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Chronic Subdural Hematoma (CSDH) is a rare but classical evolutive complication of arachnoid cysts (AC). Its management has rarely been evaluated to date. Several approaches have been proposed including conservative and surgical treatments. Endovascular treatment in such CSDH subtype remains poorly reported. We present here an original case of a 16 years-old-boy suffering from ruptured AC responsible for CSDH successfully treated with embolization. Endovascular approach may be considered in the treatment of CSDH related to arachnoid cyst rupture. [ABSTRACT FROM AUTHOR]

Background and purpose: An early understanding of stroke mechanism may improve treatment and outcome in patients presenting with large vessel occlusion stroke (LVOS) treated with mechanical thrombectomy (MT). We aimed to investigate whether spontaneous external carotid artery (ECA) embolism detection during MT is associated with stroke etiology and clinical outcome. Methods: We retrospectively reviewed our prospectively maintained institutional database including consecutive patients with anterior circulation LVOS treated with MT between January 2015 and August 2020. Results: An ECA embolus was detected in 68 of 1298 patients (5.2%). The kappa coefficient for interobserver agreement was 0.89 (95% confidence interval [CI] 0.82–0.95). ECA embolism was significantly associated with intracranial internal carotid artery (ICA) occlusion (p < 0.001), cardioembolic etiology (p < 0.001) and a lower clot burden score (p < 0.001). Day‐1 variation of National Institutes of Health Stroke Scale score (adjusted odds ratio [OR] −2.7, 95% CI −4.9 to 0.3; p = 0.021) and delta Alberta Stroke Program Early Computed Tomography Score (adjusted OR 0.9, 95% CI 0.2 to 1.5; p = 0.004) were worse among patients with ECA emboli. There was no significant difference in 90‐day functional outcome between groups (adjusted OR 0.8, 95% CI 0.42 to 1.52; p = 0.50). Conclusion: In patients with anterior circulation LVOS treated with MT, ECA embolism was significantly associated with cardioembolic etiology, high thrombus burden and proximal intracranial ICA occlusions. This underexplored angiographic pattern might provide a valuable etiologic clue to the underlying cause of anterior circulation LVOS and may also help determine the appropriate revascularization strategy. [ABSTRACT FROM AUTHOR]

background Despite constant improvements in recent years, sufficient reperfusion after mechanical thrombectomy (MT) is not reached in up to 15% of patients with large vessel occlusion stroke (LVOS). The outcome of patients with unsuccessful reperfusion after MT especially after intravenous thrombolysis (IVT) use is not known. We investigated the influence of initial IVT in this particular group of patients with failed intracranial recanalization. Methods We conducted a retrospective analysis of the Endovascular Treatment in Ischemic Stroke (ETIS) registry from January 2015 to December 2019. Patients presenting with LVOS of the anterior circulation and final modified Thrombolysis in Cerebral Infarction score (mTICI) of 0, 1 or 2a were included. Posterior circulation, isolated cervical carotid occlusions and successful reperfusions (mTICI 2b, 2c or 3) were excluded. The primary endpoint was favorable outcome (modified Rankin Scale score of 0-2) after 3 months. Secondary endpoints were safety outcomes including mortality, any intracranial hemorrhage (ICH), parenchymal hematoma (PH) and symptomatic intracranial hemorrhage (sICH) rates. results Among 5076 patients with LVOS treated with MT, 524 patients with insufficient recanalization met inclusion criteria, of which 242 received IVT and 282 did not. Functional outcome was improved in the MT +IVT group compared with the MT alone group, although the difference did not reach statistical significance (23.0% vs 12.9%; adjusted OR=1.82; 95% CI 0.98 to 3.38; p=0.058). However, 3 month mRS shift analysis showed a significant benefit of IVT (adjusted OR=1.68; 95% CI 1.56 to 6.54). ICH and sICH rates were similar in both groups, although PH rate was higher in the MT +IVT group (adjusted OR=3.20; 95% CI 1.56 to 6.54). Conclusions Among patients with LVOS in the anterior circulation and unsuccessful MT, IVT was associated with improved functional outcome even after unsuccessful MT. Despite recent trials questioning the place of IVT in the LVOS reperfusion strategy, these findings emphasize a subgroup of patients still benefiting from IVT. [ABSTRACT FROM AUTHOR]

Background Recurrence following obliteration of brain arteriovenous malformations (AVMs) is common in children surgically treated, but recurrences following endovascular (EVT) and radiosurgical approaches are scantily reported. Objective To analyze the rates and risk factors for AVM recurrence after obliteration in a single-center cohort of children with ruptured AVMs treated with multimodal approaches, and to carry out a comprehensive review and meta-analysis of current data. Methods Children with ruptured AVMs between 2000 and 2019 enrolled in a prospective registry were retrospectively screened and included after angiographically determined obliteration to differentiate children with/without recurrence. A complementary systematic review and meta-analysis of studies investigating AVM recurrence in children between 2000 and 2020 was aggregated to explore the overall recurrence rates across treatment modalities by analyzing surgery versus other treatments. Results Seventy children with obliterated AVMs were included. AVM recurrences (n=10) were more commonly treated with EVT as final treatment (60% in the recurrence vs 13.3% in the no- recurrence group, p=0.018). Infratentorial locations were associated with earlier and more frequent recurrences (adjusted relative risk=4.62, 95% CI 1.08 to 19.04; p=0.04). In the aggregate analysis, the pooled rate of AVM recurrence was 10.9% (95% CI 8.7% to 13.5%). Younger age at presentation was associated with more frequent recurrences (RR per year increase, 0.97, 95% CI 0.93 to 0.99; p=0.046). Conclusion Location of infratentorial AVMs and younger age at presentation may be associated with earlier and more frequent recurrences. The higher rates of recurrence in patients with AVMs obliterated with EVT questions its role in an intent-to-cure approach and reinforces its position as an adjunct to surgery and/or radiosurgery. [ABSTRACT FROM AUTHOR]

Background To assess the feasibility, safety and efficacy of a percutaneous doughnut vertebroplasty of circumferential aggressive vertebral hemangiomas (VHs). Methods We retrospectively reviewed our prospectively collected database of patients with VHs treated with vertebroplasty between January 2009 and January 2018. Patient demographics, clinical presentations and procedural details were recorded. All patients underwent preoperative computed tomography (CT) and magnetic resonance imaging (MRI). All vertebroplasties were performed under conscious sedation in the prone position, predominantly using biplane fluoroscopic guidance. A clinical and imaging evaluation (early CT scan and MRI) as well as a final follow-up clinical assessment was performed. Results Twenty-two patients with aggressive VHs who underwent circumferential vertebroplasty with cementation of the entire vertebral body and at least one posterior hemi-arch were included (six males, mean age 53 years). At 3 months follow-up, nine patients (41%) had complete, 11 (50%) had partial and two (9%) had no resolution of pain. Nine of 14 patients had a decrease in venous swelling on MRI. No complications were observed. Five patients (23%) underwent adjunctive surgery within 1 year for persistence or worsening of neurological symptoms. Clinical and radiographic improvements were maintained to final follow-up. Conclusions Doughnut vertebroplasty offers a miniinvasive, safe and effective treatment of aggressive circumferential VHs. This technique improves pain in over 90% of patients as well as a reduction in radicular and neurological symptoms associated with a tendency to regression of the compressive epidural venous component of these lesions. [ABSTRACT FROM AUTHOR]

Background and Purpose: The influence of chronic treatment by antiplatelet drug (APD) at stroke onset on the outcomes of patients with acute ischemic stroke (AIS) treated with combined intravenous thrombolysis (IVT) and endovascular therapy (EVT) is unclear. We investigated whether prior APD use influences the risk of symptomatic intracranial hemorrhage (sICH) and functional outcome in AIS patients treated with combined reperfusion therapy. Methods: A single‐center retrospective analysis of AIS patients with proximal intracranial occlusion who underwent IVT and EVT between January 2015 and May 2017. The main outcomes were the incidence of sICH using the Heidelberg Bleeding Classification and patients' functional status at 90 days, as defined by the modified Rankin scale (mRS). Outcomes were evaluated according to daily exposure to APD, and associations were assessed using multivariate logistic regression analysis. Results: This study included 204 patients: 71 (34.8%) were taking APD before AIS. Patients with chronic treatment by APD at stroke onset had a higher rate of sICH (26.7% vs. 3.7%; p<.001) and worse functional outcome (mRS >2) at 90 days (69% vs. 36.8%; p <.001). Prior APD use was associated with an increased likelihood of sICH (OR 9.8; 95%CI [3.6–31.3], p <.05) and of functional dependence at 90 days (OR 5.72; 95%CI [2.09–1.72], p <.001), independent of confounders on multivariate analysis. Conclusions: Chronic treatment by APD at stroke onset in AIS patients with proximal intracranial occlusion treated using IVT and EVT increases the risk of sICH and worsens the functional prognosis. Further investigation to refine acute revascularization strategies in this population might be required. [ABSTRACT FROM AUTHOR]

Background Selection of the appropriate device size mandatory during aneurysm treatment with a Woven EndoBridge (WEB). We aimed to investigate if virtual simulation with Sim&Size software may have an impact on technical, angiographic, and clinical outcomes after WEB treatment. Methods Data from two large- volume centers were collected and compared (January 2017--January 2020). Virtual simulation was systematically adopted in one center, while conventional sizing was used in the other one. Outcomes were the duration of intervention, the radiation dose (in milligrays, the number of corrective interventions for inappropriate WEB size, the number of WEBs not deployed, angiographic occlusion, and complications. Univariate and multivariate linear models were adopted. Results A total of 186 aneurysms were treated with WEB (109 with and 77 without virtual simulation). Patient characteristics and aneurysm features were comparable among virtual and conventional sizing, except for mean age (62.2±11.8 years and 56.2±10.1 years, P=0.0004) and median aspect ratio (1.6, IQR=1.2--2 and 1.2, IQR=1--1.6, P=0.0001). Years of operator experience were comparable. Virtual simulation was independently associated with shorter intervention time (45 min, IQR=33--63.5 min vs 63.5 min, IQR=41--84.7 min, P=0.0001), lower radiation dose (1051 mGy, IQR=815--1399 mGy vs 1207 mGy, IQR=898--2084 mGy, P=0.0001), and lower number of WEBs not deployed (26/77=33.7% vs 8/109=7.3%, P=0.0001). The need for additional maneuvers was significantly lower in the virtual simulation group (5/109=4.6% vs 12/77=15.6%, P=0.021). Angiographic outcomes and complications were comparable. Conclusions In this multicenter experience, virtual simulation with Sim&Size software seems to facilitate the selection of the appropriate WEB device for aneurysm treatment, reducing the time of intervention, the radiation dose, the number of devices not deployed, and the need for corrective interventions. Trial registration number clinicaltrials. gov Identifier: NCT04621552. [ABSTRACT FROM AUTHOR]

Background and purpose: Successful reperfusion can be achieved in more than two-thirds of patients with usual large-vessel occlusion stroke causes treated with mechanical thrombectomy. However, the safety and outcomes after mechanical thrombectomy in the setting of large-vessel occlusion related to infective endocarditis is not known. In this study, we investigated the impact of mechanical thrombectomy in infective endocarditis patients on angiographic and clinical outcomes. Methods: This was a multicenter study from five comprehensive stroke centers. We compared the outcomes of mechanical thrombectomy treated stroke patients due to infective endocarditis with patients presenting atrial fibrillation. Clinical outcomes included 90-day modified Rankin Scale, symptomatic intracerebral hemorrhage, and mortality. Results: Between June 2013 and March 2019, 28 patients presenting large-vessel occlusion stroke due to IE were included. These cases were matched with 84 large-vessel occlusion stroke related to atrial fibrillation. Successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b/3) was obtained in 85.7%. Symptomatic intracranial hemorrhage, favorable outcome and mortality rates were respectively 8.0%, 25.9%, and 25.9%. In the case–control analysis, we demonstrated no difference in terms of successful reperfusion, procedural complication, symptomatic intracranial hemorrhage, and mortality rates. Three-month favorable outcome was less often achieved in the infective endocarditis group. Conclusions: Mechanical thrombectomy of infective endocarditis patients presents similar safety and angiographic results compared to patients suffering from atrial fibrillation. [ABSTRACT FROM AUTHOR]

Background: Brain automatic segmentation methods have shown reliable results in measuring brain structure volumes and white matter lesions. Several studies showed that automated segmentation provides greater benefits than risks for patients affected by neurological diseases. However, few automated segmentation software are currently approved by regulatory agencies such as the US Food and Drug Administration (FDA). Here we present the methods and performance of QyScore®, an automated imaging analysis tool certified in Europe (CE marked) and US (FDA cleared) for the automatic volumetry of Grey and White Matter (GM and WM respectively) Hippocampus (HP), Amygdala (AM) and White Matter Hyperintensity (WMH). Method: A comprehensive database (N = 210) coming from several cohorts of patients with neurodegenerative diseases was established. The reliability measures considered for the validation of QyScore® imaging markers were: Dice Similarity Coefficient (DSC) and the Relative Volume Difference (RVD) for the HP, the AM, the GM and the WM volumes, DSC and the F1 metrics for the WMH. For each reliability index we identified thresholds and we hypothesized that DSC/F1 scores obtained using QyScore® markers were superior to the threshold, while RVD scores were inferior to the threshold. In addition, QyScore® performances were compared with the ones obtained from gold standard methods (manual segmentation) through regression analysis and Bland‐Altman plots. Result: Comparison with reliability measures are described in Table 1. QyScore® compared with manual segmentation methods provides reliable performances for the segmentation of the grey and white matter volumes, hippocampal and amygdala volumes, as well as white matter hyperintensity volume as described in Figure 1. Conclusion: QyScore® represents a reliable and user‐friendly tool, supporting the diagnosis made by clinicians for the early detection of neurological diseases such as MCI and AD dementia. [ABSTRACT FROM AUTHOR]

We report a young man with a history of deep coma secondary to an extensive superior sagittal sinus thrombosis despite full systemic anticoagulation. Endovascular treatment combining a 5 Max ACE reperfusion catheter (Penumbra) and Solitaire (Covidien) retrieval device permitted revascularization of the superior sagittal sinus with restoration of anterograde venous flow. This treatment led to the disappearance of cytotoxic edema on MRI and to a neurological improvement with a modified Rankin scale score of 2 after two months. Our experience shows that this technique provides a useful and safe tool after failure of anticoagulation in cerebral venous sinus thrombosis. [ABSTRACT FROM AUTHOR]

In this context, the efficacy of levosimendan has previously been described in the management of both neurogenic stress cardiomyopathy and delayed vasospasm in patients with SAH [6]. 6 J. Konczalla, S. Wanderer, J. Mrosek, E. Gueresir, P. Schuss, J. Platz, Levosimendan, a new therapeutic approach to prevent delayed vasospasm after subarachnoid haemorrhage?. [Extracted from the article]