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The ability of the current grading systems to predict optimal outcomes in stroke patients with favourable collaterals remains unexplored. We evaluated differences in the performance of grading systems between Careggi Collateral Score and ASITN/SIR collateral score to predict clinical and radiological outcomes in stroke patients with favourable collaterals who underwent thrombectomy. We included stroke patients receiving thrombectomy within 360 min after symptom onset with MCA occlusion and favourable collaterals (i.e., without poor collaterals) defined by ASITN/SIR collateral score between 2 and 4. Using ordinal regression, we estimated the association of each CCS and ASITN/SIR grade with mRS shift (0-6) at 3 months, NIHSS score (0-42) and ASPECT score (10-0) at baseline, TICI score (3-0), infarct growth, cerebral bleeding, and cerebral edema grading at 24 h by calculating the odds ratios (ORs) with two-sided 95% confidence intervals after adjustment for predefined variables. Using the best collateral grade (CCS = 4) as reference, ORs of the CCS grades were associated in the direction of unfavourable outcome on 3-month mRS shift (2.325 for CCS = 3; 5.092 for CCS = 2), in the direction of more severe baseline NIHSS score (5.434 for CCS = 3; 16.041 for CCS = 2), 24-h infarct growth (2.659 for CCS = 3; 8.288 for CCS = 4) and 24-h cerebral edema (1.057 for CCS = 3; 5.374 for CCS = 2) shift. ORs of the ASITN/SIR grades were associated in the direction of more severe baseline NIHSS score (4.332 for ASITN/SIR = 3; 16.960 for ASITN/SIR = 2) and 24-h infarct growth (2.138 for ASITN/SIR = 3; 7.490 for ASITN/SIR = 2) shift. The AUC ROC of CCS and ASITN/SIR for predicting 3-month mRS score 0-1 were 0.681 (95% CI: 0.562-0.799; p = 0.009) and 0.599 (95% CI: 0.466-0.73; p = 0.156), respectively. CCS = 4 and ASITN/SIR ≥ 3 were the optimal cut-offs to predict 3-month mRS score 0-1, respectively. CCS grading system performed better than the ASITN/SIR collateral score predicting 3-month mRS score and 24-h CED grading in stroke patients with favourable collaterals who received thrombectomy for MCA occlusion.

Background: Anti-IgLON5 disease is a rare neurodegenerative tauopathy that displays heterogeneity in clinical spectrum, disease course, cerebrospinal fluid (CSF) findings, and variable response to immunotherapy. Sleep disorders, bulbar dysfunction, and gait abnormalities are common presenting symptoms, and conventional brain MRI scanning is often unrevealing. Objective: To provide a comprehensive overview of the literature and to assess the frequency of symptoms, MRI findings, and treatment response in patients with IgLON5 autoimmunity in the serum and CSF or restricted to serum. Methods: We examined a 65-year-old woman with bulbar-onset IgLON5 disease with serum-restricted antibodies, and we also performed a systematic review of all confirmed cases reported in the English literature. Results: We identified 93 patients, included our case. Clinical data were obtained in 58 subjects, in whom the most frequent symptoms were sleep-disordered breathing, dysphagia, parasomnias, dysarthria, limb or gait ataxia, stridor or vocal cord paresis, movement disorders, and postural instability. Distinct MRI alterations were identified in 12.5% of cases, as opposed to unspecific or unremarkable changes in the remaining patients. T2-hyperintense non-enhancing signal alterations involving the hypothalamus and the brainstem tegmentum were observed only in the present case. Inflammatory CSF was found in half of the cases and serum-restricted antibodies in 4 patients. Treatment with immunosuppressant or immunomodulatory drugs led to sustained clinical response in 19/52 patients. Conclusion: Anti-IgLON5 autoimmunity should be considered in patients with sleep disorders, bulbar syndrome, autonomic involvement, and movement disorders, and high-field brain MRI can be of diagnostic help.

We report a case of a 50-year-old male presenting with right arm weakness and mixed aphasia after motorcycle accident. Basal CT/MR imaging showed absence of acute brain lesions and left internal carotid artery (ICA) wall hematoma at C1-C2 level close to a prominent styloid process. Multiphase CT angiography confirmed ICA dissection and a hypertrophic styloid process compressing the ICA at the same level; ipsilateral intracranial blood flow delay and good collateral circulation were present in the latest CTA phases [1]. Due to Patient neurological status deterioration, with progressive global aphasia and right hemiplegia onset, digital subtraction angiography (DSA) was performed urgently. DSA confirmed the CTA findings together with slowing of cerebral blood flow above the dissection; after mechanical thrombectomy by aspiration followed by balloon angioplasty, good blood flow and vessel caliber restoration were obtained. Post-procedural control and follow-up findings are described together with revision of the recent literature on the possible association between cerebral ischemic stroke and Eagle syndrome.

The Careggi Collateral Score (CCS) (qualitative–quantitative evaluation) was developed from a single-centre cohort as an angiographic score to describe both the extension and effectiveness of the pial collateral circulation in stroke patients with occlusion of the anterior circulation. We aimed to examine the association between CCS (quantitative evaluation) and 3-month modified Rankin Scale (mRS) score in a large multi-center cohort of patients receiving thrombectomy for stroke with occlusion of middle cerebral artery (MCA). We conducted a study on prospectively collected data from 1284 patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke. According to the extension of the retrograde reperfusion in the cortical anterior cerebral artery (ACA)-MCA territories, CCS ranges from 0 (absence of retrograde filling) to 4 (visualization of collaterals until the alar segment of the MCA). Using CCS of 4 as reference, CCS grades were associated in the direction of unfavourable outcome on 3-month mRS shift (0 to 6); significant difference was found between CCS of 0 and CCS of 1 and between CCS of 3 and CCS of 4. CCS ≥ 3 was the optimal cut-off for predicting 3-month excellent outcome, while CCS ≥ 1 was the optimal cut-off for predicting 3-month survival. CCS of 0 and CCS

To report our experience in treating one patient with nontraumatic subarachnoid hemorrhage (SAH) and concurrent acute ischemic stroke (AIS) due to large vessels occlusion (LVO). A man in his 50 s presented with acute right hemiparesis and aphasia. Brain CT showed a SAH in the left central sulcus; CT-angiography revealed a tandem occlusion of the left internal carotid artery and homolateral middle cerebral artery. He underwent an angiographic procedure with successful recanalization. Follow-up CT demonstrated a striatal-lenticular stroke without SAH progression. While the absolute contraindication to IVT during intracranial bleeding remains unquestionable, the potential injury/benefit from MT is still debatable. Such cases constitute a blind spot in the guidelines where physicians face the dilemma of choosing between an acute endovascular treatment with the risks of hemorrhage progression and a conservative treatment with the associated poor clinical outcome. We decided to treat our patient invasively, considering the young age, also given the absence of prognostic factors that generally predict post-procedural reperfusion injury. We believe that, in similar cases, MT should be considered—despite not free of risks and drawbacks—to avoid the detrimental consequences of untreated AIS from LVO.

Background and Purpose: Acute ischemic stroke and large vessel occlusion can be concurrent with the coronavirus disease 2019 (COVID-19) infection. Outcomes after mechanical thrombectomy (MT) for large vessel occlusion in patients with COVID-19 are substantially unknown. Our aim was to study early outcomes after MT in patients with COVID-19. Methods: Multicenter, European, cohort study involving 34 stroke centers in France, Italy, Spain, and Belgium. Data were collected between March 1, 2020 and May 5, 2020. Consecutive laboratory-confirmed COVID-19 cases with large vessel occlusion, who were treated with MT, were included. Primary investigated outcome: 30-day mortality. Secondary outcomes: early neurological improvement (National Institutes of Health Stroke Scale improvement ≥8 points or 24 hours National Institutes of Health Stroke Scale 0–1), successful reperfusion (modified Thrombolysis in Cerebral Infarction grade ≥2b), and symptomatic intracranial hemorrhage. Results: We evaluated 93 patients with COVID-19 with large vessel occlusion who underwent MT (median age, 71 years [interquartile range, 59–79]; 63 men [67.7%]). Median pretreatment National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score were 17 (interquartile range, 11–21) and 8 (interquartile range, 7–9), respectively. Anterior circulation acute ischemic stroke represented 93.5% of cases. The rate modified Thrombolysis in Cerebral Infarction 2b to 3 was 79.6% (74 patients [95% CI, 71.3–87.8]). Thirty-day mortality was 29% (27 patients [95% CI, 20–39.4]). Early neurological improvement was 19.5% (17 patients [95% CI, 11.8–29.5]), and symptomatic intracranial hemorrhage was 5.4% (5 patients [95% CI, 1.7–12.1]). Patients who died at 30 days exhibited significantly lower lymphocyte count, higher levels of aspartate, and LDH (lactate dehydrogenase). After adjustment for age, initial National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, and successful reperfusion, these biological markers remained associated with increased odds of 30-day mortality (adjusted odds ratio of 2.70 [95% CI, 1.21–5.98] per SD-log decrease in lymphocyte count, 2.66 [95% CI, 1.22–5.77] per SD-log increase in aspartate, and 4.30 [95% CI, 1.43–12.91] per SD-log increase in LDH). Conclusions: The 29% rate of 30-day mortality after MT among patients with COVID-19 is not negligible. Abnormalities of lymphocyte count, LDH and aspartate may depict a patient’s profiles with poorer outcomes after MT. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT04406090.

The technique of direct intratumoral injection of permanent liquid agents has evolved significantly over the past few decades. The percutaneous direct puncture technique is being utilised more and more for embolisation of head and neck hypervascular lesions. We describe a case treated via the direct percutaneous transnasal (TN) puncture technique for embolisation of a sinonasal hypervascular tumour, performed in a 21-year-old male patient. Due to extensive vascularisation of the tumour, preoperative embolisation was requested by our otolaryngologist team in order to minimise intraoperative bleeding and reduce surgical morbidity. A primary attempt at trans-arterial embolisation through selective ophthalmic artery catheterisation was unsuccessful due to unfavourable anatomy. An extensive devascularisation of the nasal fossa lesion was obtained using a single injection of low-density polymeric embolic agent (SQUID®). Post-operative eradication was uneventful. Final histopathology exam revealed vascular tumour consistent with a rare sinonasal glomangiopericytoma. To our knowledge, this is the first reported case of a rare sinonasal glomangiopericytoma treated by direct TN injection, utilising the liquid polymer agent SQUID®.

Motor fluctuations and dyskinesias occur in the majority of patients with Parkinson’s disease (PD) and are likely to result from changes in dopamine production, storage and release, occurring as consequences of the nigrostriatal degenerative process. All studies comparing levodopa versus dopamine agonist early therapy indicate that initiation with agonists is associated with a reduced risk of motor complications —in particular, dyskinesias— possibly because agonists’ longer half-lives provide continuous dopaminergic delivery. In advanced PD patients, switching from a pulsatile to continuous dopaminergic delivery may widen patients’ therapeutic window. Currently, this can be accomplished only with subcutaneous apomorphine or duodenal levodopa infusions. Apomorphine is a highly soluble agonist whose effect is similar to dopamine. Conversely, replacing whole oral therapy with levodopa infusion bypasses gastric emptying and avoids peaks and troughs in plasma by releasing levodopa in the duodenum/jejunum.