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Cerebral perforators are end-arteries that vascularize specific deep territories in the cerebral hemispheres and brainstem. Due to improved imaging quality, these aneurysms are increasingly diagnosed in clinical routine. High resolution 3D angiographic images are mandatory and in some occasions fusion images might be helpful to detect these aneurysms. Basilar artery perforator aneurysms (or BAPAs) are one of the most common subtypes of perforator aneurysms and might cause subarachnoid hemorrhage along the brainstem (perimesencephalic hemorrhage). Due to the limited evidence, the management of BAPAs may pose a challenge in clinical routine. While some aneurysms can be managed conservatively, a few might require treatment to prevent rebleeding. We present the cases of two patients with BAPAs managed at our center in order to increase the awareness on these potentially underdiagnosed aneurysms.

Background: Acute basilar artery occlusion (BAO) is a severe disease that is associated with an 85% mortality rate if untreated. Several studies have analyzed the use of mechanical thrombectomy (MT) in the different scenarios of BAO. However, the results remain conflicting and the role of MT as standard of care for vertebrobasilar tandem occlusions (VBTO) has not been confirmed. Our goal was to assess technical feasibility, safety, and functional outcome of endovascular treatment of VBTO in comparison to isolated BAO (IBAO)., Methods: We retrospectively reviewed all prospectively collected patients with acute BAO from six tertiary centers between September 2016 and November 2021. Patients were subsequently divided into two groups: VBTO and IBAO. Baseline data, procedural details, and outcomes were compared between groups., Results: A total of 190 patients were included, 55 presenting with a VBTO and 135 with IBAO. Successful recanalization was equally common in both groups (89.1% and 86.0%). Rates of favorable functional outcome (modified Rankin Scale: 0-2) were higher in patients with VBTO compared to IBAO (36.4% vs. 25.2%, p = 0.048) and mortality was lower (29.1% vs. 33.3%). However, these associations faded after adjustment for confounders (adjusted odds ratio [aOR] 0.86, 95% CI 0.35-2.05; aOR 0.93, 95% CI 0.35-2.45). Rates of symptomatic intracranial hemorrhage did not differ between the groups (VBTO: 7.3% vs. IBAO: 4.2%; p = 0.496)., Conclusion: Endovascular treatment of VBTO is technically feasible and safe with similar rates of successful recanalization, favorable functional outcome, and mortality to those in patients with IBAO., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Heldner reports grants from the Bangerter Foundation and Amgen Advisory board participation, not related to the present study. Dr Kaesmacher reports grants from the Swiss Academy of Medical Sciences/Bangerter Foundation, Swiss Stroke Society, and Clinical Trials Unit Bern during the conduct of the study. Dr Mordasini reports research support from Siemens, Cerenovus, iSchemaview, Medtronic and Stryker, and receipt of honoraria and consultation fees from Medtronic, Cerenovus, Phenox, and Microvention paid to the institution, not related to the present study.

Background: The no-reflow phenomenon refers to the absence of microvascular reperfusion despite macrovascular reperfusion., Aim: The aim of this analysis was to summarize the available clinical evidence on no-reflow in patients with acute ischemic stroke., Methods: A systematic literature review and a meta-analysis of clinical data on definition, rates, and impact of the no-reflow phenomenon after reperfusion therapy was carried out. A predefined research strategy was formulated according to the Population, Intervention, Comparison, and Outcome (PICO) model and was used to screen for articles in PubMed, MEDLINE, and Embase up to 8 September 2022. Whenever possible, quantitative data were summarized using a random-effects model., Results: Thirteen studies with a total of 719 patients were included in the final analysis. Most studies (n = 10/13) used variations of the Thrombolysis in Cerebral Infarction scale to evaluate macrovascular reperfusion, whereas microvascular reperfusion and no-reflow were mostly assessed on perfusion maps (n = 9/13). In one-third of stroke patients with successful macrovascular reperfusion (29%, 95% confidence interval (CI), 21-37%), the no-reflow phenomenon was observed. Pooled analysis showed that no-reflow was consistently associated with reduced rates of functional independence (odds ratio (OR), 0.21, 95% CI, 0.15-0.31)., Conclusion: The definition of no-reflow varied substantially across studies, but it appears to be a common phenomenon. Some of the no-reflow cases may simply represent remaining vessel occlusions, and it remains unclear whether no-reflow is an epiphenomenon of the infarcted parenchyma or causes infarction. Future studies should focus on standardizing the definition of no-reflow with more consistent definitions of successful macrovascular reperfusion and experimental set-ups that could detect the causality of the observed findings., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: TD reports consultancy for Medtronic. JMO reports consultancy for Bioxodes, Abbvie, and Acticor, and speaker fees from Boehringer Ingelheim and Bristol Myers Squibb. JG reports a Swiss National Funds grant for MRI in stroke. UF reports research grants from Medtronic BEYOND SWIFT registry, the Swiss National Science Foundation, and the Swiss Heart Foundation; consulting fees from Medtronic, Stryker, and CSL Behring (fees paid to institution); has membership of a data safety monitoring board for the IN EXTREMIS trial and the TITAN trial; and was on the advisory board for Portola (Alexion; fees paid to institution). JK reports financial support from Medtronic for the BEYOND SWIFT registry (fees paid to institution); and research grants from the Swiss National Science Foundation supporting the TECNO trial (fees paid to institution), Swiss Academy of Medical Sciences supporting MRI research (fees paid to institution), and Swiss Heart Foundation supporting cardiac MRI in the aetiological work-up of stroke patients (fees paid to institution).