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Background Mechanical thrombectomy is now standard of care for treatment of acute ischemic stroke secondary to large vessel occlusion in the setting of high NIHSS. We analysed a large nationwide registry focusing on patients with large vessel occlusion and low NIHSS on admission to evaluate the efficacy and safety of thrombectomy in this patient population Methods 2826 patients treated with mechanical thrombectomy were included in a multicentre registry from January 1, 2011 to December 31, 2015. We included patients with large vessel occlusion and NIHSS ≤ 6 on admission. Baseline characteristics, imaging, clinical outcome, procedure adverse events and positive and negative outcome predictors were analysed. Results 134 patients were included. 90/134 had an anterior circulation and 44 a posterior circulation stroke. One patient died before treatment. Successful revascularization (mTICI 2b-3) was achieved in 73.7% (98/133) of the patients. Intraprocedural adverse event was observed in 3% (4/133) of cases. Symptomatic intracranial haemorrhage rate was 5.3% (7/133). At three months, 70.9% (95/134) of the patients had mRS score 0-2, 15.7% (21/134) mRS 3-5 and 13.4% (18/134) mRS 6. Age and successful recanalization were significant predictors of a good clinical outcome on both univariate (p= 0.005 and p=0.007) and multivariable (p=0.0018 and p=0.009 [nat log]) analysis. Absence of vessel recanalization and symptomatic intracranial hemorrhage were independent predictors of poor outcome (p=0.021) . Conclusions Our study suggests that patients with large vessel occlusion and low NIHSS score on admission can benefit from mechanical thrombectomy. Randomized trials are warranted.

Pediatric neuromuscular diseases, clinically heterogeneous, are a diagnostic challenge, and can require invasive and expensive investigations. Two clinical cases studied with integrated electromyography (EMG) and Neuro-Muscular UltraSound (NMUS) are reported: Case 1: A 5 years-old female developing a left equinus-foot within the last year, without any trauma or infection. NMUS-examination shows selective Soleus muscle involvement with increased echogenicity and alterated architecture. The EMG-study is negative for neuropathic/myopathic disorders; the biopsy finds a Soleus’s vascular malformation. Case 2: A 12 years-old male, agonistic karateka, with pes-cavus and right lower limb’s hypometria noted in the last year following an increase in height. NMUS-study shows bilateral involvement of lower limb’s posterior loggias, mainly right, with echogenicity homogeneously increased and preserved architecture. The EMG shows a distal asymmetric polyneuropathy, predominant in the Tibial nerve. Genetic and immunological investigations are in progress. In both clinically similar cases, (paucisymptomatic, monolateral, late-onset presentation), integrated-NMUS-EMG study guided the diagnosis toward: a selective damage with muscle’s morphostructural alteration and negative EMG (case 1); a prevalent chronic damage with muscular structure preserved and EMG-detection of asymmetric neuropathy (case 2). The combined morpho-functional evaluation with integrated NMUS-EMG facilitates pediatric neuromuscular diagnosis, improving the spatial resolution with limited costs and invasiveness.

Neuromuscular ultrasound (NMUS) is a non-invasive, painless and inexpensive technique that quickly screen large areas of muscles but only few data are reported in literature about pediatric physiological muscular structural changes. We collected, by means of a NMUS Health-Technology-Assessment (HTA) study (approved by Local Ethic Committee), pediatric quantitative and qualitative normative data. By NMUS we have bilaterally studied Anterior-Tibial, Long-Toe-Extensor, Rectus-Vastus-Femoris, Forearm-Flexors, Biceps muscles, considering thickness, echogenicity, pennation in 100 healthy children (M49-F51; range 2–16, mean 10,44 years; shared in five-age-groups: (I) 2–5; (II) 6–8; (III) 9–11; (IV) 12–14; (V) 15–16 ys); in about half of them sural and/or ulnar/median perimeter and area were measured. The muscles of I–II were less echogenic than III–IV–V groups. The muscles’ thickness (MT) increased with age especially between IV and V groups. In groups I–II the females’ MT was smaller than the males’s one. MT, BMI, weight were in relationship. The nerves’ area increased from I to V group. During childhood the muscular echogenicity and thickness increased rapidly, the latter especially during the puberty. Also the nerves’ area increased with age. NMUS is a useful tool to know physiological structural changes that are crucial to correctly interpretate and guide electromyographic and neuroimaging evaluation in clinically heterogeneous pediatric neuromuscular diseases.