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Background and Purpose: Mechanical thrombectomy (MT) in ischemic stroke patients with poor prestroke conditions remains controversial. We aimed to analyze the frequency of previously disabled patients treated with MT in clinical practice, the safety and clinical response to MT of patients with preexisting disability, and the disabled patient characteristics associated with a better response to MT. Methods: We studied all consecutive patients with anterior circulation occlusion treated with MT from January 2017 to December 2019 included in the Codi Ictus Catalunya registry—a government-mandated, prospective, hospital-based data set. Prestroke disability was defined as modified Rankin Scale score 2 or 3. Functional outcome at 90 days was centrally assessed by a blinded evaluator of the Catalan Stroke Program. Favorable outcome (to return at least to prestroke modified Rankin Scale at 90 days) and safety and secondary outcomes were compared with patients without previous disability. Logistic regression analysis was used to assess the association between prestroke disability and outcomes and to identify a disabled patient profile with favorable outcome after MT. Results: Of 2487 patients included in the study, 409 (17.1%) had prestroke disability (313 modified Rankin Scale score 2 and 96 modified Rankin Scale score 3). After adjustment for covariates, prestroke disability was not associated with a lower chance of achieving favorable outcome at 90 days (24% versus 30%; odds ratio, 0.79 [0.57–1.08]), whereas it was independently associated with a higher risk of symptomatic intracranial hemorrhage (5% versus 3%; odds ratio, 2.04 [1.11–3.72]) and long-term mortality (31% versus 18%; odds ratio, 1.74 [1.27–2.39]) compared with patients without disability. Prestroke disabled patients without diabetes, Alberta Stroke Program Early CT Score >8 and National Institutes of Health Stroke Scale score Conclusions: Despite a higher mortality and risk of symptomatic intracranial hemorrhage, prestroke-disabled patients return as often as independent patients to their prestroke level of function, especially those nondiabetic patients with favorable early ischemic signs profile. These data support a potential benefit of MT in patients with previous mild or moderate disability after large anterior vessel occlusion stroke.

Introduction New treatments for acute ischaemic stroke, such as mechanical thrombectomy, can achieve reperfusion of large ischaemic tissue. Some studies have suggested that reperfusion therapies can increase the risk of suffering acute symptomatic seizure (ASS) and poststroke epilepsy (PSE). The aim of the study was to determine the incidence of ASS and PSE in patients undergoing thrombectomy, and related factors. Patients and methods This was a retrospective single-centre study including patients with ischaemic stroke and NIHSS> 8 treated with thrombectomy with a follow-up ≥5 years. We evaluated several epidemiological, radiological, clinical and electroencephalographic variables. Results Of the 344 included patients, 21 (6.1%) presented ASS, 53 (15.40%) died in the acute phase, and 13 (4.46%) died during the first year. The degree of reperfusion (p 0.029), advanced age (p 0.035), and haemorrhagic transformation (p 0.038) increased the risk of suffering ASS, with degree of reperfusion being an independent factor, OR 2.02 (1.21-4.64). The incidence of PSE was 4.12% in the first year, 3.72% in the second, and 1.61% in the fifth. The accumulated incidence at 5 years was 8.93%. Related risk factor for suffering PSE was ASS (p Conclusions Thrombectomy doesn´t increase the risk of ASS. A higher percentage of reperfusion, advanced age, and haemorrhagic transformation are associated with an increased risk of ASS. ASS is a risk factor for suffering PSE. In terms of mortality, having suffered ASS and/or PSE does not increase acute or long-term mortality.

Assessing a posterior fossa tumour in an adult can be challenging. Metastasis, haemangioblastoma, ependymal tumours, and medulloblastoma are the most common diagnostic possibilities. Our aim was to evaluate the contribution of magnetic resonance spectroscopy (MRS) in the diagnosis of these entities. We retrospectively evaluated 56 consecutive patients with a posterior fossa tumour and histological diagnosis of ependymal tumour, medulloblastoma, haemangioblastoma, and metastasis in which good-quality spectra at short (TE 30 ms) or/and intermediate (TE, 136 ms) TE were available. Spectra were compared using the Mann-Whitney U non-parametric test in order to select the spectral datapoints and the intensity ratios that showed significant differences between groups of lesions. Performance of these datapoints and their ratios were assessed with ROC curves. The most characteristic signatures on spectroscopy were high choline (Cho) in medulloblastoma (p

Introduction Endovascular thrombectomy was recently established as a new standard of care in acute ischemic stroke patients with large artery occlusions. Using small area health statistics, we sought to assess dissemination of endovascular thrombectomy in Catalonia throughout the period 2011–2015. Patients and methods We used registry data to identify all endovascular thrombectomies for acute ischemic stroke performed in Catalonia within the study period. The SONIIA registry is a government-mandated, population-based and externally audited data base that includes all reperfusion therapies for acute ischemic stroke. We linked endovascular thrombectomy cases identified in the registry with the Central Registry of the Catalan Public Health Insurance to obtain the primary care service area of residence for each treated patient, age and sex. We calculated age-sex standardized endovascular thrombectomy rates over time according to different territorial segmentation patterns (metropolitan/provincial rings and primary care service areas). Results Region-wide age-sex standardized endovascular thrombectomy rates increased significantly from 3.9 × 100,000 (95% confidence interval: 3.4–4.4) in 2011 to 6.8 × 100,000 (95% confidence interval: 6.2–7.6) in 2015. Such increase occurred in inner and outer metropolitan rings as well as provinces although highest endovascular thrombectomy rates were persistently seen in the inner metropolitan area. Changes in endovascular thrombectomy access across primary care service areas over time were more subtle, but there was a rather generalized increase of standardized endovascular thrombectomy rates. Discussion This study demonstrates temporal and territorial dissemination of access to endovascular thrombectomy in Catalonia over a 5-year period although variation remains at the completion of the study. Conclusion Mapping of endovascular thrombectomy is essential to assess equity and propose actions for access dissemination.

The skull vault, formed by the flat bones of the skull, has a limited spectrum of disease that lies between the fields of neuro- and musculoskeletal radiology. Its unique abnormalities, as well as other ubiquitous ones, present particular features in this location. Moreover, some benign entities in this region may mimic malignancy if analyzed using classical bone-tumor criteria, and proper patient management requires being familiar with these presentations. This article is structured as a practical review offering a systematic diagnostic approach to focal calvarial lesions, broadly organized into four categories: (1) pseudolesions: arachnoid granulations, meningo-/encephaloceles, vascular canals, frontal hyperostosis, parietal thinning, parietal foramina, and sinus pericrani; (2) lytic: fibrous dysplasia, epidermal inclusion and dermoid cysts, eosinophilic granuloma, hemangioma, aneurysmal bone cyst, giant cell tumor, metastasis, and myeloma; (3) sclerotic: osteomas, osteosarcoma, and metastasis; (4) transdiploic: meningioma, hemangiopericytoma, lymphoma, and metastasis, along with other less common entities. Tips on the potential usefulness of functional imaging techniques such as MR dynamic susceptibility (T2*) perfusion, MR spectroscopy, diffusion-weighted imaging, and PET imaging are provided.

Background: The etiology of stroke remains unknown over 25% of cases. Stroke with Large Vessel Occlusion (LVO) treated with endovascular treatment (EVT) and complete recanalization are a good group to analyze efficiency of diagnosis studies. After hospitalization the percentage and clinical impact of hidden atrial fibrillation (AF) diagnosis in embolic strokes of unknown source are uncertain. Methods: We reviewed patients treated with EVT from 2010 to 2016. We evaluated percentage of cases with new clinical diagnosis of atrial fibrillation during long-term follow-up in several etiologic subgroups. We analyze several epidemiologic variables, functional recovery and other relevant pathologies. Results: A total of 514 patients with complete cardiac diagnosis tests treated with EVT were analyzed over 3,9 years of follow-up. The etiology of stroke was unknown in 123 patients (23,9%). During follow-up were diagnosed 8% of patients with new atrial fibrillation/flutter in unknown etiology subgroup (3% in atherothrombotic and none in unusual subgroup). Half of them presented minor cardiologic symptoms but none of them had presented a new stroke. Variables significant associated to new finding of AF were >6 supraventricular extrasystoles or tachycardia in 24Holter test and severe auricular dilatation evaluated by means echocardiography during hospitalization (p:0.004). Only 2% patients were studied with long-term heart rhythm recorder. Other new diagnoses in follow-up of EVT were malignant neoplasm (7%) and delayed seizures (6%). Conclusions: The findings of atrial fibrillation in follow-up of patients treated with EVT with complete cardiac diagnosis tests are infrequent. The recurrence of stroke seems rare in follow-up, however we must select patients for catch atrial fibrillation by means long-term heart recorder systems according to signs of auricular impairment.

Background and Purpose— Since demonstration of the benefit of endovascular treatment (EVT) in acute ischemic stroke patients with proximal arterial occlusion, stroke care systems need to be reorganized to deliver EVT in a timely and equitable way. We analyzed differences in the access to EVT by geographical areas in Catalonia, a territory with a highly decentralized stroke model. Methods— We studied 965 patients treated with EVT from a prospective multicenter population-based registry of stroke patients treated with reperfusion therapies in Catalonia, Spain (SONIIA). Three different areas were defined: (A) health areas primarily covered by Comprehensive Stroke Centers, (B) areas primarily covered by local stroke centers located less than hour away from a Comprehensive Stroke Center, and (C) areas primarily covered by local stroke centers located more than hour away from a Comprehensive Stroke Center. We compared the number of EVT×100 000 inhabitants/year and time from stroke onset to groin puncture between groups. Results— Baseline characteristics were similar between groups. Throughout the study period, there were significant differences in the population rates of EVT across geographical areas. EVT rates by 100 000 in 2015 were 10.5 in A area, 3.7 in B, and 2.7 in C. Time from symptom onset to groin puncture was 82 minutes longer in group B (312 minutes [245–435]) and 120 minutes longer in group C (350 minutes [284–408]) compared with group A (230 minutes [160–407]; P Conclusions— Accessibility to EVT from remote areas is hampered by lower rate and longer time to treatment compared with areas covered directly by Comprehensive Stroke Centers.

Background: Endovascular treatment with stent-retrievers has been approved and has demonstrated effective in treating strokes with large vessel occlusions. However number of passes through occluded artery and probability of recanalization in each artery could be an important technical and clinical topic. Methods: We performed an analysis of consecutives patients treated with stent-retriever from January 2011-May 2017. We analyze the number of passes to get recanalization (TICI 2b-3) according to occluded arteries. We assessed good functional outcome in Rankin scale (0-2) at 3 month, symptomatic intracranial hemorrhage (SICH) and mortality according to number of stent-retriever passes in each treated artery. Results: A total of 626 patients were analyzed, mean age 67+/-13, baseline NIH:17, OSTP (onset stroke time to groin puncture):268 min. Rankin 0-2 in 3month: 53%. Percentage of complete recanalization TICI 2-3 was 74% (43% after first pass of stent retriever, 65% in whom received a second pass, 76 % in third pass and 82% over four passes). Patients with few pass of stent retrievers (three passes) present a significant good functional outcome compared to patients treated with > 4 passes (61%vs19%), with same percentage SICH ( 7,4%vs8%). A variable associated to number of passes was OSTP. The percentage of successful recanalization (TICI 2b-3) with first-second pass of stent retriever were significantly different in TICA 54%, tandem 58%, basilar 56 % and 74% M1-M2 occlusions. Conclusions: Successful recanalization (TICI 2b-3) is highly probable till third pass of stent retriever. New devices could be tested in cases of failed recanalization after this third attempt.

Background: Multiple randomized trials have demonstrated that endovascular treatment(EVT) in selected stroke patients is associated with good clinical outcome (90 days mRankin 0-2: 33-60%). The percentage of complete functional recovery (mRankin Score: 0) is the most optimist and desirable result after endovascular treatment and their predictor factors are unknown. Methods: Consecutive patients with ischemic stroke who received endovascular reperfusion treatment were retrospectively analyzed between August 2010 and May 2017. We review the percentage of recanalization (TICI 2b-3), good outcome in 90days follow-up(mRS0-2) and complete recovery(mRS 0) after EVT. We evaluate which variables are associated to complete recovery and excellent outcome. Results: We reviewed 802 endovascular treatments. Ninety-five percent of occlusions were located in middle cerebral artery or terminal internal carotid, (45% women, mean age 67+/-13 years; NIHSS at admission 17. Successful recanalization (TICI 2b-3) was achieved in 82%. At 90 days good functional outcome (mRS 0-2) was seen in 51% . A complete functional recovery was achieved in 19% of EVT. We compare patients who achieve 90d mRS:0 vs 90d mR:1-2; in this analysis baseline NIH (14 vs 17) and OSTP (Onset Stroke Time to Puncture: 256 vs 281 min) were predictor variables significantly associated to complete functional recovery after adjustment (p:0.001). Radiologic variables: baseline ASPECTS>9, M1-M2 occlusion, a single pass of stent-retriever and absence of hemorrhagic transformation in 24hCT are related in multivariate analysis to 90d mRS 0. Nine percent of patients showed abscence of infarct in DWI sequence of MRI performed in acute phase of stroke. Conclusions: Excellent functional outcome after thrombectomy could be achieved in highly percentage of patients with short OSTP. Good radiological findings warrant excellent results.

The main objective of this prospective observational study is to describe the pharmacokinetic profile of pa- tients with hemophilia A in prophylaxis with Advate® in Spain using myPKFiT®.

Background: Recent guidelines recommend thrombectomy to treat stroke due to large vessel occlusions within first six hours after onset stroke time. There is no age limit, however elderly patients (>=80 years old) transferred from community hospital (CH) to comprehensive stroke center (CSC) possibly present different radiological findings in comparison with younger patients, that finally exclude them of endovascular treatment and could avoid unnecessary transfers to CSC. Method: We reviewed consecutive patients transferred from five CH to our CSC from January 2012 to July 2016. We analyzed radiological findings in ASPECTS (Alberta Stroke Program Early CT Scale) and segment of occluded artery in NonContrastCT (NCCT) and CT-angiography, both realized in CH (pre-transfer) and CSC. We evaluated the changes in NCCT between both centers related to onset stroke time, time of transfer, vascular occlusion segment and other epidemiological variables. Results: A total of 3825 patients were evaluated in our CSC as stroke code (24% elderly and increasing annually); 21% were transferred from CH to CSC with large vessel occlusion diagnosis and NIHSS>8. Subgroup of elderly patients presented worse score in ASPECTS-NCCT evaluated at CSC previous to endovascular treatment than younger patients (mean 6.8 vs 8.4;p: 0.001). An ASPECT score 6) in NCCT at CSC (AUC: 0.69; S: 61%, E: 85%). Conclusions: Patients over 83 years old and low score in ASPECT (score

To assess whether 1H-MRS may be useful to reinforce the radiological suspicion of PCNSL. In this retrospective study, we included 546 patients with untreated brain tumours in which single-voxel spectroscopy at TE 30 ms and 136 ms had been performed. The patients were split into two subgroups: “training set” and “test set.” Differences between PCNSL and five other types of intracranial tumours were assessed in the test set of patients using the Mann-Whitney U nonparametric test and cut-off values for pair-wise comparisons defined by constructing receiver operating characteristic curves. These thresholds were used to construct classifiers for binary comparison between PCNSL and non-PCNSL. The performance of the obtained classifiers was assessed in the independent test set of patients. Significant differences were found between PCNSL and the other groups evaluated. All bilateral comparisons performed in the test set obtained accuracy values above 70 % (71–89 %). Lipids were found to be useful to discriminate between PCNSL and glioblastoma/metastasis at short TE. Myo-inositol resonance was found to be very consistent for discriminating between PCNSL and astrocytomas at short TE. 1H-MRS is useful to reinforce diagnostic suspicion of PCNSL on MRI. • 1 H-MRS can be used to reinforce the diagnostic suspicion of PCNSL. • Lipids can be used to discriminate between PCNSL and GB/MET. • Myo-inositol resonance can be used to discriminate between PCNSL and astrocytomas.

Pathological vertebral fractures are caused by various entities. They cause significant pain and impaired quality of life of patients. The CT-guided kyphoplasty relieves or eliminates pain and stabilizes the fractured vertebral bodies. 49 patients were treated. The procedure is performed percutaneously by inserting a needle that is subsequently removed, leaving a cannula. Through this a balloon-like device is introduced and subsequently inflated to create a cavity, which is then filled with polymethylmethacrylate (PMMA). The techni-que was performed successfully in all cases without serious complications, with good results. Its advantages are that the needle placement as well as the injection of PMMA can be correctly visualized using real-time CT fluoroscopy. In addition a single needle is used throughout the entire procedure, which minimizes the risk of complications as it is less traumatic.Keywords: CT scan, Kyphoplasty, Pain, Polymethylmethacrylate, Vertebral fracture. Resumen

Background: Endovascular treatment (EVT) is an effective treatment in strokes with persistent large artery occlusion despite previous intravenous thrombolisis (IVT) as rescue treatment. Performing computer tomography angiography (CTA) before IVT could allow early activation of neurointerventional teams; however routine CTA could delay unnecessary door-to-needle time of IVT and may be infeasible. Methods: We reviewed stroke code activations between May 2011 and June 2015 in our comprehensive stroke center and divided into groups based on NIHSS and patency of arterial occlusion according to non-enhanced CT on admission (dense artery sign or dot sign) and baseline CTA. We assessed patients treated with IVT and selected to EVT according to results in CTA post-IVT. We analyze percentage of recanalization or migration of thrombus after IVT alone and variables associated to successful treatment. Results: Of 2856 stroke codes registered during the study period 1810 were diagnosis of ischemic strokes. We treated 520 patients with IVT, 202 had a radiological evidence of large artery occlusion (55%M1, 32% M2, 5%TICA, 5%ICA, 3% basilar). Thirty-two percent of patients showed changes in CTA carried out after IVT(17% successfully recanalized, 15% distal migration of thrombus) so they were not selected to endovascular treatment. There were significant difference between M1 and M2 occlusion regarding changes in CTA after IVT (23% vs 70%; p Conclusions: We consider defer CTA angiography until after IVT in stroke code patients with moderate clinical impairment (NIH

Summary Background Transcranial Doppler (TCD) is a specific test for brain death diagnosis. Several Doppler patterns could change slightly during an increase of intracranial pressure related to mass effect. Methods We present two patients with a clinical diagnosis of brain death after massive brain hemorrhage. A Doppler pattern of reverse flow with small diastolic positive flow in both middle cerebral arteries and basilar arteries was observed in both cases. Results TCD was repeated 6 h later, showing an increase of systolic and diastolic flow associated with high intracranial pressure (ICP) in the first patient and a decrease of ICP in the second patient associated with polyuria. Transient improvements of blood cerebral flow could be related to the use of adrenergic drugs or the use of osmotic drugs to decrease ICP. Finally the patients showed a pattern of low spikes that led to the diagnosis of cerebrovascular arrest and brain death. Conclusions Therapeutics drugs to decrease ICP and several physiological processes can change several patterns of TCD associated with progression of brain death.

BACKGROUND AND PURPOSE Recent reports have indicated that mechanical thrombectomy may have potential to treat acute ischemic stroke. However, few comparative studies of neurothrombectomy devices are reported. This study aims to compare the safety and effectiveness of two retrievable stent systems in acute ischemic stroke patients. METHODS A prospective study comparing the clinical, radiological, and functional outcome of 33 patients with an angiographically verified occlusion of the anterior cerebral circulation. Patients were treated either with Trevo RetrieverTM or Solitaire StentTM according to the neurointerventionalist preference. Successful recanalization was defined as TICI grade 2a to 3. Good outcome was defined as a modified Rankin Scale score ≤ 2 at 3 months. RESULTS Revascularization was achieved in 10 patients (77%) in the Trevo group and in 12 (60%) of the Solitaire group (P = .456). Rate of symptomatic ICH was 0% for Trevo versus 15% for Solitaire (P = .261). Four patients (30%) died during the 3-month follow-up period in the Trevo versus 5 patients (25%) in the solitaire group (P = 1.000). Rate of good outcome was 38% and 40% for Trevo and Solitaire respectively (P = .435). CONCLUSIONS Our study showed no significant differences between both stentrievers. Moderately high recanalization rates are possible with both, however larger series may depict safety-related variations.

Introduction: Cerebellar infarction (CI) is uncommon, but may result in severe complications. The aim of our study was to determine the characteristics of patients with CI, as well as their outcomes as regards the territories affected. Patients and methods: Data were collected from 124 patients admitted to our department during a five-year period, with a radiological diagnosis of CI, and with or without involvement of other brain territories. Results: The mean age in our series was 65.2 years, with most being male (68.5%). The posterior inferior cerebellar artery (PICA) was the most commonly affected territory at 49.2%, followed by superior cerebellar artery (SCA) at 17.7%, and anterior inferior cerebellar artery (AICA) at 10.5%. There was simultaneous supratentorial involvement in 13.7%, and two or three cerebellar arteries involved in 8.9%. The main aetiology in PICA was atherothrombosis (P = .02). On the other hand, cardio-embolism was the main origin in cases with more than one affected territory (P = .04). No particular aetiology could be found in SCA and AICA. There was haemorrhagic transformation in 29 patients (23.4%), particularly in the PICA and when other territories were involved. There was hydrocephalus in 15 patients (12.1%, 12 of them PICA; P = .02) in 2.9 ± 1.5 days from stroke onset. At discharge, the degree of disability was worse if more than one arterial territory was involved (Rankin ≥ 3, 64% versus 31–36%; P = .05). Four (3.2%) patients died. Conclusions: CI is very heterogeneous. Nevertheless, it is noteworthy that PICA infarction is the most frequent type and its aetiology is usually atherothrombotic. Moreover, it is the territory most frequently associated with severe complications, which take place during the first week of the stroke. Resumen: Introducción: Los infartos cerebelosos (IC) son infrecuentes pero pueden presentar complicaciones graves. Nuestro objetivo ha sido estudiar las características de los pacientes con IC, así como su evolución, en función del territorio afectado. Pacientes y métodos: Se han recogido datos de 124 pacientes ingresados en nuestro servicio durante un periodo de 5 años, con diagnóstico radiológico de IC, con y sin afectación de otras regiones cerebrales. Resultados: La edad media de nuestra serie es de 65,2 años, con predominio masculino (68,5%). El territorio más afectado fue la arteria cerebelosa posteroinferior (PICA) en el 49,2%, seguido de la arteria cerebelosa superior (ACS) en el 17,7% y cerebelosa anteroinferior (AICA) en el 10,5%. Se afectaron territorios supra-infratentoriales en el 13,7% y dos/tres territorios cerebelosos en el 8,9%. La etiología aterotrombótica fue más prevalente en PICA (p = 0,02) y la cardioembólica en la afectación de múltiples territorios (p = 0,04), siendo similares en ACS y AICA. Se produjo transformación hemorrágica en 29 pacientes (23,4%), sobretodo en la afectación de múltiples territorios y en PICA. Se asoció hidrocefalia en 15 pacientes (12,1%, 12 de ellos PICA; p = 0,02), apareciendo de media a los 2,9 ± 1,5 días del inicio del ictus. Al alta, la dependencia funcional (Rankin ≥ 3) era mayor si la afectación territorial era múltiple (64% vs 31-36%; p = 0,05). Se contabilizaron 4 defunciones (3,2%). Conclusiones: Los IC tienen gran heterogeneidad. Sin embargo, cabe destacar que los infartos de PICA son los más prevalentes, su etiología suele ser aterotrombótica y son los más asociados a complicaciones graves, que ocurren durante la primera semana del ictus. Keywords: Cerebellar infarction, Cerebellum, Hydrocephalus, PICA, Stroke, Palabras clave: Cerebelo, Hidrocefalia, Ictus, Infarto cerebeloso, PICA

Object Nidal embolization of brain arteriovenous malformations (bAVMs) has become an increasingly important component of bAVM treatment. However, controversy exists as to the relative efficacy and safety of single-stage versus multistage approaches to bAVM embolization, with recent literature favoring multistage strategies. The authors present a series of consecutive bAVMs embolized at their institution, demonstrating the safety and efficacy of a predominantly single-stage embolization strategy. The safety and efficacy of embolization are reported in the context of predetermined treatment strategies to provide more generalizable insight into treatment outcome. Methods One hundred thirty consecutive patients with 131 bAVMs underwent endovascular embolization at a single center. Diagnostic angiography with superselective microcatheterizations was performed in all patients. Postembolization angiograms were reviewed by 3 neuroradiologists for degree of occlusion and angiographic evidence of procedural complications. Patients were divided into cohorts based on the prospectively determined treatment strategy, which included the following: global devascularization of the bAVM (Devasc); targeting of a focal angioarchitectural weakness (Target), typically as an adjunct to surgery or Gamma Knife treatment; and primary occlusion of the bAVM by embolization alone (Occlude). Safety and efficacy were evaluated in the context of these treatment groups. Results The 131 bAVMs were treated over an average of 1.28 embolization sessions per bAVM; 105 bAVMs (80%) were treated in a single stage. The average percentage devascularization in the Devasc arm was 85.3%, which was statistically significantly greater than the 72% aggregate devascularization reported in 8 modern N-butyl cyanoacrylate and Onyx papers based on 1-sample Wilcoxon rank-sum testing (p < 0.001). Focal angioarchitectural weaknesses were successfully embolized for all 24 bAVMs in the Target group, directly with the embolic agent in 23 bAVMs and indirectly in 1 bAVM with a venous aneurysm/pseudoaneurysm by reducing arterial inflow and inducing venous thrombosis. Lesions in all patients in the Occlude arm were 100% occluded with embolization alone. Overall, the bAVMs in the Occlude arm were significantly smaller and required embolization of fewer pedicles than those in the Devasc group. One patient (0.8%) experienced significant morbidity following embolization, and 1 patient in the cohort died (0.8%). Conclusions This research communicates the authors' experience in developing a largely single-stage strategy for embolization of bAVMs. The results suggest that an aggressive, single-stage embolization may be implemented with a margin of safety and effectiveness similar to the multistage approaches more commonly reported in the literature. This work additionally introduces the importance of prospective assignment to a treatment strategy in assessing procedural outcome in bAVM embolization, thereby improving generalizability of the results and allowing for more rigorous interpretation of efficacy and safety.

Summary Pulsatile tinnitus is an uncommon form of tinnitus. Several vascular causes, such as carotid dissection and arteriovenous fistulae, have been associated to pulsatile tinnitus. Methods We present two patients who complained of pulsatile tinnitus and headache in the last 2 weeks. Results Transcranial Doppler demonstrated disturbances in systolic blood flow consisting of turbulences in the middle cerebral artery in one patient and disturbances in a vertebral artery in the other. MR and CT angiography confirmed the diagnosis of vertebrobasilar arteriovenous fistula. Daily compression maneuvers reduced the flow and bruit of both fistulas. Conclusions Hemodynamic changes in cerebral flow through a non-invasive and feasible test such as TCD or duplex can be very useful for the etiological diagnosis of pulsatile tinnitus.

Background and Purpose— Although there is generally thought to be a 2% to 4% per annum rupture risk for brain arteriovenous malformations (bAVMs), there is no way to estimate risk for an individual patient. Methods— In this retrospective study, patients were eligible who had nidiform bAVMs and underwent detailed pretreatment diagnostic cerebral angiography at our medical center from 1996 to 2006. All patients had superselective microcatheter angiography, and films were reviewed for the purpose of this project. Patient demographics, clinical presentation, and angioarchitectural characteristics were analyzed. A univariate analysis was performed, and angioarchitectural features with potential physiological significance that showed at least a trend toward significance were added to a multivariate logistic regression model. Results— One hundred twenty-two bAVMs met criteria for study entry. bAVMs with single venous drainage anatomy were more likely to present with hemorrhage. In addition, patients with multiple draining veins and a venous stenosis reverted to a risk similar to those with 1 draining vein, whereas those with multiple draining veins and without stenosis had diminished association with hemorrhage presentation. Those bAVMs with associated aneurysms were more likely to present with hemorrhage. These findings were robust in both univariate and multivariate models. Conclusions— The results of this article lead to the first physiological, internally consistent model of individual bAVM hemorrhage risk, where 1 draining vein, venous stenosis, and associated aneurysms increase risk.

Background and Purpose— We sought to assess outcomes after endovascular treatment/therapy of acute ischemic stroke, overall and by subgroups, and looked for predictors of outcome. Methods— We used data from a mandatory, population-based registry that includes external monitoring of completeness, which assesses reperfusion therapies for consecutive patients with acute ischemic stroke since 2011. We described outcomes overall and by subgroups (age ≤ or >80 years; onset-to-groin puncture ≤ or >6 hours; anterior or posterior strokes; previous IV recombinant tissue-type plasminogen activator or isolated endovascular treatment/therapy; revascularization or no revascularization), and determined independent predictors of good outcome (modified Rankin Scale score ≤2) and mortality at 3 months by multivariate modeling. Results— We analyzed 536 patients, of whom 285 received previous IV recombinant tissue-type plasminogen activator. Overall, revascularization (modified Thrombolysis In Cerebral Infarction scores, 2b and 3) occurred in 73.9%, 5.6% developed symptomatic intracerebral hemorrhages, 43.3% achieved good functional outcome, and 22.2% were dead at 90 days. Adjusted comparisons by subgroups systematically favored revascularization (lower proportion of symptomatic intracerebral hemorrhages and death rates and higher proportion of good outcome). Multivariate analyses confirmed the independent protective effect of revascularization. Additionally, age >80 years, stroke severity, hypertension (deleterious), atrial fibrillation, and onset-to-groin puncture ≤6 hours (protective) also predicted good outcome, whereas lack of previous disability and anterior circulation strokes (protective) as well as and hypertension (deleterious) independently predicted mortality. Conclusions— This study reinforces the role of revascularization and time to treatment to achieve enhanced functional outcomes and identifies other clinical features that independently predict good/fatal outcome after endovascular treatment/therapy.

BACKGROUND AND PURPOSE Recent reports have indicated that mechanical thrombectomy may have the potential to treat acute ischemic stroke. This study aims to describe the safety and effectiveness of Trevo Retriever, using Stentriever technology, in revascularization of patients with acute ischemic stroke. METHODS Prospective study evaluating the clinical, radiological, and functional outcome of 13 patients with an angiographically verified occlusion of the anterior cerebral circulation. All patients underwent thrombectomy with TR as monotherapy or in combination with intra-arterial thrombolysis, within the first 8 hours from the onset of symptoms. Successful revascularization was defined as thrombolysis in cerebral ischemia grade 2a to 3. Good outcome was defined as modified Rankin Scale score ≤ 2. RESULTS Median baseline National Institutes of Health Stroke Scale score was 19(16-22). The occlusion site was middle cerebral artery in 8 patients and internal carotid artery in 5 patients. Revascularization was achieved in 10 of 13 patients (77%). The mean time from groin puncture to recanalization was 95 ± 31 minutes. No significant intra-procedural complications occurred. Four patients (30%) died during the 90-day follow-up period and 4 patients (30%) achieved functional independence. CONCLUSION Early clinical experience suggests that the TR can allow safe and effective revascularization in certain subjects with acute ischemic stroke.

Introduction Since April 2010, a pilot experience has been set for offering intra-arterial treatment for stroke to a 3.5 million people population. We aim to share our experience from the standpoint of technical complications. Material and Methods The review of 122 patients (69 male and 53 female, mean age 65,4 years) show that twelve cases presented technical complications. In four patients, distal emboli to other territories than the occluded vessel were seen. Two of them were not specifically treated and showed a bad outcome, while the other two were successfully treated with good final Rankin Score. Hemorrhage during microcateterization was noted in four patients. Even though the bleeding was controlled with glue or coils, bad outcome was noted in those patients. One patient presented a femoral pseudoaneurysm related to the puncture site, with severe bleeding and other co-morbidity leading to death. Carotid stent issues in tandem lesions were seen in two patients. In one case, the thrombectomy device was let in place (M1) due to impossibility to retrieve it. Some subclinical incidences as balloon rupture (1 case), M1, M2 or M3 vasospasm, easily resolved with intraarterial nimodipine (3 cases) and some degree of vessel dissection without significant caliber reduction (3 cases) were also recorded. Results and Conclusion In our series, around a ten percent of intraarterial thrombectomy treatments presented procedure related complications. In our opinion, four of them can be attributed to our learning curve, leading to a theoretical complication risk of around a 7% for technical complications. Competing interests None.