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Background: This study investigates the impact of general anesthesia (GA) versus conscious sedation/local anesthesia (CS/LA) on the outcome of patients with minor stroke and isolated M2 occlusion undergoing immediate mechanical thrombectomy (iMT)., Methods: The databases of 16 comprehensive stroke centers were retrospectively screened for consecutive patients with isolated M2 occlusion and a baseline National Institutes of Health Stroke Scale score ≤5 who received iMT. Propensity score matching was used to estimate the effect of GA versus CS/LA on clinical outcomes and procedure-related adverse events. The primary outcome measure was a 90-day modified Rankin Scale (mRS) score of 0-1. Secondary outcome measures were a 90-day mRS score of 0-2 and all-cause mortality, successful reperfusion, procedural-related symptomatic subarachnoid hemorrhage, intraprocedural dissections, and new territory embolism., Results: Of the 172 patients who were selected, 55 received GA and 117 CS/LA. After propensity score matching, 47 pairs of patients were available for analysis. We found no significant differences in clinical outcome, rates of efficient reperfusion, and procedural-related complications between patients receiving GA or LA/CS (mRS score 0-1, P = 0.815; mRS score 0-2, P = 0.401; all-cause mortality, P = 0.408; modified Treatment in Cerebral Infarction score 2b-3, P = 0.374; symptomatic subarachnoid hemorrhage, P = 0.082; intraprocedural dissection, P = 0.408; new territory embolism, P = 0.462)., Conclusions: In patients with minor stroke and isolated M2 occlusion undergoing iMT, the type of anesthesia does not affect clinical outcome or the rate of procedural-related complications. Our results agree with recent data showing no benefit of one specific anesthesiologic procedure over the other and confirm their generalizability also to patients with minor baseline symptoms., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Unruptured brain arteriovenous malformations (AVMs) represent a complex disease in young healthy adults. Most often AVMs are clinically silent but also can display a neurologic syndrome due to hypoperfusion/hypometabolism in perilesional brain tissue called steal phenomenon., Case Description: A 34-year-old woman was admitted to a secondary neurologic center complaining of a right hemiparesis and secondarily generalized seizures. Computed tomography scan and magnetic resonance imaging of the brain showed a left prerolandic AVM without signs of acute or previous bleedings. Digital subtraction angiography confirmed a left juxta-central AVM, with a diffuse pattern, fed by hypertrophic rolandic branches from the left middle cerebral artery. An 18 F-fluorodeoxyglucose positron emission tomography-magnetic resonance imaging scan was performed 3 days after the critical episode. A significant hypometabolism in parenchymal regions ipsilaterally to the AVM was detected. Two embolization sessions were performed by means of N-butyl cyanoacrylate glue. At the end of the second procedure, a decrease of the shunt-flow and AVM size was observed. Six months later, 18 F-fluorodeoxyglucose positron emission tomography-magnetic resonance imaging scan showed persistent hypometabolism located in the AVM area, with a significant improvement of the cortical hemispheric hypometabolism. The patient was asymptomatic and was sent to stereotactic radiosurgery to complete the treatment., Conclusions: In clinical practice, irritative symptoms in patients with unruptured AVMs could lead to erroneous evaluations. In case of fluctuating clinical syndromes, like our case, establishing that symptoms are related to a steal phenomenon is usually difficult., (Copyright © 2019 Elsevier Inc. All rights reserved.)

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 (PSV MCA ) and PSV MCA ratio (recanalized PSV MCA /contralateral PSV MCA ) 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 PSV MCA ratio (3.4 ± 0.1 vs. 2.4 ± 0.1, P < 0.0001) than patients without ICH, respectively. In multivariate analysis, early PSV MCA 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 PSV MCA 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 PSV MCA 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., (Copyright © 2019 Elsevier Inc. All rights reserved.)

In vestibular schwannoma surgery, the preservation of facial and cochlear nerves is of paramount concern regarding to their effect on patients' quality of life. The rate of nerve function preservation has increased with advancements in surgical technique and neuroimaging and the introduction of intraoperative neuromonitoring. The preoperative depiction of anatomical issues between the nerves and tumor could help in surgical planning. Many studies investigating advanced imaging for cranial nerves detection, in particular diffusion tensor imaging, have been reported in the past decade. A systematic review of the reported data evaluating preoperative facial nerve fiber tracking, followed by intraoperative verification, was conducted. Seventeen studies with 223 patients (mean age, 47.5 years; range 17-77; male/female ratio 1:1.4) met our inclusion criteria. Preoperative facial nerve fiber tracking was obtained for 214 patients (96%), and subsequent intraoperative verification revealed a correct prediction for 187 cases (85.5%). The results from the present review have confirmed that preoperative fiber tracking for facial nerve identification during large vestibular schwannoma surgery is valuable and reliable. However, the included studies were not comparable in terms of images, acquisitions, or postprocessing elaboration. Larger series and homogenous magnetic resonance imaging parameters are required to strengthen these findings., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The aim of this study is to report data on a multimodal monitoring strategy based on the intraoperative use of neurophysiological monitoring, flowmetry by microflow probe, and intraoperative indocyanine green video angiography (ICG-VA) during microsurgical clipping of intracranial aneurysms., Methods: This retrospective analysis was performed on 85 consecutive patients undergoing clipping of 96 intracranial aneurysms with the present monitoring strategy. Patient outcomes were evaluated by assessing rate of aneurysm exclusion and postoperative occurrence of ischemic injury. Intraoperative data for the strategy in addition to changes in each monitoring technique depending on aneurysm features were reported., Results: Complete aneurysm exclusion was achieved in 98.9% of cases. Postoperative symptomatic ischemic injury was recorded in 2.08% aneurysms. Clip repositioning occurred in 40.6% of cases: because of motor evoked potential (MEP) decrease in 9.3%, flowmetry in 22.91%, and ICG-VA in 8.3% of treated aneurysms (1.05% after ICG injection, 7.4% after the squeezing maneuver). The role of each technique differed according to aneurysm features; flowmetry alterations occurred more frequently in distal than in proximal aneurysms (P = 0.0001) and in atherosclerotic aneurysms (P = 0.0001). MEP impairment occurred more often in proximal aneurysms (P < 0.05). ICG-VA disclosed remnant aneurysms mainly in atherosclerotic aneurysms (P < 0.05); only one false negative remnant neck was recorded with a negative predictive value of 98.8%., Conclusions: Microsurgical clipping assisted by a multimodal monitoring strategy achieved a high rate of aneurysm exclusion with low morbidity in our series. Our data show that the 3 techniques used in our strategy were complementary and that a monitoring strategy can be tailored to aneurysm features., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Endovascular treatment (EVT) is an effective therapy for acute ischemic stroke due to large artery occlusion of the anterior circulation. Yet some patients do not experience clinical improvement despite successful recanalization and reperfusion. The reasons are unknown, but one possible explanation is microvessel obstruction downstream. The aim of this study was to assess the presence of microembolic signals (MES) with transcranial Doppler and define their role as predictors of clinical outcome in stroke patients after EVT., Materials and Methods: We enrolled 40 consecutive patients (23 men, mean age 65.8 ± 7.6 years) with an acute ischemic stroke caused by large artery occlusion of the anterior circulation who underwent EVT. Presence and rate of MES were assessed by 60-minute transcranial Doppler monitoring at the end of the procedure and after 15 days from stroke onset., Results: MES were detected in 65% (26/40) of patients after EVT. Ipsilateral carotid occlusion (P = 0.05), ≥50% ipsilateral carotid stenosis (P = 0.05), incomplete recanalization (P = 0.03), and inadequate collaterals (P = 0.04) were associated with a significantly higher MES count, which was correlated with a worse functional prognosis (P = 0.03), higher mortality (P = 0.02), higher distal embolization burden even outside the original ischemic territory (P = 0.02), and higher risk of cardiovascular events (P = 0.04)., Conclusions: MES monitoring in stroke patients after EVT provides useful prognostic information, sheds light on the lack of clinical improvement despite successful recanalization, and might guide medical treatment in higher risk patients., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background and Objective: Stentriever thrombectomy failure in patients with acute ischemic stroke caused by anterior circulation large artery occlusion is not a rare event. The purpose of this study was to investigate whether other procedures (tirofiban, permanent stenting) are able to recanalize the occluded vessel and determine a better outcome without increasing mortality and intracranial hemorrhage rates., Methods: Among 513 patients consecutively admitted with anterior circulation stroke, 109 underwent stentriever thrombectomy. Modified Thrombolysis in Cerebral Ischemia (mTICI) 2b-3 recanalization was achieved in 60 patients (55.0%, group 1). Only 3 of 19 patients (group 2) obtained additional recanalization with intra-arterial infusion of tirofiban. The remaining 46 either underwent permanent stenting (n = 23, group 3) or were left nonrecanalized (n = 23, group 4). The rate of mTICI 2b-3 and clinical outcomes were analyzed in the different groups., Results: A successful recanalization (mTICI 2b-3) was achieved in 17 patients of group 3 (73.9%). A significantly better outcome was observed in group 3 (modified Rankin Scale [mRS] score, 0-2) than in group 4 at 3 months (56.5% vs. 17.4%). Symptomatic intracranial hemorrhage rates were not different between group 3 and group 4 (4.3% vs. 4.3%), whereas there was a significantly higher mortality in group 4 than in group 3 (39.1% vs. 4.3%). On multivariate analysis, permanent stenting was the only factor independently associated with favorable outcome and mortality., Conclusions: Permanent stenting might be a feasible solution in patients with acute large artery occlusion after stentriever thrombectomy failure., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Ophthalmic artery aneurysms with medial and superior projection in exceptionally rare cases can split the optic nerve. Treatment of these aneurysms is challenging, because the aneurysm dome is hidden from the optic nerve, rendering its visualization and clipping confirmation difficult. In addition, optic nerve function should be preserved during surgical maneuvers. Preoperative detection of this growing feature is usually missing., Case Description: We illustrate the first case of indocyanine green videoangiography (ICG-VA) application in an optic penetrating ophthalmic artery aneurysm treatment. A 57-year-old woman presented with temporal hemianopsia, slight right visual acuity deficit, and new onset of headache. The cerebral angiography detected a right ophthalmic artery aneurysm medially and superiorly projecting. The A1 tract of the ipsilateral anterior cerebral artery was elevated and curved, being suspicious for an under optic aneurysm growth. Surgery was performed. Initially the aneurysm was not visible. ICG-VA permitted the transoptic aneurysm visualization. After optic canal opening, the aneurysm was clipped and transoptic ICG-VA confirmed the aneurysm occlusion. ICG-VA showed also the slight improvement of the optic nerve pial vascularization. Postoperatively, the visual acuity was 10/10 and the hemianopsia did not worsen., Conclusions: The elevation and curve of the A1 tract in medially and superiorly projecting ophthalmic aneurysms may be an indirect sign of under optic growth, or optic splitting aneurysms. ICG-VA transoptic aneurysm detection and occlusion confirmation reduces the surgical maneuvers on the optic nerve, contributing to function preservation., (Copyright © 2016 Elsevier Inc. All rights reserved.)