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Intra-procedural intrasaccular device migration is an uncommon complication of endovascular treatment of wide-neck aneurysms. We report the case of a 52-years old Caucasian male who presented with a 3 × 3 mm posterior facing top of the basilar aneurysm in which treatment with WEB-SL (Woven EndoBridge-single layer) device was tempted. Inadvertent WEB migration in the right posterior cerebral artery occurred after detachment. Two retrieval attempts were performed using a combined technique with two different stent-retrievers and a 5-Fr distal access catheter. Upon WEBectomy attempt, the device rolled over the stents, and the passages were unsuccessful. The device was successfully removed using a microSnare, catching and retrieving it inside the 5-Fr distal access catheter. Micro-Snare is an effective bail-out technique to recover migrated intrasaccular WEB devices in cerebral arteries. [ABSTRACT FROM AUTHOR]

Background: The burden of stroke is high in Romania and data regarding access to post – stroke rehabilitation are almost non–existent. We aimed to determine the percentage of patients who benefited from post–stroke rehabilitation and to describe the most common rehabilitation settings. Methods: A structured telephone-based questionnaire regarding access to post–stroke rehabilitation therapy and outcomes was administered to all patients with ischemic stroke who benefited from reperfusion therapy in a tertiary center in 2019. Results: 211 stroke patients received reperfusion therapy during the studied period. Out of these, 208 patients were included in the initial analysis and 109 patients were deemed eligible for post–stroke rehabilitation therapy. 57 patients (55.8%) performed post–stroke rehabilitation. In-hospital rehabilitation was reported by 35 patients (32.1%) with a median length of hospital stay of 14 days. 28 patients (25.6%) performed home based physical therapy with a median frequency of 3 sessions per week. 12 patients (11.1%) were admitted to nursing homes. Compared to stroke patients who did not perform in–hospital rehabilitation, those who did were younger (median age 65 years vs. 73 years, p=0.01) and more likely to have moderate–severe post–stroke disability (mRS score 3 – 5 at discharge 80% vs. 59.4%, p=0.03). mRS score at discharge ≤ 2 was a significant predictor for not pursuing post-stroke rehabilitation (p < 0.001). Conclusion: Approximately 50% of the stroke patients treated with reperfusion therapies were eligible for post–stroke rehabilitation and approximately 50% of them had access to rehabilitation therapy while only 30% had access to in-hospital rehabilitation.

Cardiac abnormalities are frequently reported in acute subarachnoid hemorrhage (SAH) patients. However, frank ST-elevation and myocardial dysfunction mimicking acute coronary syndrome is a rare occurrence. Systemic and local catecholamine release mediate myocardial injury and may explain raised troponin levels, concordant regional wall motion abnormalities and systolic dysfunction. These findings can pose a significant problem in the acute setting where “time-is-muscle” paradigm can rush clinicians towards a “rule-in” diagnosis of acute myocardial infarction.

Background Cangrelor is an intravenous P2Y12 inhibitor with rapid onset and fast offset of antiplatelet action. Dose adjusted cangrelor based on platelet function testing is suggested to be advantageous for use during neuroendovascular procedures. In this study, we aimed to assess the efficacy and safety of this strategy. Methods This retrospective study included consecutive patients who received low dose intravenous cangrelor (5 µg/kg; infusion 1 µg/kg/min) for ruptured (RIA) and unruptured (UIA) intracranial aneurysms, and acute ischemic stroke (AIS). Indications were acute stenting or intraluminal thrombus. Outcomes were assessed at 24 hours by brain CT and CT angiography. The primary efficacy outcome was the rate of stent occlusion or persistent intraluminal thrombus. The primary safety outcome was the rate of major hemorrhages. Results 101 patients (56 men; median age (IQR) 59 (51-70) years) received low dose cangrelor for acute stenting (79/101 (78%)) and intraprocedural thrombus (22/101 (22%)). Overall, 5 (4.9%) patients experienced stent occlusion within 24 hours (RIA 3/28; AIS 2/52). There were no cases of failure among UIA patients. Stent mis-opening (fish mouthing or stenosis >50%) was significantly associated with stent occlusion (P<0.001). The overall rate of major hemorrhage was 2% (2/101), which occurred in AIS patients. Platelet reactivity unit (PRU) values were lower in those presenting with major hemorrhage (PRU 4 (SD 1.4) vs PRU 60 (SD 63); P=0.043). Mortality rate after cangrelor related hemorrhage was 1%. Conclusions Low dose cangrelor appears to be effective in preventing stent thrombosis and arterial patency with a low hemorrhagic risk. [ABSTRACT FROM AUTHOR]

Background The optimal management of chronic total carotid artery occlusion (CTO) is still debated. Endovascular treatment is being increasingly used with heterogeneous technical and clinical results. Methods Patients with CTO treated with modern endovascular approaches during the past several years (January 2018-December 2021) were retrospectively reviewed. Results Twenty patients, with a mean age of 63.7 years, were treated during the study period. Indications for treatment were recurrent stroke in 12 (60%), hemodynamic impairment in 4 (20%), and progressive stroke in 4 (20%) patients. In 6 (30%) patients, the occlusion was limited to the cervical portion, in 5 (25%) to the petrous segment, and in 9 (45%) to the cavernous segment. Technical treatment success was achieved in 80% of cases. In patients with successful recanalization, median pretreatment hypoperfusion volumes dropped from 126 mL (25-75 IQR, 33-224 mL) to 0 mL (25-75 IQR, 0-31.5 mL). Symptomatic procedure-related complications were 30% and permanent procedure-related morbidity-mortality was 5%. Early stent occlusion occurred in 5 (25%) cases. Two cases were asymptomatic and were not retreated, 3 cases presented transient symptoms of which two were successfully recanalized. Stent occlusion was not associated with permanent symptoms. In successfully recanalized patients no intraprocedural emboli were observed. Conclusions In the modern endovascular era, revascularization of CTO is a feasible procedure in most cases, and it may be offered in selected patients. However, the high re-occlusion rate is still a limitation of the technique, underlining the need for more research on the technical procedural and periprocedural management. [ABSTRACT FROM AUTHOR]

Background and objectives: The time interval between stroke onset and hospital arrival is a major barrier for reperfusion therapies in acute ischemic stroke and usually accounts for most of the onset-to-treatment delay. The present study aimed to analyze the pre-hospital delays for patients with acute ischemic stroke admitted to a tertiary stroke center in Romania and to identify the factors associated with a late hospital arrival. Material and methods: The study population consisted of 770 patients hospitalized with the diagnosis of acute ischemic stroke in the University Emergency Hospital Bucharest during a 6-month period, between 1 January and 30 June 2018. Data regarding pre-hospital delays were prospectively collected and analyzed together with the demographic and clinical characteristics of the patients. Results: In total, 31.6% of patients arrived at the hospital within 4.5 h from stroke onset and 4.4% in time intervals between 4.5 and 6 h from the onset, and 28.7% of the patients reached the hospital more than 24 h after onset of symptoms. Transport to hospital by own means was the only factor positively associated with arrival to hospital > 4.5 h from stroke onset and more than doubled the odds of late arrival. Factors negatively associated with hospital arrival > 4.5 h after stroke onset were prior diagnosis of atrial fibrillation, initial National Institute of Health Stroke Scale (NIHSS) score ≥ 16 points, presence of hemianopsia, facial palsy and sensory disturbance. Factors increasing the odds of hospital arrival after 24 h from stroke onset were living alone and living in rural areas. Conclusions: Almost one in three ischemic stroke patients presenting to our center reaches hospital more than 24 h after onset of symptoms. These findings highlight the need for urgent measures to improve not only stroke awareness but also pre-hospital protocols in order to provide timely and appropriate care for our stroke patients. [ABSTRACT FROM AUTHOR]

Background and Objectives: Neutrophil-to-lymphocyte ratio (NLR), a very low cost, widely available marker of systemic inflammation, has been proposed as a potential predictor of short-term outcome in patients with intracerebral hemorrhage (ICH). Methods: Patients with ICH admitted to the Neurology Department during a two-year period were screened for inclusion. Based on eligibility criteria, 201 patients were included in the present analysis. Clinical, imaging, and laboratory characteristics were collected in a prespecified manner. Logistic regression models and receiver operating characteristics (ROC) curves were used to assess the performance of NLR assessed at admission (admission NLR) and 72 h later (three-day NLR) in predicting in-hospital death. Results: The median age of the study population was 70 years (IQR: 61–79), median admission NIHSS was 16 (IQR: 6–24), and median hematoma volume was 13.7 mL (IQR: 4.6–35.2 mL). Ninety patients (44.8%) died during hospitalization, and for 35 patients (17.4%) death occurred during the first three days. Several common predictors were significantly associated with in-hospital mortality in univariate analysis, including NLR assessed at admission (OR: 1.11; 95% CI: 1.04–1.18; p = 0.002). However, in multivariate analysis admission, NLR was not an independent predictor of in-hospital mortality (OR: 1.04; 95% CI: 0.9–1.1; p = 0.3). The subgroup analysis of 112 patients who survived the first 72 h of hospitalization showed that three-day NLR (OR: 1.2; 95% CI: 1.09–1.4; p < 0.001) and age (OR: 1.05; 95% CI: 1.02–1.08; p = 0.02) were the only independent predictors of in-hospital mortality. ROC curve analysis yielded an optimal cut-off value of three-day NLR for the prediction of inhospital mortality of ≥6.3 (AUC = 0.819; 95% CI: 0.735–0.885; p < 0.0001) and Kaplan–Meier analysis proved that ICH patients with three-day NLR ≥6.3 had significantly higher odds of in-hospital death (HR: 7.37; 95% CI: 3.62–15; log-rank test; p < 0.0001). Conclusion: NLR assessed 72 h after admission is an independent predictor of in-hospital mortality in ICH patients and could be widely used in clinical practice to identify the patients at high risk of in-hospital death. Further studies to confirm this finding are needed. [ABSTRACT FROM AUTHOR]

Chronic carotid total occlusion (CCTO) is a known cause of ischemic stroke and transient ischemic attack. Symptomatic CCTO is associated with up to 30% risk of recurrent ischemic stroke, despite optimal medical treatment. Notably, a randomized controlled trial reported that previous surgical management did not improve the overall prognosis of these patients. Endovascular treatment of CCTO has been proposed as a feasible strategy to re-establish cerebral perfusion in symptomatic patients. However, its use is controversial and not supported by evidence from randomized clinical trials. Recently, a meta-analysis reported a reasonably high procedural success without an excess periprocedural complication rate, but several steps are needed before the procedure is mature enough to be tested in randomized controlled trials. This review highlights the developments in the endovascular recanalization of CCTO and emphasizes key steps towards standardizing the procedure. [ABSTRACT FROM AUTHOR]

Common carotid artery (CCA) occlusion with patency of the internal carotid artery (ICA) is a rare cause of stroke with no consensus on optimal management.1 Open surgery, most often CCAsubclavian or CCA-aortic arch bypass techniques, have been used to recanalize short proximal occlusions. 1 2 Endovascular revascularization of chronic total ICA occlusion was proposed with promising results in previous reports.3-5 However, endovascular recanalization for chronic CCA occlusion has rarely been described in the literature, and the reports involved mainly right-sided occlusions or occlusions with residual CCA stumps.6 Anterograde endovascular management of chronic long left-sided CCA occlusions is problematic due to lack of support, notably when no proximal stump is present.4 In this video, we present a case of known long-chronic CCA occlusion managed by retrograde echo-guided ICA puncture and stent-assisted reconstruction.(video 1) [ABSTRACT FROM AUTHOR]

Precise localization and understanding of the origin of cerebrospinal fluid (CSF) leak is crucial to allow targeted treatment. We report the technical feasibility and utility of dorsal-decubitus dynamic computed tomography (DDDCT) myelography to localize posteriorly located dural defects in patients with suspicion of posterolateral dural tears.This study reports a series of four consecutive patients with posteriorly located SLEC and suspicion of posterolateral CSF leak who received DDDCT to localize the site of the leak. Patients were collected between October 2022 and October 2023. The technique of DDDCT and its efficacy to detect the site of CSF leak are reported.In all four patients (three females, one male, mean age 39 years), DDDCT myelography was technically successful and precisely demonstrated the site of the CSF leak. In one patient with both anterior and posterior SLEC, DDDCT allowed to exclude the presence of a posteriorly located leak, while a subsequent ventral decubitus dynamic CT myelography localized the leak. Leak sites were all thoracic, except for one that was cervical. Information obtained from the DDDCT myelography was considered useful to target the treatment of the leak.Based on our experience, DDDCT provided sufficient spatial and temporal resolution to pinpoint fast CSF leaks and it may be considered to localize posterolateral dural defects. [ABSTRACT FROM AUTHOR]

Opsoclonus-myoclonus syndrome (OMS) is a very rare condition with different autoimmune, infectious and paraneoplastic aetiologies or in most cases idiopathic. We report the case of a 75-year-old woman who was admitted in our department in early fall for altered mental status, opsoclonus, multifocal myoclonus, truncal titubation and generalized tremor, preceded by a 5 day prodrome consisting of malaise, nausea, fever and vomiting. Brain computed tomography and MRI scans showed no significant abnormalities and cerebrospinal fluid changes consisted of mildly increased protein content and number of white cells. Work-up for paraneoplastic and autoimmune causes of OMS was negative but serologic tests identified positive IgM and IgG antibodies against West Nile virus (WNV). The patient was treated with Dexamethasone and Clonazepam with progressive improvement of mental status, myoclonus, opsoclonus and associated neurologic signs. Six months after the acute illness she had complete recovery. To our knowledge this is the 14th case of WNV associated OMS reported in the literature so far. We briefly describe the clinical course of the other reported cases together with the different treatment strategies that have been employed. [ABSTRACT FROM AUTHOR]

Endovascular treatment (EVT) for large vessel, acute ischemic stroke in children remains a subject of debate, with evidence for its benefits derived from case series and individual case reports. At present, guidelines are cautious in recommending EVT for children under 5 years of age, mainly due to a lack of data and incomplete cerebral and femoral vessel development. However, based on the small number of cases reported in the literature, EVT appears to be safe and effective for pediatric use and arterial diameters can accommodate currently available devices. Available evidence shows that in patients with a normal arterial development, a 6-Fr femoral approach can be safely used by 2 years of age. We describe the case of a 2-year-old child who benefited from late-window EVT for a basilar occlusion. The procedure was safely performed using a 6-Fr femoral introducer, a 6-Fr guide catheter, and a 5-Fr aspiration catheter. We discuss also normal cerebral and femoral vessel development, providing descriptive tables of compatibility between femoral and cerebral arterial diameters by age groups and currently available endovascular devices. [ABSTRACT FROM AUTHOR]

Despite advances in secondary stroke prevention during the last several years, cryptogenic stroke remains associated with a high risk of recurrence. Studies have shown that the recurrence risk is higher in patients with large artery disease in which complex carotid plaques and carotid WEBs are identified.This is a case series of six patients with cryptogenic recurrent stroke in which conventional imaging and extensive workup did not identify an etiology. Intravascular optic coherence tomography (OCT) was performed using a ballon-guided flow-arrest technique to identify possible covert carotid lesions.We present six cases in which, with the help of OCT, we identified three carotid WEBs with associated thrombosis and two ulcerated carotid artery plaques. Four patients were subsequently treated with endovascular stent placement without complications. OCT permitted the distinction between complicated carotid artery plaque and carotid WEB.Intravascular OCT is a feasible and safe approach to identifying patients with covert carotid wall abnormalities, like carotid WEBs and ulcerated plaques, that are amenable to carotid stenting to reduce recurrent stroke risk. [ABSTRACT FROM AUTHOR]

Peduncular hallucinosis is a rare syndrome that develops with upper brainstem and diencephalon lesions. Patients complain of vivid hallucinations that usually occur in hypnagogic states but maintain critical appraisal. Pathological disruption of the reticular activating systems partially explains this clinical phenomenon. We report the case of a 47-year-old man presenting with peduncular hallucinosis associated with central auditory disturbance consisting of bilateral hypoacusis and left-sided paradoxical hyperacusis, secondary to a pontine haemorrhage. [ABSTRACT FROM AUTHOR]