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Background The degree of reperfusion is the most important modifiable predictor of 3 month functional outcome and mortality in ischemic stroke patients treated with mechanical thrombectomy. Whether the beneficial effect of reperfusion also leads to a reduction in long term mortality is unknown. Methods Patients undergoing mechanical thrombectomy between January 2010 and December 2018 were included. The post-thrombectomy degree of reperfusion and emboli in new territories were core laboratory adjudicated. Reperfusion was evaluated according to the expanded Thrombolysis in Cerebral Infarction (eTICI) scale. Vital status was obtained from the Swiss population register. Adjusted hazard ratios (aHRs) using time split Cox regression models were calculated. Subgroup analyses were performed in patients with borderline indications. Results Our study included 1264 patients (median follow-up per patient 2.5 years). Patients with successful reperfusion had longer survival times, attributable to a lower hazard of death within 0-90 days and for >90 days to 2 years (aHR 0.34, 95% CI 0.26 to 0.46; aHR 0.37, 95% CI 0.22 to 0.62). This association was homogeneous across all predefined subgroups (p for interaction >0.05). Among patients with successful reperfusion, a significant difference in the hazard of death was observed between eTICI2b50 and eTICI3 (aHR 0.51, 95% CI 0.33 to 0.79). Emboli in new territories were present in 5% of patients, and were associated with increased mortality (aHR 2.3, 95% CI 1.11 to 4.86). Conclusion Successful, and ideally complete, reperfusion without emboli in new territories is associated with a reduction in long term mortality in patients treated with mechanical thrombectomy, and this was evident across several subgroups. [ABSTRACT FROM AUTHOR]

Background and purpose Acute basilar artery occlusion (BAO) is a devastating disease with a high rate of mortality and morbidity, and early recanalization is crucial to achieve a good prognosis. The best treatment strategy for BAO combined with a proximal stenosis (tandem occlusion) is not yet clear. Our study aimed to evaluate whether and how vertebrobasilar tandem occlusions can be treated effectively and safely compared with isolated BAO. Materials and methods Fifty-two patients with acute vertebrobasilar occlusive stroke treated with mechanical thrombectomy were identified in a prospective database from March 2010 to September 2016. We retrospectively analysed the clinical, technical, and functional outcomes of the patients. results Of the 52 patients, 15 presented with a tandem occlusion, 14 with a single intracranial occlusion due to an underlying stenosis, and 23 with a single embolic BAO. Successful recanalization was achieved in all of the patients with tandem occlusions (modified Thrombolysis in Cranial infarction 2b/3) and in 35 of 37 patients with a single BAO (with and without stenosis). A favourable outcome was achieved (modified Rankin Scale ≤2) in 8 of the 15 patients with a tandem occlusion compared with 4 of the 14 patients with a single BAO with underlying stenosis and 5 of the 23 patients with isolated embolic BAO (p=0.18). Conclusions We suggest that endovascular treatment of vertebrobasilar tandem occlusions is safe and feasible, with a high rate of good outcome. [ABSTRACT FROM AUTHOR]

Introduction Dual coaxial lumen balloon microcatheters through which small stents can be delivered have recently been described. We report a series of a new type of dual lumen balloon catheter with a parallel lumen design enabling enhanced inflation and deflation properties through which larger stents may be deployed, including flow diverters (FD). Methods All aneurysms that were treated with a Copernic 2L (COP2L) dual lumen balloon catheter at our institution between February 2014 and December 2016 were assessed. Patient demographics, aneurysm characteristics, clinical and angiographic follow-up, as well as adverse events were analyzed. results A total of 18 aneurysms in 16 patients (14 women) were treated with the COP2L. Mean maximal aneurysm diameter was 6.4 mm, mean neck size was 3.3 mm (min 1; max 6.3), and mean aneurysm height/width was 1.1 (min 0.5; max 2.1). The COP2L was used for balloon-remodeled coiling exclusively in 2 aneurysms; coiling and FD stenting in 8; coiling and braided stent delivery in 3; coiling, braided and FD stenting in 1; and FD stenting without coiling in 4 (stenting alone). The rate of Roy-Raymond 1 (complete occlusion) changed from 22% in the immediate postoperative period to 100% at 3 months (mean imaging follow-up 8.2 months). There were three technical complications (3/16, 18.7%), including a perforation and two thromboembolic asymptomatic events that were rapidly controlled with the COP2L. There was no immediate or delayed morbidity or mortality (modified Rankin Scale score 0-1 in 100% of patients). Conclusion The COP2L is a new type of dual lumen balloon catheter that may be useful for balloon and/or stent-assisted coiling of cerebral aneurysms. The same device can be used to deliver stents up to 4.5 mm and to optimize stent/wall apposition or serve as a life-saving tool in case of thromboembolic or hemorrhagic events. Long-term efficacy and safety need to be further assessed with larger case-controlled cohorts. [ABSTRACT FROM AUTHOR]

Background and purpose Thrombus composition has been postulated to affect the success of endovascular therapy. calcified clots are composed of large amounts of calcium phosphate which influences their mechanical properties and may serve as a model for testing this hypothesis. The aim of this study was to evaluate the recanalization and complication rates of calcified thromboemboli in patients with acute ischemic stroke who underwent thrombectomy. Material and methods A retrospective analysis was performed of all calcified intracranial thromboemboli in patients suffering an acute ischemic stroke, referred for endovascular therapy at two centers between January 2013 and July 2016. results eight patients with a calcified intracranial clot underwent stent retriever thrombectomy (five women; mean age 80 years). Mean clot attenuation was 305 HU (range 150-640 HU). successful reperfusion defined, as Thrombolysis in Cerebral infarction grade 2b-3 was achieved in only one patient (12.5%). Two periprocedural adverse events occurred: one peripheral vessel perforation which was coiled and one inadvertent stent retriever detachment due to fracture of the stent retriever wire. Conclusion stent retriever thrombectomy of calcified thromboemboli seems less effective than with other types of clots. Different mechanical properties of calcified clots may render them stiffer and less accessible for stent retrievers. When faced with a calcified intracranial thromboembolus in clinical practice, a more contained approach may be warranted in view of low recanalization rates, and the potential for periprocedural adverse events. [ABSTRACT FROM AUTHOR]

Purpose: Stent retrievers apply mechanical force to the intracranial vasculature. Our aim was to evaluate the safety and efficacy of the long Solitaire 4 × 40 mm stent retriever for large vessel occlusion in stroke patients. Methods: We conducted a retrospective analysis of all patients treated for acute ischemic large vessel occlusion stroke with the Solitaire 2 FR 4 × 40 device between May and October 2016 at our institution. Patient-specific data at baseline and at discharge were documented. Reperfusion was graded with the thrombolysis in cerebral infarction (TICI) classification. Postinterventional angiograms and follow-up cross-sectional imaging were used to evaluate complications. Results: TICI 2b/3 recanalization was achieved in 20 of 23 patients (87.0%), in 17 patients with the first retriever pass. NIHSS improved from a mean score at presentation of 16 (range 4-36) to 11 (range 0-41) at discharge. Mean mRS score at discharge was 3 (range 0-6) and 3 (range 0-6) at 90 days post-treatment. No infarcts in other territories were observed. One patient showed a (reversible) vasospasm in the postinterventional angiogram and another a small contrast extravasation in follow-up imaging. Conclusion: The Solitaire 2 FR 4 × 40 stent retriever is a safe and efficient device for large vessel occlusion acute ischemic stroke with a high recanalization rate and a low peri- and postinterventional complication rate together with a good clinical outcome. Despite potentially higher friction and shearing forces, no increased incidence of visible damage to the vessel wall was observed. [ABSTRACT FROM AUTHOR]

Background: Recent studies suggested that modified Thrombolysis in Cerebral Infarction grade (mTICI) 3 reperfusions are associated with superior outcome to mTICI2b reperfusions, questioning if neurointerventionalists should generally strive to achieve mTICI3.Methods: Retrospective analysis of successfully reperfused MCA occlusions (n=246) with available angiography runs between every manoeuvre was performed. Final reperfusion success and those between all single manoeuvres were evaluated applying the modified version of the TICI score (including TICI2c). Final TICI2c/3 reperfusions were dichotomized as 'direct' (reperfusion before final manoeuvre ≤mTICI2a) or 'secondary improved' (mTICI2b was achieved).Results: Patients with mTICI2c reperfusion had similar outcome to patients with mTICI3 rather than mTICI2b reperfusions. Compared with mTICI2c/3-patients, mTICI2b-patients had lower rates of neurological improvement (33.3% vs. 61.2%, p<0.001) and good functional outcome (28.7% vs. 46.5%, p=0.008). In 28 patients, mTICI2b reperfusion was improved to mTICI2c/3 without complications. Outcome of patients with 'direct' or 'secondary improved' mTICI2c/3 did not differ (p>0.5).Conclusion: Improving mTICI2b reperfusions to mTICI2c/3 reperfusions is sometimes technically feasible and safe, and associated with clinical benefit comparable to 'direct' mTICI2c/3 reperfusions. If confirmed, a more aggressive treatment approach in cases of already achieved mTICI2b may be justified, although proper patient selection is needed.Key Points: • Patients with mTICI2c or 3 reperfusions have a comparable clinical course. • mTICI2c/3 are associated with a larger therapeutic benefit than are mTICI2b reperfusions. • Improving reperfusion from mTICI2b to mTICI2c/3 is sometimes feasible and reasonably safe. • Outcome of patients with 'secondary improved' and 'direct' mTICI2c/3 is not different. [ABSTRACT FROM AUTHOR]

Background and purpose Coincidental aneurysms in the target vessels of stroke patients with large vessel occlusions (LVO) may pose risks during endovascular mechanical thrombectomy (MTE), but there are almost no data on this subject. Motivated by an incident of rupture of a hidden aneurysm induced by withdrawal of a stent retriever during a MTE procedure, this study examines the prevalence of aneurysms, associated complications, and implications for treatment strategies in patients with LVO stroke. Methods A single-center retrospective analysis of angiographic and CT/MRI images and case records of 300 consecutive patients with LVO stroke treated with MTE was performed. Results Aneurysms related to target vessels were detected in 11/300 patients, in 10/11 in the anterior circulation. In 9/11 patients the aneurysms were unknown prior to the stroke. The observed prevalence was >2-fold higher than expected for a healthy reference population. There was one complication (aneurysm rupture), as described above. In two subsequent patients with known aneurysms, MTE was conducted mainly with aspiration techniques which failed, contributing to a low recanalization rate in patients with aneurysm (45%). Conclusions The prevalence of aneurysms is relatively high in patients with LVO stroke, particularly in older, female, hypertensive patients, presumably reflecting overlapping risk factors. MTE should not be withheld from patients with LVO stroke with aneurysms, but particularly cautious approaches may be warranted. Further research in larger samples is required to obtain precise data on the prevalence and associated complication rates in MTE procedures. This is necessary to estimate the true risk and to tailor endovascular strategies in these patients. [ABSTRACT FROM AUTHOR]

Purpose To propose a modified dynamic CT myelographic technique to locate cerebrospinal fluid (CSF) leaks, also known as cryptogenic leaks, in patients with spontaneous intracranial hypotension (SIH) in whom previous imaging did not show the dural breach. Materials and Methods This retrospective analysis included 74 consecutive patients with SIH and a myelographically proven CSF leak who were evaluated between February 2013 and October 2017. In 14 patients, dynamic CT myelography in the prone or lateral position showed the exact leakage point after unsuccessful previous imaging. During image analysis, the first time point showing extrathecal contrast material was defined as the site of dural breach point. Results Mean population age was 44 years (range, 25-65 years [nine women; mean age, 44 years; age range, 25-65 years] [five men; mean age, 46 years; age range, 29-61 years]). All patients had previously undergone spine MRI, conventional dynamic myelography, and CT myelography. Subsequent dynamic CT myelography covered a mean range of seven vertebral levels. The leak was caused by a calcified microspur in 10 patients and by a dural tear at the axilla of a spinal nerve root in the remaining four. The mean volume CT dose index of dynamic CT myelography was 107 mGy (range, 12-246 mGy), and the mean dose-length product was 1347 mGy·cm (range, 550-3750 mGy·cm). Conclusion Dynamic CT myelography is a valuable adjunctive tool with which to identify the precise location of a dural tear when other examinations are unsuccessful. © RSNA, 2018 See also the editorial by Dillon in this issue.