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Objectives: Collaterals have an effect on the protection of penumbra tissue. We evaluated the effect of collaterals on single-phase computed tomography angiography (CTA) in patients with AIS treated with MT after 6 hours. Methods: We evaluated patients with ICA or M1 segment of MCA occlusion, time of symptom-groin puncture >6 hours, having CTA before MT, modified Treatment In Cerebral Ischemia score (mTICI) 2b-3 recanalization after MT. Data of collateral levels, outcome measures, timings and other variables were collected from Turkish Interventional Neurology Database. The level of collaterals was assessed with modified Tan scale. Results: A total of 57 patients were included in our study. The median age was 64[56.5-75] years. The median NIHSS score at onset was 15[12-17.5] points. A total of 33 (57.9%) patients had good collaterals on CTA. Hypertension (HT) and diabetes mellitus (DM) rates were increased in the poor collaterals group. NIHSS scores decreased at the 24th hour in both good and poor collaterals groups. Twenty-two (66.7%) patients in the good collaterals group and 11 (45.8%) patients in the poor collaterals group had good clinical outcomes. However, there was not a significant difference (p=0.174, OR: 2.364; 95% CI: 0.802-6.697). Mortality rates were different in both groups, but the difference was not found to be significant (5[15.2%] versus 8[33.3%], p=0.124, OR:0.357; 95% CI: 0.1-1.278). Conclusion: Good collaterals on single-phase CTA was not associated with improved neurological outcomes in AIS patients treated after 6 hours.

Background: Blood viscosity (BV) is relationship cerebrovascular events. However, the association with between BV and clinical outcomes after acute ischemic stroke (AIS) has not been studied. This study evaluated the relationship between whole blood viscosity (WBV) and clinical outcomes after AIS.Materials and Methods: The study enrolled 240 consecutive patients with AIS who underwent mechanical thrombectomy (MT) between 2017 and 2019 years. The all patients were divided according to the modified Rankin Scale (mRS) score, as good (mRS 0–2) and poor (mRS 3–6) clinical outcomes group. WBV was calculated by the formula derived from total protein and haematocrit levels.Results: Poor clinical outcomes group presented significantly higher WBV values both at LSR and HSR (p < 0.001). Multivariate analysis, both high WBV at LSR (Odd ratio: 2.679, p < 0.001) and high WBV at HSR (Odd ratio: 1.278, p < 0.001) were independent predictors for poor clinical outcomes. In receiver operating characteristic analysis, value of 16.1 WBV at HSR had 76.7% sensitivity and 76% specificity for predicting poor clinical outcomes and a value of 38.5 WBV at LSR had 75.3% sensitivity and 78% specificity for predicting poor clinical outcomes. There was a significant positive correlation between WBV at LSR and mRS score (0-6) (r = 0.457, p

Background We performed this meta-analysis of randomized clinical trials to compare the outcomes in patients treated with endovascular thrombectomy who receive prior intravenous thrombolysis with those who do not receive such treatment. Recently, one randomized trial reported outcomes to address this issue, so timely update of meta-analysis is needed to determine the value of administering intravenous thrombolysis before endovascular thrombectomy. Materials and methods Four randomized clinical trials are included in our meta-analysis. We calculated pooled odds ratios and 95% CIs using random-effects models. The primary efficacy endpoint was a favorable outcome defined by a modified Rankin Scale score of 0 (no symptoms), 1 (no significant disability), or 2 (slight disability) at 90 days post-randomization. Secondary endpoints analyzed were any intracerebral hemorrhage, symptomatic intracerebral hemorrhage, and mortality. Results Of the 1633 patients randomized, the proportion of patients who achieved a favorable outcome was similar between endovascular thrombectomy alone and combined approach with intravenous thrombolysis and endovascular thrombectomy (1631 patients analyzed; odds ratio 1.02; CI 0.84–1.25; p = 0.83). Risk of any intracerebral hemorrhage was significantly lower among those randomized to endovascular thrombectomy alone (1633 patients analyzed; odds ratio 0.75; CI 0.57–0.99; p = 0.04). Rates of symptomatic intracerebral hemorrhage (p = 0.36) and mortality (p = 0.62) were not significantly different between the two groups. Conclusions Compared with endovascular thrombectomy preceded by intravenous thrombolysis, endovascular thrombectomy resulted in similar rates of favorable outcome with a lower rate of intracerebral hemorrhage. A large phase 3 trial is required to conclusively demonstrate equivalency of both approaches to guide future practice.

We evaluated the predictive factors of symptomatic intracranial hemorrhage (SICH) in endovascular treatment of stroke. We included 975 ischemic stroke patients with anterior circulation occlusion. Patients that had hemorrhage and an increase of ≥4 points in their National Institutes of Health Stroke Scale (NIHSS) after the treatment were considered as SICH. The mean age of patients was 65.2±13.1 years and 469 (48.1%) were women. The median NIHSS was 16 (13–18) and Alberta Stroke Program Early CT 9 (8–10). In 420 patients (43.1%), modified Rankin Scale was favorable (0–2) and mortality was observed in 234 (24%) patients at the end of the third month. Patients with high diastolic blood pressure ( P

Background The NeVa™ thrombectomy device (Vesalio LLC, Nashville, USA) has been reported to succeed in large vessel occlusion thrombectomy in animal, in-vitro, and clinical studies. Designed with Drop Zone technology, a closed distal tip, and strong expansive radial force, the device demonstrated particular efficiency in resistant “white” thrombi in preclinical research. Our goal is to determine the safety and performance of this novel stent retriever on first-pass rates and overall recanalization. Methods The Interventional Neurology Database is a prospectively maintained database of anterior and posterior circulation stroke thrombectomy cases. We retrospectively analyzed cases where the NeVa™ thrombectomy device was used as the first-line treatment strategy. Data collection occurred between January 2019 and January 2020. First-pass recanalization, final recanalization, 90-day functional outcome, complication, and bleeding rates are reported. Results One hundred eighteen patients were treated with the NeVa™ thrombectomy device. The mean patient age was 69 ± 14 years, the median baseline National Institutes of Health Stroke Scale was 14, and the median initial Alberta Stroke Program Early Computed Tomography score was 8. The median time from groin puncture to successful recanalization was 29 min (interquartile range (IQR): 20–40). First-pass recanalization rates were 56.8% (modified treatment in cerebral infarction (mTICI) 2b/3) and 44.9% (mTICI 2c/3). Final successful recanalization rate was 95.8% (thrombolysis in cerebral infarction 2b/3). Favorable functional outcome (modified Rankin Scale 0–2) was 53% in the “first-pass” subgroup and 42.4% in the total patient population. The median number of passes to achieve the final recanalization score was 1 (IQR 1–2). The rate of embolization into new territory was 1.7%. Four patients (3.3%) had symptomatic hemorrhage. Conclusions In our experience, the NeVa™ device demonstrated high first-pass and overall recanalization rates along with a good safety profile.

Background and purpose Cerebral vasodilatory capacity assessment for risk stratification in patients with extracranial arterial stenosis or occlusion may be useful. We describe a new method that assesses cerebral vasodilatory capacity as part of catheter-based cerebral angiography. Methods We prospectively assessed regional cerebral blood volume (rCBV) in the arterial distribution of interest using a controlled contrast injection in the common carotid or the subclavian arteries. rCBV maps were created using a predefined algorithm based on contrast distribution in the venous phase (voxel size: .466 mm3 ). rCBV maps were acquired again after selective administration of intra-arterial nicardipine (2.0 mg) distal to the stenosis. Two independent observers graded the change in rCBV in 10 predefined anatomical regions within the tributaries of the artery of interest (0 = reduction, 1 = no change, 2 = increase) and total rCBV change scores were summated. Results Twenty-five patients with internal carotid artery stenosis (n = 18; 0-90% in severity) or extracranial vertebral artery stenosis (n = 7; 0-100% in severity) were assessed. There was an increase in rCBV in a tributary of the artery of interest in 18 of 25 after intra-arterial nicardipine (mean score: 11.98; range 0-19.5). There was no change or decrease in rCBV in 7 of 25 patients. The mean rCBV change score was similar in patients with an assessment of internal carotid artery or vertebral artery distributions (12.2 ± 5.3; 11.4 ± 2.5; P = .68). Conclusion Selective vasodilatory response to intra-arterial nicardipine in the affected arterial distribution during catheter-based cerebral angiography may provide new data for risk stratification.

Objective To present guidance for clinicians caring for adult patients with acuteischemic stroke with confirmed or suspected COVID-19 infection. Methods The summary was prepared after review of systematic literature reviews,reference to previously published stroke guidelines, personal files, and expert opinionby members from 18 countries. Results The document includes practice implications for evaluation of stroke patientswith caution for stroke team members to avoid COVID-19 exposure, during clinicalevaluation and conduction of imaging and laboratory procedures with specialconsiderations of intravenous thrombolysis and mechanical thrombectomy in strokepatients with suspected or confirmed COVID-19 infection. Results Conclusions—The summary is expected to guide clinicians caring for adult patientswith acute ischemic stroke who are suspected of, or confirmed, with COVID-19infection.

Background and purpose On 11 March 2020, World Health Organization (WHO) declared the COVID-19 infection a pandemic. The risk of ischemic stroke may be higher in patients with COVID-19 infection similar to those with other respiratory tract infections. We present a comprehensive set of practice implications in a single document for clinicians caring for adult patients with acute ischemic stroke with confirmed or suspected COVID-19 infection. Methods The practice implications were prepared after review of data to reach the consensus among stroke experts from 18 countries. The writers used systematic literature reviews, reference to previously published stroke guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate practice implications. All members of the writing group had opportunities to comment in writing on the practice implications and approved the final version of this document. Results This document with consensus is divided into 18 sections. A total of 41 conclusions and practice implications have been developed. The document includes practice implications for evaluation of stroke patients with caution for stroke team members to avoid COVID-19 exposure, during clinical evaluation and performance of imaging and laboratory procedures with special considerations of intravenous thrombolysis and mechanical thrombectomy in stroke patients with suspected or confirmed COVID-19 infection. Conclusions These practice implications with consensus based on the currently available evidence aim to guide clinicians caring for adult patients with acute ischemic stroke who are suspected of, or confirmed, with COVID-19 infection. Under certain circumstances, however, only limited evidence is available to support these practice implications, suggesting an urgent need for establishing procedures for the management of stroke patients with suspected or confirmed COVID-19 infection.

INTRODUCTION: Large vessel occlusion can present with minor stroke in 30% of cases. Although the efficacy of mechanical thrombectomy in minor stroke National Institute of Health Stroke Scale (NIHSS

One of the most important reasons why the use of the intravenous (IV) tissue plasminogen activator (tPA), which is one of the key elements of acute ischemic stroke treatment, is not sufficiently widespread is the fact that many common questions have not been adequately answered. In this review, questions about systemic nonneurologic conditions, problems related with IV tPA treatment and complications of treatment, which were collected from our colleagues practicing in Turkey and which are more important in clinical practice, were answered on the basis of the current literature and clear recommendations are made

Use of intravenous tissue plasminogen activator (tPA) is one of the key elements of acute ischemic stroke management. Its use has not become widespread, and has faced significant problems in our country for more than a quarter of a century most probably due to many unanswered questions about issues related with daily practice. However, recent developments, which adequately focused and found solutions for most of these problems and questions, have led to a major change of point of view and understanding of the hyperacute management of stroke. This article, in the light of the relevant literature, discusses and provides clear recommendations for questions directed by neurologists practicing in Turkey mainly about typical neurologic issues faced in the setting of tPA use for acute stroke

Background and purpose Different techniques regarding efficient utilization of thrombectomy devices have been reported. Here, we described a novel technique named ADVANCE that is based on advancing a distal access catheter over the stent retriever. In this study, we aimed to report our initial results with this novel thrombectomy technique. Methods and results Sixty-seven consecutive acute anterior circulation ischemic stroke patients (35 male, 32 female) between January 2015 and January 2016 who were treated by mechanical thrombectomy were included in this prospective study. Patients were classified randomly into two groups: patients treated with either the ADVANCE technique or standard technique. Patients had a mean age of 61.1 ± 12.9 years. The average NIHSS score was 15.8 ± 3.8. In the ADVANCE group, the successful revascularization (mTICI 2b–3) rate was 87.1% and the 90-day good functional outcome rate (mRS 0–2) was 74.1%. The revascularization rate in the ADVANCE group was significantly ( p = 0.005) better than the standard technique group and good functional outcome at 90 days in the ADVANCE group was non-significantly better than the standard technique group ( p = 0.052). Conclusions ADVANCE is the first comparison of this technique to standard stent retriever thrombectomy with a higher rate of revascularization with no emboli to new territory and fewer distal emboli to target territory. This safe and efficient technique needs to be validated in large patient series in new thrombectomy trials.

Background: Intravenous recombinant tissue plasminogen activator (IV rt-PA) prior to thrombectomy may reduce the risk of intraprocedural distal embolization in acute ischemic stroke patients. Methods: We analyzed the diffusion-weighted imaging acquired with 1.5- or 3-T magnetic resonance imaging (MRI) scans obtained within 24 hours of thrombectomy in consecutive acute ischemic stroke patients. An independent physician identified distal embolization, defined as discrete foci of restricted diffusion independent of the primary area of infarction on MRI scan. Patients were stratified based on whether they had or did not receive IV rt-PA prior to thrombectomy. Results: Distal embolization was seen in 59 (ipsilateral in 56) of 63 patients (mean age ± SD; 64.6 ± 15.3 years) who underwent thrombectomy (mean number 8.6; range 0-32). There was no difference in mean number of ipsilateral hemispheric distal embolization between the 2 groups (7.9 ± 6.1 versus 7.5 ± 7.6, P = .82). After adjusting for age, admission National Institutes of Health Stroke Scale score, the time interval between symptom onset and thrombectomy, there was no association between receiving IV rt-PA prior to thrombectomy and number of ipsilateral distal emboli (P = .90). There was no relationship between the number of ipsilateral emboli and rates of favorable outcome after adjusting for other confounders (adjusted odds ratio 1.0; 95% confidence interval .89 - 1.0; P = .40). Conclusions: Although distal embolization is very common after thrombectomy, IV rt-PA prior to procedure does not reduce the risk of intraprocedural distal embolization.

Background: The efficacy and safety of endovascular treatment for proximal large vessel occlusion after 6 hours of symptom onset have recently been studied in randomized controlled trials. We performed this meta-analysis to identify the combined effect of endovascular treatment on various outcomes in this patient population. Methods: We performed this meta-analysis of all available randomized controlled clinical studies that involved the use of endovascular treatment in after 6 hours of symptom onset. We calculated pooled odds ratios (ORs) and 95% confidence intervals (CIs) using random-effects models. The primary end point was a favorable outcome defined by a modified Rankin Scale (mRS) of 0 (no symptoms), 1 (no significant disability), or 2 (slight disability) at 90 days post-randomization. Other outcome variables included symptomatic intracerebral hemorrhage, excellent outcome (mRS 0-1), and mortality at 90 days post-randomization. Results: Three trials were identified that included 447 patients. The proportion of subjects who achieved a favorable outcome was significantly greater among those randomized to endovascular treatment compared with best medical treatment (445 subjects analyzed; OR 4.34; 95% CI, 2.65-7.14; P < .001). Excellent outcome was also significantly greater among those randomized to endovascular treatment (445 subjects analyzed; odds ratio, 3.29; 95% CI, 1.98-5.46, P < .001). Risk of symptomatic intracranial hemorrhage and mortality were similar between endovascular treatment and best medical treatment with p-value of 0.320 and 0.375, respectively. No risk of heterogeneity was observed in any of outcome variables. Conclusion: We found a prominent benefit (4 times higher odds) with endovascular treatment in appropriately selected patients with large vessel occlusion ischemic stroke presenting after 6 hours of symptom onset

Background: Cerebral vasodilatory capacity assessment for risk stratification in patients with extracranial arterial stenosis or occlusion may be useful. We describe a new method that assesses cerebral vasodilatory capacity as part of catheter-based cerebral angiography. Methods: We prospectively assessed regional cerebral blood volume (rCBV) in the arterial distribution of interest using a controlled contrast injection in the common carotid or the subclavian arteries. rCBV maps were created using a predefined algorithm based on contrast distribution in the venous phase (voxel size 0.466 mm 3 ). rCBV maps were acquired again after selective administration of intra-arterial nicardipine (2.5 mg) distal to the stenosis. Two independent observers graded the change in rCBV in 10 predefined anatomical regions within the tributaries of the artery of interest (0=reduction, 1=no change, 2=increase) and total rCBV change scores were summated. The rCBV score values were averaged between the two observers for each patient. Mean arterial pressure was monitored at baseline and at 1 minute intervals post nicardipine administration for 5 minutes. Results: Twenty-five patients with internal carotid artery stenosis (n=18; 0%-90% in severity) or extracranial vertebral artery stenosis (n=7; 0%-100% in severity) were assessed. There was an increase in rCBV in a tributary of the artery of interest in 18 of 25 after intra-arterial nicardipine (mean score 11.98; range 0-19.5). There was no change or decrease in rCBV in 7 of 25 patients. The mean rCBV change score was similar in patients with assessment of internal carotid artery or vertebral artery distributions (12.2 ± 5.3; 11.4 ± 2.5; p=0.68 by ANOVA). There was an average (±SD) reduction of mean arterial pressure of 14mmHg ± 7.5 after intra-arterial nicardipine. There was no correlation between the magnitude of mean arterial pressure reduction post nicardipine (regression coefficient -0.13; p=0.38) or between the severity of stenosis (regression coefficient -0.04; p=0.29) and rCBV change scores. Conclusions: We describe a new technique for selective assessment of cerebral vasodilatory response in the affected arterial distribution during catheter-based cerebral angiography.

Background: Thrombus composition may vary among acute ischemic stroke patients. Thrombus composition is a key factor in determining susceptibility to mechanical and pharmacological thrombus disruption and thus the degree of successful recanalization. Many studies have reported the correlation between thrombus components and parameters such as stroke etiology, treatment outcome but there is still a lack of information due to a small sample size. We determined the relationship of thrombus composition on the success of thrombectomy in this multicenter study. Methods: We analyzed the data on 111 acute stroke patients, treated with mechanical thrombectomy, taken from 3 different stroke centers. Retrieved clots underwent semiquantitative proportion analysis by pathologists blinded to patient characteristics and imaging findings. Thrombus type was classified as erythrocyte rich, fibrin-rich and mixed type. Primary outcome assessment was the effect of clot composition on recanalization attempts. Multivariate analysis was performed to identify predictors of attempt number. Successful recanalization is defined as thrombolysis in cerebral infarction (TICI) scale 2b and 3. The good functional outcome is defined as modified Rankin Scale (mRS) 0-2 at 3 months. Results: Successful recanalization was achieved in 86 of 111 patients who underwent acute thrombectomy. Pathological characteristics did not differ significantly when compared to the number of attempts for recanalization (p = 0.469). Symptom recanalization time was shorter for patients recanalized with fewer attempts (p=0.0027). National Institute of Health Stroke Scale (NIHSS) or Stroke Etiologic Subtype was not correlated significantly with thrombectomy attempts ( p=0.76 and 0.22, respectively) as well. There was a no significant trend for good functional outcome with fewer attempts (p=0.10). There was no predictor of the number of attempts in multivariate analysis. Conclusions: In our study, histological thrombus composition had no impact on the number of attempts of thrombectomy done in acute ischemic stroke patients.

Background: It has been hypothesized that intravenous recombinant tissue plasminogen activator (rt-PA) prior to mechanical thrombectomy reduces the risk of intraprocedural distal embolization in acute ischemic stroke patients. Methods: We analyzed the diffusion-weighted imaging (DWI) acquired with 1.5- or 3- Tesla magnetic resonance imaging (MRI) scans obtained within 24 hours of mechanical thrombectomy in consecutive acute ischemic stroke patients. DWI was performed with single-shot echo-planar technique at b values of 0-1000 s/mm 2 . An independent physician identified distal embolization related foci of restricted diffusion on ipsilateral and contralateral hemispheres. Distal embolization was defined as discrete foci of restricted diffusion independent of the primary area of infarction on MRI. Patients were stratified based on whether they had or did not receive intravenous rt-PA prior to thrombectomy. Results: Distal embolization was seen in 48 of 50 patients (mean age ± SD; 62.9 ± 15.5 years) who underwent mechanical thrombectomy (mean number 9.1; range 0-22). The mean number of distal embolization was not significantly different between patients who had and those who did not receive intravenous rt-PA prior to mechanical thrombectomy (9.5 ± 6.2 versus 8.7 ± 6.5; p=0.67 by ANOVA). There was no difference in mean number of ipsilateral hemispheric distal embolization between the two groups (8.5 ± 6.4 versus 7.6 ± 6.4, p=0.61 by ANOVA). There was no relationship between mean number of emboli and age of the patient (regression coefficient 0.004; p=0.94) or time interval between symptom onset and thrombectomy (regression coefficient -0.02; p=0.67) on linear regression analyses. Conclusion: Although distal embolization is very common after thrombectomy, we did not find any evidence that intravenous rt-PA prior to procedure reduces the risk of intraprocedural distal embolization.

Background: Anemia will negatively affect cerebral collaterals and penumbra. Eventually, it may cause worse clinical outcomes and even increase mortality rates in stroke patients. Anemia has recently been suggested to be an independent risk factor for ischemic stroke. Therefore, we aimed to investigate the effects of the presence of anemia on clinical outcomes in ischemic stroke patients undergoing mechanical thrombectomy. Methods: This was a retrospective study involving the prospectively and consecutively collected data of 90 adult patients between January 2015 and August 2016. Hemoglobin (Hb) cutoff levels were accepted as 12 g/dL for women and 13 g/dL for men. Patients having anemia were further divided into three subgroups as severe anemia (Hb Results: Forty of the subjects (44.4%) had anemia. Moderate anemia was detected in 14 out of 90 patients (15.5%) and severe anemia was found in only four of them (4.4%). Poor functional outcome (mRS 3-6) was similar in both anemic and non-anemic patients (37.5% vs. 38%, respectively, p = 0.08), but poor functional outcome was found to be statistically significant with severe anemic group (Hb p = 0.003). In multiple logistic regression analysis, moderate and severe anemia has been found to increase the mortality (p = 0.032). Conclusions: Our study demonstrated a poor functional outcome only in moderate to severe anemic patients. Clinicians should keep in mind the negative effect of moderate to severe anemia in the clinical course of acute stroke patients treated with mechanical thrombectomy.

Background The aim of the study was to assess the efficacy of balloon angioplasty-assisted mechanical thrombectomy without urgent stenting in the carotid artery as another approach for endovascular treatment of tandem occlusions. Methods Fifteen consecutive cases of tandem occlusions treated with the endovascular approach between January 2014 and May 2016 were reviewed. The study cohort included patients with an etiology of large vessel atherosclerosis. Extracranial carotid stenting was performed in another session if post-thrombectomy mRS modified Rankin Score (mRS) was 0–2. Good clinical outcome was determined by follow-up at 7–10, 30 and 90 days according to the mRS. Results Most patients (80%) were male. Eight (53.4%) patients received intravenous thrombolysis before angiography. Proximal revascularization was successful in 100% of cases with balloon angioplasty internal carotid artery (ICA) origin. Successful recanalization (modified thrombolysis in cerebral infarction (mTICI) 2b-3) (mTICI 2 b–3) occurred in 12 cases (80%) and good clinical outcomes were achieved in 10 patients (66.7%). Cervical ICA stent placement was performed in 10 patients with good clinical outcomes. No symptomatic intracranial hemorrhage occurred after delayed ICA stenting Conclusions This is the first reported case series to evaluate this approach for endovascular treatment of tandem occlusions. Carotid angioplasty-assisted mechanical thrombectomy without urgent stenting seems to be a safer approach.

Dolichoectasia is a term used to describe marked widening, tortuosity and elongation of an artery. Intracranial vertebral and basilar arteries are most commonly involved. Vertebrobasilar dolichoectasia is usually asymptomatic. Both vertebrobasilar and bilateral carotid dolichoectasia has been reported very rarely in the literature. Cranial nerve compression and cerebral ischemia findings are frequently seen in symptomatic patients. We reported a 67-year-old female, without medical or family history for cerebrovascular disease, presented with vertebrobasilar and bilateral carotid dolichoectasia and subarachnoid hemorrhage, manifesting as reduced level of consciousness and weakness, and left abducens palsy.

OBJECTIVE: In recent years, Digital Subtraction Angiography (DSA) and endovascular treatment’s importance increases gradually. We aimed to emphasize the importance of the Interventional Neurology in neurology practice and we aimed to share our experience about DSA examination which we have done for a short time in our Neurology clinic. MATERIAL and METHODS: 27 patients with a diagnosis of carotid stenosis or aneurisym were included in the study between June 2011 and June 2012. Patients were between the ages of 24 and 78 and the average was 59.7 years old. DSA examination was applied in our Interventional Neurology Clinic and their results were analysed. RESULTS: Seven female and 20 male, total 27 patient, with the average age of 59.7, were analyzed. One patient with the diagnosis of subclavian steal syndrome, 4 patient with the diagnosis of the aneurisym, 22 patient with the diagnosis of the carotid stenosis were underwent to DSA examination. Dural arteriovenous fistula was determined in one of four patients with the diagnosis of aneurysm and in another patient, vertebrobasilar and bilateral carotid dolichoectasia was determined. In DSA examination, over 70% of the internal carotid artery stenosis were found in five of 22 patients with the diagnosis of carotid stenosis. In six patients right total internal carotid artery stenosis was determined. Carotid stent implantation were applied in four of 5 patients. CONCLUSION: Despite advances in noninvasive diagnostic neuroimaging, diagnostic cervicocerebral angiography remains the criterion standard for the evaluation of patients with cerebrovascular disease.

ObjectiveTo determine the relative effectiveness of proximal and distal protection in prevention of cerebral ischemic events during carotid artery stent (CAS) placement using diffusion-weighted MRI (DW-MRI).MethodsWe analyzed data from patients who had undergone DW-MRI before and within 24 hours of CAS for symptomatic internal carotid artery (ICA) stenosis (with last ischemic events within 3 months). The study was performed prospectively; patients were not randomized, and were treated either with a proximal balloon occlusion system (Mo.Ma; Invatec, Roncadelle, Italy) or filter-type distal protection device (Spider device; ev3, Plymouth, Minnesota, USA).ResultsOf the 45 patients (mean age±SD: 66.9±9.8 years; 73.3% were men) who underwent CAS, 19 had proximal protection and 26 distal protection. New ischemic lesions were detected in 26/45 patients on DW-MRI scans obtained within 24 hours after CAS. The proportion of patients with new lesions on DW-MRI at 24 hours was not different between the two groups (47.4% vs 65.4% for proximal and distal protection, respectively). The mean number of new ischemic lesions on post-CAS DW-MRI was non-significantly higher in patients who underwent CAS with distal protection (2.80±3.54 for proximal protection vs 4.96±5.11 for distal protection; p=0.12). The proportion of patients with new lesions >1 cm did not differ between the two groups (5.3% for proximal protection vs 11.5% for distal protection; p=0.62). There was no difference in the rates of ischemic stroke between patients who underwent CAS treatment using proximal and distal protection (5.3% vs 7.7%; p=1.000).ConclusionsWe found a relatively high rate of new ischemic lesions in patients undergoing CAS with cerebral protection. There was no difference in the proportion of patients with new lesions between patients treated using distal protection and those treated using proximal protection.

AIM To report patient and procedure-related factors affecting the angiographic and clinical outcome in patients treated with the Silk device. MATERIAL AND METHODS All patients with intracranial aneurysms in whom treatment was attempted with the Silk flow diverter by our neurovascular team between October 2010 and November 2013 were included consecutively. The data was analyzed by an independent stroke neurologist not involved in the treatment of the patients. RESULTS A total of 96 patients (64 female) with ages range from 3 to 78 were included in this study. We found that 54 of the patients were asymptomatic and 42 of them symptomatic, while 21 had a prior history of subarachnoid hemorrhage (SAH). Mean aneurysm size was 10.2 mm (range 2 to 40 mm). 2 patients died due to consequences of SAH. 3 patients developed visual decline on the follow-up, 2 of these were procedure-related. Symptomatic thromboembolic events were noted in 7 cases. Patients with aneurysms smaller than 13 mm had significantly less complications and higher occlusion rates. The complication rate was significantly high in patients admitted with symptoms. Adjunctive coiling had no impact on outcome. CONCLUSION Safety and efficacy of flow diversion in this series was closely related to aneurysm size and presenting symptoms. A size cut-off for safety and efficacy has not been reported before and will be useful not only for future studies but also for patient counseling in daily practice. The futility of adjunctive coiling in this series calls for reappraisal of the current recommendations for this specific device.

AIM We evaluated the procedural outcomes of intracranial aneurysm treatment with the Silk device and its relation with operator experience. We also detailed some technical points we learned throughout our experience. MATERIAL AND METHODS One hundred and six consecutive patients with intracranial aneurysms treated using Silk (BaltExtrusion, Montmorency, France) stent between October 2010 and November 2013 were included. Patients were evaluated in terms of age, sex, aneurysm size, location, technical success, and adverse events. RESULTS There were 106 patients (71 female) undergoing 116 procedures with a mean age of 49.8 (range: 3-78 years). Mean aneurysm size was 10.7±8.0 (range, 2-40 mm). Technical success of the procedures was 96.5%. Adverse event rate was 11.2%. Among adverse events, there were 4 adverse events without complications, 2 mild complications, 7 severe complications, 4 of which resulted with death. The adverse event rate was significantly higher during the first half of the operator's experience. The rate of adverse events seemed to stabilize after around 50 patients. Adverse events, regardless of the presence or absence of a clinical complication, were more frequent in aneurysms larger than 18.5 mm. CONCLUSION Safety of flow-diverter (FD) placement for intracranial aneurysms increases with operator experience. Training programs in endovascular management of cerebrovascular diseases and relevant fellowship curricula must be adapted to include sufficient flow diverter experience. The learning curve needs to be kept in mind when studies comparing different FD devices or those comparing other treatments to FDS are planned.

By comparing neurocognitive test results from patients with obstructive sleep apnea syndrome (OSAS) and those from patients with simple snoring, we aimed to establish whether OSAS negatively influences cognition. Patients with mild-to-severe OSAS (n = 29) and nonhypoxic simple-snoring patients (n = 30) were admitted to the study. All participants in both groups were evaluated with polysomnography and neurocognitive tests, including the Stroop Test, Rey Auditory Verbal Learning Test, Judgment of Line Orientation, Trail-Making Test, and Symbol Digit Modalities Test (SDMT). Significant differences were identified between the groups for test scores on the Rey 1, SDMT, and Stroop tests. We propose that accurate OSAS diagnosis and treatment might help to prevent cognitive decline.

Current evidence suggests that endogenous dopamine may act as a neurotoxin following its oxidation to an o-quinone and reaction with cellular thiols, which are neutoxic, which may occur spontaneously or via reaction with tyrosinase or some other enzymes. Tyrosinase (E.C. 1.14.18.1) with two cupper ions coordinated by three histidines is a bifunctional enzyme that catalyses both the hydroxylation of tyrosine to L-DOPA and the consequent oxidation of the resulting catechol-containing species to an o-quinone. Therefore, tyrosinase may play a role in neuromelanin formation in the brain and could be central to dopamine neurotoxicity by contributing to the neurodegeneration associated with Parkinson's disease. In the present study, inhibitory effect of ascorbic acid against tyrosinase has been investigated and it has shown a remarkable inhibitory effect in in vitro assays. Then, the in silico-based experiments established through molecular docking calculations and scoring, docking search algorithm, and data plotting indicated that ascorbic acid is strong inhibitor of tyrosinase by interacting with four amino acid units (histidine 263, serine 282, phenylalanine 264, and valin 283) in the active site of the enzyme. The compound also had two long distant hydrogen bindings with Cu1 and Cu2 with distances of 3.57 and 3.41 angstrom, respectively, through its O5 atom.

Background and aim: Ischemic cerebrovascular events are the most common reason for patients to be bedridden and the third most common reason for death. Many studies in recent years have demonstrated that carotid artery stenting (CAS) may be an alternative to carotid endarterectomy (CEA). In this study, we aimed to report early outcomes of patients who were treated with CAS in our clinic and discuss practicability, advantages and safety of CAS. Methods and Findings: Eighty patients who underwent CAS between December 2009 and May 2011 were eligible. The mean age was 65 years (range, 49 - 89 years). Of the study group, 73.75% were males and 26.25% were female. The percentage of asymptomatic patients was 11.7%, and the remaining patients were symptomatic. A distal embolic protection device (Angioguard®) was used in 22% of the patients whereas, in the other patients (78%), a proximal blockage system (Mo.MA®) was used. Self-expandable hybrid stents were implanted in all patients and post-dilatation was performed after implantation. None of the patients suffered from stroke, myocardial infarction or death due to CAS during their hospital stay. The mean follow-up period was 10 months (range 2 - 18 months) after discharge. None of the patients had died or had a stroke, a transient ischemic attack (TIA), or a myocardial infarction during the follow-up period. Re-stenosis was not observed in the follow-up carotid Doppler ultrasonography; flow rates were within normal limits. Conclusion: No major complication was observed during the early follow-up period in patients who underwent CAS in our clinic. Only 2 (2.5%) patients showed transient numbness and weakness and these did not lead to morbidity. In the management guide of extracranial carotid and vertebral artery diseases, CAS, in the light of recent studies, is recommended as an alternative to CEA in recommendations for revascularization. One of the important issues emphasized in this guide is the experience of centers. Very low complication rates after CAS suggested that, with suitable patient selection and an experienced team, similar results may be obtained.

Cholinesterase enzyme family consisting of acetylcholinesterase (AChE) and butrylcholinesterase (BChE) is important in pathogenesis of Alzheimer's disease (AD), explained by "cholinergic hypothesis". Accordingly, deficiency of the neuromediator called "acetylcholine" excessive amount of BChE has been well-described in the brains of AD patients. Consequently, cholinesterase inhibition has become one of the most-prescribed treatment strategies for AD. In fact, cholinesterase inhibitors have been also reported for their effectiveness in some other diseases including glaucoma, myasthenia gravies, as well as Down syndrome, lately. They play a role in the action of mechanism of insecticidal drugs such as carbamate derivatives as well as nerve gases such as malathion and parathion. All these utilizations can make them a multi-targeted drug class putting a special emphasis on AD therapy in the first place. Several inhibitors of cholinesterases with synthetic and natural origins are available in drug market; however, the reasons including side effects, relatively low bioavailability, etc. limit their uses in medicine and there is still a great demand to discover new cholinesterase inhibitors. Galanthamine, an alkaloid derivative isolated from snowdrop (Galanthus nivalis L.), is the latest anticholinesterase drug used against AD. Huperzine A, isolated from Huperzia serrata (Thunb.) Trev. is the most-promising drug candidate with potent anticholinesterase effect and it is a licensed anti-AD drug in China. In this review, a short introduction will be given on known cholinesterase inhibitors and, then, galanthamine and huperzine A will be covered in regard with their cholinesterase inhibitory potentials and mass productions by organic synthesis and in vitro culture techniques. © 2011 Bentham Science Publishers Ltd.