized by restricted diffusion suggest a metabolic toxic effect of the disease on the brain. [ABSTRACT FROM AUTHOR]

Introduction: Rescue intracranial stenting is necessary to provide sufficient recanalization after mechanical thrombectomy (MT) in patients with acute large vessel occlusions (LVO) due to an underlying intracranial atherosclerotic disease (ICAD). The CREDO heal is a novel stent that provides a potentially lower thrombogenicity due to surface modification. We present the first multicentric experience with the CREDO heal for acute rescue stenting., Methods: Data of 81 patients who underwent rescue stenting after MT at 12 centers in Germany and Spain were prospectively collected and retrospectively evaluated., Results: Final mTICI 2b‑3 was reached in 95.1% after median two MT maneuvers and stenting. Four periprocedural complications resulted in clinical deterioration (4.9%). Intraparenchymal hemorrhage occurred in one patient (1.2%) and functional independence at FU was reached by 42% of the patients. Most interventions were performed under Gp IIb/IIIa inhibitors., Conclusion: CREDO heal was effective and safe in our case series. However, more data is needed to define the optimal antithrombotic regime. The use under single antiplatelet medication is not supported by our study., Competing Interests: Conflict of interest: F. Dorn has (outside of this work) received outside of this work consulting honoraria from Cerenovus, Balt, Microvention, speakers honoraria from Q’Apel, Cerenovus, Acandis, Asahi Inc, Penumbra, Medtronic, Stryker, research grants from Cerenvous (outside of this work). P. Stracke has received consultancy honoraria from Acandis, Balt, speakers honoraria from Acandis, Q’Apel (outside of this work). M. Moehlenbruch has received grants outside this work from Balt, Covidien/Medtronic, MicroVention, and Stryker and consulting honoraria, speaker honoraria, and travel support outside this work from Codman and Siemens. M. Moreu is a Consultant for Stryker, Balt, Cardiva, Inspire, iVascular, Shareholder of Medtronic, Basecamp, Investigator for Angionautix, Stryker, Balt, Anaconda, Cerenovus, iVascular and has received speakers honoraria from Balt, Accandis, Stryker, Medtronic, iVascular, Inspire (outside of this work). H. Nordmeyer has recieved honoraria for lectures, presentations, educational events from Acandis, Cerenovus, Phenox, Rapid medical (outside of this work). J.H. Buhk Buhk is a consultant for Acandis, Cerenovus, Medtronic, MicroVention, Stryker, Vesalio (outside of this work). D. Vollherbst is a consultant for Medtronic (outside of this work). Y.L. Voss, M. Zidan, S. Neuhaus, N. Lehnen, W. Schwindt, M. Ergawy, C. Dyzmann, M. Moehlenbruch, J. Jesser, M. Moreu, C. Pérez-García, M. Bester, F. Flottmann, A. Simgen, S. Schob, A. Berlis, C. Maurer, H. Hentschel, C. Loehr, B. Eckert, J. Saura, F. Delgado and D. Paech declare that they have no competing interests., (© 2024. The Author(s).)

Purpose: Identification of independent treatment factors associated with high radiation exposure during endovascular mechanical thrombectomy (EMT) in acute ischemic stroke., Methods: This retrospective analysis included all patients treated by means of EMT during the 2‑year period 2017-2018 in a comprehensive stroke center. The EMT were performed by four internal and three external certified neuroradiologists in a clinic overlapping on call system. Radiation exposure as the dependent variable (dose area product DAP, Gy ⋅ cm 2 ) was dichotomized in < 100 Gy ⋅ cm 2 and ≥ 100 Gy ⋅ cm 2 . Independent variables were age (< 75 years vs. ≥ 75 years), time of intervention (during vs. beyond workday), treating neuroradiologist (internal vs. external), occlusion type ("mono" vs. "tandem"), reperfusion success (TICI 0-2A vs. TICI 2B/3), recanalization attempts (≤ 2 vs. > 2) and dose protocol (normal dose in 2017 vs. low dose in 2018)., Results: The EMT treatment of 208 patients (111 female, 97 male, mean age 71.6 years) was analyzed. Median DAP was 86.6 Gy ⋅ cm 2 and could be reduced from 104.8 Gy ⋅ cm 2 (N = 105 in 2017) to 73.3 Gy ⋅ cm 2 (N = 103 in 2018) with LD program. Univariable and multivariable binary logistic regression analysis revealed a significantly increased radiation exposure (≥ 100 Gy ⋅ cm 2 ) in tandem occlusion type (P < 0.001), > 2 recanalization attempts (P < 0.001) and normal dose protocol (P = 0.002)., Conclusion: Low dose programs can significantly reduce the radiation exposure in EMT. High radiation exposure is significantly associated with more than two recanalization attempts and in cases of tandem occlusions., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Purpose: The treatment mode in acute vertebrobasilar occlusion (VBO) remains uncertain. We analyzed efficacy and safety of intravenous glycoprotein IIb/IIIa inhibitor (IV GPI) plus subsequent intra-arterial thrombolysis with or without additional endovascular mechanical therapy (percutaneous transluminal angioplasty/stenting or thrombus aspiration) and sought treatment factors that predict good clinical outcome., Methods: We retrospectively analyzed 120 cases of patients with angiographically proven acute VBO. Multivariate logistic regression was used to identify independent predictors for clinical outcome and included level of consciousness, age, sex, time to angiography, GPI agent, admission mode, occlusion type, recanalization success, and endovascular treatment mode. Clinical follow-up was dichotomized in no to moderate disability (modified Rankin scale (mRS) 0-3) vs. severe disability or death (mRS 4-6)., Results: Median National Institutes of Health stroke scale (NIHSS) score on admission was 32, and mean NIHSS score was 24. A total of 49 patients (41 %) developed no to moderate disability (mRS 0-3), and 39 patients (33 %) died. Thrombolysis in myocardial infarction 2/3 recanalization success was achieved in 97 patients (80.8 %). Symptomatic intracerebral hemorrhages occurred in 11 patients (9 %). Mild impairment of consciousness (p < 0.001) and embolic occlusion type (p = 0.01) were significant predictors of favorable outcome. Clinical outcome in recanalized patients was better, but not statistically significant (p = 0.055)., Conclusions: Our results indicate that combined therapy with IV GPI and subsequent endovascular therapy may be a valid treatment strategy in acute VBO. With this treatment approach, a preserved vigilance before treatment and an embolic occlusion type are associated with no to moderate disability.

There is an ongoing discussion about reimbursement of stent-angioplasty for the treatment of intracranial stenoses in Germany. The discussion was initiated by the statutory health insurance companies after publication of the SAMMPRIS study results, which were in favor for medical management compared to stent-angioplasty with the Wingspan® stent system. A report (Rapid report N14-01) mainly based on SAMMPRIS was written by the German Institute for Quality and Efficiency in Health Care (IQWiG) and serves as a basis for the decision-making process. This report was previously commented by the medical societies involved. Limitations of the SAMMPRIS trial and vital indications for intracranial stenting were outlined in this comment (acute vessel occlusion, hemodynamic impairment, recurrent symptoms under medical treatment). Currently also emergency stent procedures are a matter of debate. In this context a second IQWiG report was commissioned (GA 15 - 02) addressing the results of the VISSIT trial, the transferability of the results of the first report to emergency treatments and the practice of emergency intracranial stent treatment in Germany. Regarding transferability of results the main conclusion was that there was no evidence that the results of the studies analyzed for the first report (mainly SAMMPRIS) could not be transferred to emergency treatments. From a medical professional and scientific standpoint it is inacceptable to compare outcomes of a secondary prophylactic treatment with emergency procedures. The analysis of emergency treatments in Germany based on retrospective case series with a cumulative number of 31 patients. Since most emergency procedures are performed in a clinical context and are not necessarily subject to scientific evaluation, this does not reflect current practice in Germany. The first part of this statement briefly outlines the design of SAMMPRIS and VISSIT and the interpretation of the trial results from a professional perspective. The current state of discussion regarding reimbursement of intracranial stenting is summarized. The second section contains a detailed comment on the current IQWiG report GA15-02 "Stents for the treatment of intracranial artery stenosis: VISSIT study and acute treatment in Germany".