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Supplemental Digital Content is available in the text., Background and Purpose— Computed tomography (CT) perfusion (CTP) provides potentially valuable information to guide treatment decisions in acute stroke. Assessment of interobserver reliability of CTP has, however, been limited to small, mostly single center studies. We performed a large, internet-based study to assess observer reliability of CTP interpretation in acute stroke. Methods— We selected 24 cases from the IST-3 (Third International Stroke Trial), ATTEST (Alteplase Versus Tenecteplase for Thrombolysis After Ischaemic Stroke), and POSH (Post Stroke Hyperglycaemia) studies to illustrate various perfusion abnormalities. For each case, observers were presented with noncontrast CT, maps of cerebral blood volume, cerebral blood flow, mean transit time, delay time, and thresholded penumbra maps (dichotomized into penumbra and core), together with a short clinical vignette. Observers used a structured questionnaire to record presence of perfusion deficit, its extent compared with ischemic changes on noncontrast CT, and an Alberta Stroke Program Early CT Score for noncontrast CT and CTP. All images were viewed, and responses were collected online. We assessed observer agreement with Krippendorff-α. Intraobserver agreement was assessed by inviting observers who reviewed all scans for a repeat review of 6 scans. Results— Fifty seven observers contributed to the study, with 27 observers reviewing all 24 scans and 17 observers contributing repeat readings. Interobserver agreement was good to excellent for all CTP. Agreement was higher for perfusion maps compared with noncontrast CT and was higher for mean transit time, delay time, and penumbra map (Krippendorff-α =0.77, 0.79, and 0.81, respectively) compared with cerebral blood volume and cerebral blood flow (Krippendorff-α =0.69 and 0.62, respectively). Intraobserver agreement was fair to substantial in the majority of readers (Krippendorff-α ranged from 0.29 to 0.80). Conclusions— There are high levels of interobserver and intraobserver agreement for the interpretation of CTP in acute stroke, particularly of mean transit time, delay time, and penumbra maps.

Background: Stroke in diabetics may delay recovery and increases the risk of early recurrence of stroke. We compared the outcomes of patients (with and without diabetes) admitted with an acute ischemic stroke (AIS) in the state of Qatar. Patients and methods: We prospectively compared the clinical presentation, complications, discharge outcome, and stroke recurrence at 90 days in patients with and without diabetes. Results: Five thousand two hundred twenty-eight stroke patients were admitted between January 2014 and December 2017. Two thousand nine hundred sixty-one had confirmed AIS, 1695 (57.2%) had diabetes, 429 (14.5%) had prediabetes and 873 (29.5%) had no diabetes. Comparing diabetic patients to prediabetic and nondiabetics, they were significantly older (58.5 ± 11.9 versus 54.0 ± 12.9 versus 49.5 ± 13.8, P = .0001), had higher rates of hypertension (80.8% versus 67.4% versus 59.2%), previous stroke (18.0% versus 5.4% versus 6.2%), and coronary artery disease (12.9% versus 5.6% versus 5.0%; P = .001 for all). The percentage of patients with modified Rankin scale 3-6 at discharge (39.7% versus 32.6% versus 30.2%; P = .0001) and 90 days (26.7% versus 18.8% versus 21.4%, P = .001); 90-day mortality (6.2% versus 2.2% versus 5.2%; P = .03) and stroke recurrence (4.2% versus .7% versus 2.2%; P = .005) was significantly higher in diabetic patients. Conclusions: Patients with diabetes and AIS have more in-hospital complications, worse discharge outcomes, higher mortality and stroke recurrence at 90 days, compared to prediabetes and no diabetes.

Objective:To compare the accuracy of Alberta Stroke Program Early Computed Tomography Score (ASPECTS) and CT perfusion to detect established infarction in acute anterior circulation stroke.Methods:We performed an observational study in 59 acute anterior circulation ischemic stroke patients who underwent brain noncontrast CT, CT perfusion, and MRI within 100 minutes from CT imaging. ASPECTS scores were calculated by 4 blinded vascular neurologists. The accuracy of ASPECTS and CT perfusion core volume to detect an acute MRI diffusion lesion of ≥70 mL was evaluated using receiver operating characteristics analysis and optimum cutoff values were calculated using Youden J.Results:Median ASPECTS score was 8 (interquartile range [IQR] 5–9). Median CT perfusion core volume was 22 mL (IQR 10.4–71.9). Median MRI diffusion lesion volume was 24.5 mL (IQR 10–63.9). No significant difference was found between the accuracy of CT perfusion and ASPECTS (c statistic 0.95 vs 0.87, p value for difference = 0.17). The optimum ASPECTS cutoff score to detect a diffusion-weighted imaging lesion ≥70 mL was R = 0.88; R2 = 0.77).Conclusions:We found no significant difference between the accuracy of CT perfusion and ASPECTS to predict hyperacute MRI lesion volume in ischemic stroke.

IMPORTANCE: The benefit of mechanical thrombectomy (MT) in patients with stroke presenting with mild deficits (National Institutes of Health Stroke Scale [NIHSS] score

BackgroundThe use of retrievable stents for endovascular clot retrieval has dramatically improved successful revascularization and clinical outcome in selected patients with acute stroke.ObjectiveTo describe the rate and clinical consequences of unwanted spontaneous detachment of these devices during mechanical thrombectomy.MethodsWe studied 262 consecutive patients treated with the retrievable stent, Solitaire, for acute ischemic stroke between November 2008 and April 2015. Clinical, procedural, and outcome variables were compared between patients with and without unexpected detachment of this device. Detachment was classified as proximal to the stent proximal marker (type A) or distal to the marker (type B). Poor functional outcome was defined as modified Rankin scale score >2 at 90 days.ResultsUnwanted detachment occurred in 6/262 (2.3%) cases, four of type A and two of type B. Stent recovery was possible in three patients, all of ‘type A’, but in none of ‘type B’. The number of prior passes was higher in patients with undesired detachment (3 (2–5) vs 2 (1–3), p=0.007). Detachment was associated with higher rate of symptomatic intracranial hemorrhage (SICH) (33.3% vs 4.3%, p=0.001), poorer outcome (100% vs 54.8%, p=0.028), and higher mortality rate at 90 days (50% vs 17%, p=0.038).ConclusionsUnwanted detachment of a Solitaire is an uncommon complication during mechanical thrombectomy in patients with acute ischemic stroke and is associated with the clot retrieval attempts, SICH, poor outcome, and higher mortality.

Introduction: Cervical artery dissection (CAD) is the cause of 2% to 3% of ischaemic strokes and 10% to 25% of the ischaemic strokes in young people. Our objective is to evaluate whether the implementation of a comprehensive stroke centre (CSC) improves the diagnosis and modifies the prognosis of patients with acute stroke due to CAD. Patients and methods: Retrospective study of a registry of consecutive patients with acute stroke due to CAD. They were classified according to the period of care at our centre: pre-CSC (October 2004 to March 2008, 42 months) or post-CSC (April 2008 to June 2012, 51 months). We compared baseline characteristics, methods of diagnosis, treatment and outcome of these patients in both periods. Results: Nine patients were diagnosed with CAD in the pre-CSC and 26 in the post-CSC, representing 0.8% and 2.1% of all ischaemic strokes treated in each period, respectively. The diagnosis of CAD was made within the first 24 hours in 42.3% of the patients in the post-CSC versus 0% in the pre-CSC, through the use of urgent cerebral angiography as a diagnostic test in 46.2% of cases in the second period compared to 0% in the first. The severity of stroke (median NIHSS score 11 vs. 3, P = .014) and time to neurological care (265 min vs. 148, P = .056) were higher in the post-CSC period. Endovascular treatment was performed in 34.3%, all in the post-CSC. The functional outcome was comparable in both periods. Conclusions: The implementation of a CSC increases the frequency of the diagnosis of CAD, as well as the treatment options for these patients in the acute phase of stroke. Resumen: Introducción: La disección de arterias cervicales (DAC) es la causa del 2-3% de ictus isquémicos y del 10-25% en pacientes jóvenes. Nuestro objetivo es evaluar si la implementación de un centro terciario de ictus (CTI) facilita el diagnóstico y modifica el pronóstico de los pacientes con ictus agudo por DAC. Pacientes y métodos: Estudio retrospectivo de un registro de pacientes consecutivos con ictus agudo por DAC. Se clasificaron según el periodo de atención: pre-CTI (octubre 2004-marzo 2008, 42 meses) o post-CTI (abril 2008-junio 2012, 51 meses). Se compararon las características basales, el método diagnóstico, el tratamiento y la evolución de estos pacientes entre ambos periodos. Resultados: Se diagnosticó a 9 pacientes con DAC en el periodo pre-CTI y 26 en el post-CTI, representando el 0,8 y el 2,1% de los ictus isquémicos atendidos en cada periodo. El diagnóstico de DAC se realizó en las primeras 24 h en el 42,3% de pacientes en el periodo post-CTI frente al 0% en el pre-CTI, gracias al uso de la arteriografía cerebral urgente como prueba diagnóstica en el 46,2% de los casos en el segundo periodo frente al 0% en el primero. La gravedad del ictus (mediana puntuación escala NIHSS 11 vs. 3, p = 0,014) y el tiempo hasta la atención neurológica (265 minutos vs. 148, p = 0,056) fueron mayores en la fase post-CTI. Se realizó tratamiento endovascular en el 34,3%, todos en el periodo post-CTI. El pronóstico funcional fue comparable en ambos periodos. Conclusiones: La implementación de un CTI incrementa la frecuencia en el diagnóstico de DAC y aumenta las opciones terapéuticas en la fase aguda del ictus en estos pacientes. Keywords: Cervical artery dissection, Stroke, Comprehensive stroke centre, Angiography, Systemic thrombolysis, Endovascular treatment, Palabras clave: Disección de arterias cervicales, Ictus, Centro terciario de ictus, Arteriografía, Trombólisis sistémica, Tratamiento endovascular

Resumen: Introducción: La disección de arterias cervicales (DAC) es la causa del 2-3% de ictus isquémicos y del 10-25% en pacientes jóvenes. Nuestro objetivo es evaluar si la implementación de un centro terciario de ictus (CTI) facilita el diagnóstico y modifica el pronóstico de los pacientes con ictus agudo por DAC. Pacientes y métodos: Estudio retrospectivo de un registro de pacientes consecutivos con ictus agudo por DAC. Se clasificaron según el periodo de atención: pre-CTI (octubre 2004-marzo 2008, 42 meses) o post-CTI (abril 2008-junio 2012, 51 meses). Se compararon las características basales, el método diagnóstico, el tratamiento y la evolución de estos pacientes entre ambos periodos. Resultados: Se diagnosticó a 9 pacientes con DAC en el periodo pre-CTI y 26 en el post-CTI, representando el 0,8 y el 2,1% de los ictus isquémicos atendidos en cada periodo. El diagnóstico de DAC se realizó en las primeras 24 h en el 42,3% de pacientes en el periodo post-CTI frente al 0% en el pre-CTI, gracias al uso de la arteriografía cerebral urgente como prueba diagnóstica en el 46,2% de los casos en el segundo periodo frente al 0% en el primero. La gravedad del ictus (mediana puntuación escala NIHSS 11 vs. 3, p = 0,014) y el tiempo hasta la atención neurológica (265 minutos vs. 148, p = 0,056) fueron mayores en la fase post-CTI. Se realizó tratamiento endovascular en el 34,3%, todos en el periodo post-CTI. El pronóstico funcional fue comparable en ambos periodos. Conclusiones: La implementación de un CTI incrementa la frecuencia en el diagnóstico de DAC y aumenta las opciones terapéuticas en la fase aguda del ictus en estos pacientes. Abstract: Introduction: Cervical artery dissection (CAD) is the cause of 2% to 3% of ischaemic strokes and 10% to 25% of the ischaemic strokes in young people. Our objective is to evaluate whether implementation of a comprehensive stroke centre (CSC) improves the diagnosis and modifies the prognosis of patients with acute stroke due to CAD. Patients and methods: Retrospective study of a registry of consecutive patients with acute stroke due to CAD. They were classified according to the period of care at our centre: pre-CSC (October 2004-March 2008, 42 months) or post-CSC (April 2008-June 2012, 51 months). We compared baseline characteristics, methods of diagnosis, treatment and outcome of these patients in both periods. Results: Nine patients were diagnosed with CAD in pre-CSC and 26 in post-CSC, representing 0.8% and 2.1% of all ischaemic strokes treated in each period, respectively. The diagnosis of CAD was made within the first 24 hours in 42.3% of the patients in post-CSC versus 0% in pre-CSC, by using urgent cerebral angiography as a diagnostic test in 46.2% of cases in the second period compared to 0% in the first. Both severity of stroke (median NIHSS score 11 vs. 3, P=.014) and time to neurological care (265 min vs 148, P=.056) were higher in the post-CSC period. Endovascular treatment was performed in 34.3%, and all treatments were post-CSC. The functional outcome was comparable for both periods. Conclusions: Implementation of a CSC increases the frequency of the diagnosis of CAD, as well as the treatment options for these patients in the acute phase of stroke. Palabras clave: Disección de arterias cervicales, Ictus, Centro terciario de ictus, Arteriografía, Trombólisis sistémica, Tratamiento endovascular, Keywords: Cervical artery dissection, Stroke, Comprehensive stroke center, Angiography, Systemic thrombolysis, Endovascular treatment

Cocaine is a widespread recreational drug that has the potential to induce neurological vascular diseases, including ischaemic and haemorrhagic stroke. Although arterial vasospasm has been suggested as a pathogenic factor in the development of neurovascular complications, it remains unclear whether cocaine users carry an increased risk to suffer iatrogenic vasospasm during endovascular procedures. We report the case of two patients with a history of cocaine abuse, who developed unusual severe vasospasms during different interventional procedures. The first case occurred in a middle-aged woman with an unruptured left internal carotid artery bifurcation aneurysm who was scheduled for treatment by remodelling assisted coiling. Just after the placement of the remodelling balloon, a severe occlusive vasospasm interrupted the procedure. The second case happened to a 46-year-old man with a non-aneurysmal subarachnoid haemorrhage and a symptomatic vasospasm in the right-sided anterior circulation who developed another occlusive vasospasm after the first attempt at transluminal balloon angioplasty. Further research is needed to establish a relation between cocaine use and increased risk of iatrogenic vasospasm in endovascular procedures, but we suggest practitioners be extremely cautious when treating this subgroup of patients.

We aimed to evaluate how predefined candidate cerebral perfusion parameters correlate with collateral circulation status and to assess their capacity to predict infarct growth in patients with acute ischemic stroke (AIS) eligible for endovascular therapy. Patients enrolled in the SWIFT PRIME trial with baseline computed tomography perfusion (CTP) scans were included. RAPID software was used to calculate mean relative cerebral blood volume (rCBV) in hypoperfused regions, and hypoperfusion index ratio (HIR). Blind assessments of collaterals were performed using CT angiography in the whole sample and cerebral angiogram in the endovascular group. Reperfusion was assessed on 27-h CTP; infarct volume was assessed on 27-h magnetic resonance imaging/CT scans. Logistic and rank linear regression models were conducted. We included 158 patients. High rCBV ( p = 0.03) and low HIR ( p = 0.03) were associated with good collaterals. A positive association was found between rCBV and better collateral grades on cerebral angiography ( p = 0.01). Baseline and 27-h follow-up CTP were available for 115 patients, of whom 74 (64%) achieved successful reperfusion. Lower rCBV predicted a higher infarct growth in successfully reperfused patients ( p = 0.038) and in the endovascular treatment group ( p = 0.049). Finally, rCBV and HIR may serve as markers of collateral circulation in AIS patients prior to endovascular therapy.

Background Clinical experience with the Pipeline Embolization Device (PED) has been widely described in the literature since it obtained its European CE and FDA approvals in 2008 and 2011, respectively. The new generation of PED, the Pipeline Flex Embolization Device, received the CE mark of approval in March 2014. While the implant composition has not changed, its new delivery system has some differences. One of the main changes from the previous generation is a new delivery system that makes the device resheathable until deployed over 90% of its length. We present our preliminary experience using this device. Methods Between May and June 2014, six patients with six aneurysms were treated with the Pipeline Flex device. Results All devices were placed properly, without technical difficulties. We successfully resheathed and repositioned the device in two cases. Minor and major intraprocedural or periprocedural events were noted. Conclusions The Pipeline Flex device allows more precise and controlled deployment than the current PED device. Although this preliminary experience seems positive, multicenter larger series will be needed to confirm the safety and durability of this new device.

Background and Purpose— Selection of best responders to reperfusion therapies could be aided by predicting the duration of tissue-at-risk viability, which may be dependant on collateral circulation status. We aimed to identify the best predictor of good collateral circulation among perfusion computed tomography (PCT) parameters in middle cerebral artery (MCA) ischemic stroke and to analyze how early MCA response to intravenous thrombolysis and PCT-derived markers of good collaterals interact to determine stroke outcome. Methods— We prospectively studied patients with acute MCA ischemic stroke treated with intravenous thrombolysis who underwent PCT before treatment showing a target mismatch profile. Collateral status was assessed using a PCT source image–based score. PCT maps were quantitatively analyzed. Cerebral blood volume (CBV), cerebral blood flow, and Tmax were calculated within the hypoperfused volume and in the equivalent region of unaffected hemisphere. Occluded MCAs were monitored by transcranial Duplex to assess early recanalization. Main outcome variables were brain hypodensity volume and modified Rankin scale score at day 90. Results— One hundred patients with MCA ischemic stroke imaged by PCT received intravenous thrombolysis, and 68 met all inclusion criteria. A relative CBV (rCBV) >0.93 emerged as the only predictor of good collaterals (odds ratio, 12.6; 95% confidence interval, 2.9–55.9; P =0.001). Early MCA recanalization was associated with better long-term outcome and lower infarct volume in patients with rCBV Conclusions— High rCBV was the strongest marker of good collaterals and may characterize durable tissue-at-risk viability in hyperacute MCA ischemic stroke.

Objective: To compare the predictive capacity to detect established infarct in acute anterior circulation stroke between the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) on non-contrast computed tomography (CT) and CT perfusion. Methods: Fifty-nine acute anterior circulation ischemic stroke patients received brain non-contrast CT, CT perfusion and hyperacute magnetic resonance imaging (MRI) within 100 minutes from CT imaging. ASPECTS scores were calculated by 4 independent vascular neurologists, blinded from CT perfusion and MRI data. CT perfusion infarct core volumes were calculated by MIStar software. The accuracy of commonly used ASPECTS cut-off scores and a CT perfusion core volume of ≥ 70 mL to detect a hyperacute MRI diffusion lesion of ≥ 70 ml was evaluated. Results: Median ASPECTS score was 9 (IQR 7-10). Median CT perfusion core volume was 22 ml (IQR 10.4-71.9). Median MRI diffusion lesion volume was 24,5 ml (IQR 10-63.9). ASPECTS score of < 6 had a sensitivity of 0.37, specificity of 0.95 and c-statistic of 0.66 to predict an acute MRI lesion ≥ 70 ml. In comparison, a CT perfusion core lesion of ≥ 70 ml had a sensitivity of 0.76, specificity of 0.98 and c-statistic of 0.92. The CT perfusion core lesion covered a median of 100% of the acute MRI lesion volume (IQR 86-100%). Conclusions: CT perfusion is superior to ASPECTS to predict hyperacute MRI lesion volume in ischemic stroke.

Atherosclerotic intracranial arterial stenosis is an important cause of stroke that is increasingly being treated with percutaneous transluminal angioplasty and stenting (PTAS) to prevent recurrent stroke. However, PTAS has been compared with medical management in a randomized trial (SAMMPRIS), where aggressive medical management was superior to PTAS with the use of the Wingspan stent system, however in our experience we have had good results and have experienced no complications with this therapy. In a retrospective, single-center study we enrolled seven consecutive patients with a symptomatic angiographically proven atherosclerotic intracranial arterial stenosis of the anterior and posterior circulation. All cases received adjuvant therapy (aspirin and clopidogrel or ticlopidine) before and after deployment of the device. The procedures were performed with the patient under general anesthesia. We use the Wingspan stent system. The occlusion site was middle cerebral artery (MCA) in three patients, proximal internal carotid artery (ICA) in one patient and vertebrobasilar artery in three patients. Primary interventional successful revascularization was achieved in all cases. Four patients had no residual stenosis, and the other three had 20%, 30% and 40% residual stenosis (Table 1). All patients showed a clinical improvement after stent deployment. No peri-interventional events or neurologic complications occurred directly related to the technique. Patency rate was 100% at the last examination in six cases, one case had a pre-occlusive stenosis, requiring angioplasty. No patients died during the follow-up period, and 100% of patients showed good functional outcome at three months (modified Rankin Scale score ≤ 2). Although the SAMMPRIS study showed that aggressive medical management was superior to PTAS, our results suggest that intracranial stenting is safe and effective, probably due to an extraordinary selection of candidates and to an exquisite technique.

We thank Das et al. and Compagne et al. for the interest in our article.[1][1] An individualized reperfusion treatment approach based on specific imaging profiles will become the standard of care.[2][2],[3][3] Our data indicate that Alberta Stroke Program Early CT Score (ASPECTS) has poorer

OBJECTIVE Insulin resistance (IR) may not only increase stroke risk, but could also contribute to aggravate stroke prognosis. Mainly through a derangement in endogenous fibrinolysis, IR could affect the response to intravenous thrombolysis, currently the only therapy proved to be efficacious for acute ischemic stroke. We hypothesized that high IR is associated with more persistent arterial occlusions and poorer long-term outcome after stroke thrombolysis. RESEARCH DESIGN AND METHODS We performed a prospective, observational, longitudinal study in consecutive acute ischemic stroke patients presenting with middle cerebral artery (MCA) occlusion who received intravenous thrombolysis. Patients with acute hyperglycemia (≥155 mg/dL) receiving insulin were excluded. IR was determined during admission by the homeostatic model assessment index (HOMA-IR). Poor long-term outcome, as defined by a day 90 modified Rankin scale score ≥3, was considered the primary outcome variable. Transcranial Duplex-assessed resistance to MCA recanalization and symptomatic hemorrhagic transformation were considered secondary end points. RESULTS A total of 109 thrombolysed MCA ischemic stroke patients were included (43.1% women, mean age 71 years). The HOMA-IR was higher in the group of patients with poor outcome (P = 0.02). The probability of good outcome decreased gradually with increasing HOMA-IR tertiles (80.6%, 1st tertile; 71.4%, 2nd tertile; and 55.3%, upper tertile). A HOMA-IR in the upper tertile was independently associated with poor outcome when compared with the lower tertile (odds ratio [OR] 8.54 [95% CI 1.67–43.55]; P = 0.01) and was associated with more persistent MCA occlusions (OR 8.2 [1.23–54.44]; P = 0.029). CONCLUSIONS High IR may be associated with more persistent arterial occlusions and worse long-term outcome after acute ischemic stroke thrombolysis.

Anabolic androgenic steroids (AAS) are synthetic substances derived from testosterone and usually employed to gain muscle strength and athletic performance. Supraphysiological doses of AAS can cause harmful conditions such as cardiovascular, hematological, hepatic, and psychiatric disorders. Among their cardiovascular effects, heart disease and sudden death have been frequently described. Furthermore, several cases of stroke in young patients possibly related to the consumption of these hormones have been reported. AAS may contribute to the onset of a stroke through direct cardiac effects and indirect prothrombotic and proatherogenic mechanisms. In professional sports, AAS consumption is regulated by international agencies and affects a relatively small population. However, the major use of these substances in our society is currently made by many young bodybuilding enthusiasts in gyms, without adequate regulation and sanitary control. Owing to the illegal nature of their consumption, stroke related to anabolic steroids is probably underdiagnosed. Thus, we recommend performing a straight anamnesis toward a possible covert use of these substances, especially in young patients with cryptogenic stroke.

Background and Objective: Acute ischemic stroke (AIS) associated with tandem extracranial internal carotid artery (EICA) - middle cerebral artery (MCA) occlusion is burdened with a poor clinical outcome. The recanalization rate of extracranial ICA occlusion after i.v. thrombolysis and its prognostic significance in this group of patients remain largely unknown. Methods: Retrospective analysis of a prospectively collected database including consecutive AIS patients treated with i.v. thrombolysis. All patients underwent urgent assessment of extracranial and intracranial large arteries with either computed tomography angiography (CTA) or echo-Doppler ultrasound to document an acute EICA-MCA tandem occlusion prior to thrombolysis. EICA was monitored by control carotid ultrasound and/or CTA in order to detect transition from occlusion to relevant stenosis. Outcome variables: carotid revascularization, in-hospital mortality, Rankin 0-2 at three months, and infarct volume. Results: From January 2008 to December 2013, 606 AIS patients received i.v. thrombolysis, of whom 53 (9%) had a documented EICA-MCA tandem occlusion. Four of them died within first 24 hours and EICA could not be monitored. Occluded EICA evolved towards a severe stenosis in 14/49 (29%) after thrombolysis. Angiographic confirmation was obtained in 11 of them, who underwent carotid endarterectomy. EICA recanalization was more frequent among active smokers and was associated with carotid revascularization (79% vs. 0%, p Conclusion: Around 30% of AIS patients with tandem EICA-MCA occlusion treated with i.v. thrombolysis experience transition from initially occluded to severely stenosed EICA that can be rescued for revascularization. This evolution is associated with a lower mortality and smaller infarct volume.

Background and objective: Secondary prevention after embolic stroke of undetermined source (ESUS) remains a clinical problem. Presence of asymptomatic cerebral large-artery atherosclerosis or small vessel disease could be aprioristically taken as an indicator of a lower risk for an occult cardiac source of emboli, thus influencing our secondary prevention strategy. We aimed to study the relationship between presence and degree of coexisting cerebrovascular disease and the risk of occult paroxysmal atrial fibrillation (OPAF) in ESUS patients. Methods: Longitudinal prospective study in patients fulfilling ESUS criteria after complete neurovascular and cardiac diagnostic workup, who were implanted with a subcutaneous REVEAL-XT loop-recorder to detect OPAF and followed-up for≥ 6 months. At baseline, cerebral large-artery atherosclerosis was assessed with cervical and transcranial ultrasound. Brain magnetic resonance imaging was used to evaluate small vessel disease. Periventricular (PV) and subcortical (SC) white matter hiperintensities (WMH) were categorized using the Fazekas score. Results: We studied 136 ESUS patients from October 2010 to December 2013 (71 men, mean age 67), who were followed-up for a mean time of 594 days. OPAF was detected in 56 (41%) of them. No relationship was found between extracranial or intracranial atherosclerosis and OPAF. Kaplan-Meier curves and crude Cox-regression analyses found associations between OPAF risk and age, smoking, CHA2DS2VASC score, presence of lacunar infarctions, and presence and degree of PVWMH & SCWMH. A multivariable-adjusted Cox regression model identified grade 2-3 PVWMH (HR 3.6, [2.0-6.5], p Conclusion: Coexisting small vessel disease, specifically in the form of periventricular WMH, is a predictor of OPAF in ESUS patients. Presence of large-artery atherosclerosis does not lower the risk for OPAF. Therefore, OPAF should be actively pursued in ESUS patients regardless the coexistence of asymptomatic cerebrovascular disease.

Arterial revascularization is the most effective therapy for acute stroke patients. Systemic thrombolysis with recombinant tissue plasminogen activator based on baseline non-contrast CT (NCCT) imaging criteria is the only treatment approved to date, which is limited by severe timing and medical restrictions, and a narrow efficacy. The simple imaging methodology required contrast with the current wide range of imaging modalities available, which permits the physician to rapidly obtain an estimation of the most relevant pathophysiological factors involved in an acute stroke, overcoming the limited capability of NCCT. Multimodal CT and MRI combine techniques that aim to depict the neurovasculature and the status of the brain parenchyma, including the presence of hemorrhage and infarction, as well as the viability of the cerebral ischemic areas involved. These additional imaging procedures have been explored in clinical studies and trials to guide intravenous thrombolysis in acute stroke patients beyond the currently established time windows, with inconclusive results. However, emergent endovascular materials and techniques are evolving, showing promising results with increasing rates of arterial recanalization with an acceptable safety profile, therefore becoming a potential alternative and complimentary treatment, although the current lack of a high level of evidence is limiting their use in routine clinical practice. Nevertheless, these advanced neuroimaging methods can be used to improve the selection of candidates for these novel invasive therapies and, moreover, to help the interventionist to design a faster and safer procedure. In this article, we review the basic aspects of both CT and MRI modalities and the state of the evidence of these imaging tools to guide endovascular therapy, as well as the advantages and disadvantages of each method.

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.

Introduction: Futile arterial recanalization (FAR), considered as a lack of functional recovery despite complete recanalization, is observed in up to 30-50% of acute stroke patients treated with endovascular therapy. We aimed to develop a prognostic scale based on baseline clinical and radiological factors to predict FAR. Methods: Prospective analysis of consecutive stroke patients with anterior circulation occlusion treated with endovascular therapy (97% mechanical thrombectomy with stent-retrievers). Complete recanalization was considered as a TICI 2b-3. FAR was defined as a modified Rankin scale >2 at 90 days in patients with complete recanalization. Baseline factors associated with FAR were detected on univariate analysis and were used to compose the predictive scale. Results: From a total of 229 patients with anterior arterial occlusion, 166 (72.5%) achieved complete recanalization. FAR was observed in 80/166 (48.2%). Factors significantly associated with FAR were included to compose the predictive scale as follow: Age (scoring 0 if ≤70 and 1 if >70 years old), history of diabetes mellitus (0 if absent, 1 if present), history of hypertension (0 if absent, 1 if present), NIHSS (1 if NIHSS ≤10, 2 if NIHSS 10-19, 3 if NIHSS>19), ASPECTS (1 if ASPECTS 9-10, 2 if ASPECTS 7-8, 3 if ASPECTS7 increased FAR up to 86%. Conclusion: We developed a simple scale that can easily predict futile arterial recanalization (FAR) in stroke patients with large arterial occlusion treated with endovascular therapies. A larger validation study is necessary to confirm the utility of this predictive scale.

Background: Selection of best responders to endovascular reperfusion could be aided by predicting the expected duration of tissue-at-risk viability, which may be dependant on collateral circulation status. We aimed to identify the best predictor of good collateral circulation among perfusion computed tomography (PCT) parameters in middle cerebral artery (MCA) ischemic stroke, and to analyze how early MCA response to intravenous thrombolysis and PCT-derived markers of good collaterals interact to determine stroke outcome. Methods: We prospectively studied acute MCA ischemic stroke patients treated with intravenous thrombolysis who underwent PCT prior to treatment showing a target-mismatch profile. Collateral status was assessed using a PCT source-images based score. PCT maps were quantitatively analyzed. Cerebral blood volume (CBV), cerebral blood flow (CBF) and Tmax were calculated within the hypoperfused volume and in the equivalent region of unaffected hemisphere. Occluded MCAs were monitored by transcranial Duplex to assess early recanalization. Main outcome variables were final infarct volume and modified Rankin score at day 90. Results: One hundred MCA ischemic stroke patients imaged by PCT received intravenous thrombolysis, and 68 met all inclusion criteria. A relative CBV > 0.93 emerged as the most robust predictor of good collaterals [OR 12.6 (95% CI 2.9-55.9), p=0.001]. Early MCA recanalization was strongly associated with better long-term outcome and lower infarct volume in patients with rCBV Conclusion: rCBV was the strongest marker of collateral status and may help predict the duration of tissue-at-risk viability in hyperacute MCA ischemic stroke

Background: Currently, treatment options for patients with strokes with unknown time of onset (UKO) remain limited. With the advance of neuroimaging and endovascular treatment (EVT), selected patients might have a chance of a therapeutic option. We sought to compare clinical outcome after EVT in patients with known time of stroke onset (KO) and in those with UKO. Methods: We prospectively registered consecutive patients with acute large artery occlusion of the anterior territory who underwent EVT. Multimodal MR or Alberta Stroke Program early CT score (ASPECTS) and transcranial color-coded Duplex sonography were used to select patients for EVT. Recanalization, periprocedural complications, intracranial hemorrhage (ICH) and outcome were recorded. Symptomatic ICH (sICH) was defined as a worsening of ≥4 points in the National Institutes of Health Stroke Scale (NIHSS) score within 36 h in any bleeding. Favorable outcome was defined as a modified Rankin score ≤2 at 3 months. Results: A total of 141 patients were studied, 109 with KO and 32 with UKO. Mean age was 66.5 versus 64.7 years (p = 0.005) and median baseline NIHSS was 18 versus 17 (p = 0.095), respectively. Prior IV tPA was more frequently administered to KO patients (62.4 vs. 9.4%, p < 0.001), whereas patient selection using multimodal MR was more frequent in patients with UKO (78.1 vs. 45.4%, p < 0.001). Median time from stroke onset or from the last time the patient was seen well to groin puncture and to recanalization was significantly longer in patients with UKO, but no differences were found in the duration of the procedure. For KO/UKO patients recanalization was seen in 77.1 vs. 65.7% (p = 0.084), sICH occurred in 10 versus 0% (p = 0.061) and favorable outcome at 3 months was achieved in 41.3 versus 50% (p = 0.382), respectively. Conclusions: Clinical outcomes in this series of EVT in ischemic stroke patients due to large anterior arterial occlusion with salvageable brain are similar for patients treated with KO and UKO. These data support a randomized study of EVT in extended or uncertain time windows.

Background Acute ischemic stroke patients with unclear onset time presenting >4.5 h from last-seen-normal (LSN) time are considered late patients and excluded from i.v. thrombolysis. We aimed to evaluate whether this subgroup of patients is different from patients presenting >4.5 h from a witnessed onset, in terms of eligibility and response to computed tomography perfusion (CTP)-guided i.v. thrombolysis. Methods We prospectively studied consecutive acute non-lacunar middle cerebral artery (MCA) ischemic stroke patients presenting >4.5 h from LSN. All patients underwent multimodal CT and were considered eligible for i.v. thrombolysis according to CTP criteria. Two patient groups were established based on the knowledge of the stroke onset time. We compared the proportion of candidates suitable for intravenous thrombolysis between both groups, and their outcome after thrombolytic therapy. Results Among 147 MCA ischemic stroke patients presenting >4.5 h from LSN, stroke onset was witnessed in 74 and unknown in 73. Thirty-seven (50%) patients in the first group and 32 (44%) in the second met CTP criteria for thrombolysis (P = 0.7). Baseline variables were comparable between both groups with the exception of age, which was higher in the unclear onset group. The rates of early neurological improvement (54.1% vs 46.9%), 2-h MCA recanalization (43.5% vs 37%), symptomatic hemorrhagic transformation (3% vs 0%) and good 3-month functional outcome (62.2% vs 56.3%) did not differ significantly between both groups. Conclusion Delayed stroke patients with unknown onset time were no different than patients >4.5 h regarding eligibility and response to CTP-based i.v. thrombolysis.

Background and purpose Perfusion-computed tomography-source images (PCT-SI) may allow a dynamic assessment of leptomeningeal collateral arteries (LMC) filling and emptying in middle cerebral artery (MCA) ischaemic stroke. We described a regional LMC scale on PCT-SI and hypothesized that a higher collateral score would predict a better response to intravenous (iv) thrombolysis. Methods We studied consecutive ischaemic stroke patients with an acute MCA occlusion documented by transcranial Doppler/transcranial color-coded duplex, treated with iv thrombolysis who underwent PCT prior to treatment. Readers evaluated PCT-SI in a blinded fashion to assess LMC within the hypoperfused MCA territory. LMC scored as follows: 0, absence of vessels; 1, collateral supply filling ≤ 50%; 2, between> 50% and

Background: Extending the therapeutic window of intravenous thrombolysis for acute ischemic stroke beyond the established 4.5-hour limit is of critical importance in order to increase the proportion of thrombolysed stroke patients. In this setting, the capacity of MRI to select acute stroke patients for reperfusion therapies in delayed time windows has been and is being tested in clinical trials. However, whether the more available and cost-effective perfusion computed tomography (PCT) may be useful to select candidates for delayed intravenous thrombolysis remains largely unexplored. We aimed to evaluate the safety and efficacy of PCT-guided intravenous thrombolysis beyond 4.5 h after stroke onset. Methods: We prospectively studied all consecutive acute ischemic stroke patients treated with intravenous tissue plasminogen activator (tPA) in our stroke unit between January 2008 and December 2010. Patients treated within 0– 4.5 h were treated according to non-contrast CT (NCCT) criteria. Beyond 4.5 h, patients received intravenous tPA according to PCT criteria, i.e. an infarct core on cerebral blood volume (CBV) maps not exceeding one third of the middle cerebral artery (MCA) territory and tissue at risk as defined by mean transit time-CBV mismatch greater than 20%. Predetermined primary endpoints were symptomatic hemorrhagic transformation and favorable long-term outcome, while early neurological improvement and MCA recanalization were considered secondary endpoints. Statistical analysis included bivariate comparisons between the two groups for each endpoint and logistic regression models when significance was found in bivariate analyses. This study was approved by our local ethics committee. Results: A total of 245 patients received intravenous thrombolysis. After the groups were matched by baseline National Institutes of Health Stroke Scale score, 172 patients treated at 4.5 h were finally included. Early and late groups were comparable regarding baseline variables; only cardioembolic etiology was more frequent in the >4.5 h group. Rates of symptomatic hemorrhagic transformation (2.9% in the 4.5 h group; p = 1.0) and good long-term outcome (64.5 vs. 60.5%, respectively; p = 0.620) were similar between the groups. However, delayed intravenous thrombolysis was independently associated with a worse early clinical course [odds ratio (OR) 2.07, 95% confidence interval (CI) 1.04–4.1; p = 0.038] and lower 2-hour MCA recanalization rates (OR 0.4, 95% CI 0.17–0.92; p = 0.03). Conclusion: Primary safety and efficacy endpoints were comparable between the early and delayed thrombolysis groups. The results of our exploratory study may justify a randomized clinical trial to test the safety and efficacy of PCT-guided intravenous thrombolysis in acute ischemic stroke patients presenting beyond 4.5 h from symptom onset.

Introduction Intraoperative monitoring (IOM) has been introduced in different types of surgical procedures since the 1980s. Nonetheless, its regular use during the daily clinical routine of the interventional neuroradiology unit has been achieved in only a few centers. The aim of this study is to report our experience after standardized IOM implementation during endovascular treatment of central nervous system vascular pathology. Material and methods From November 2011 to May 2013, 14 patients (11 with brain and 3 with spinal cord pathology) and 21 procedures were monitored. Basic IOM methodologies were somatosensory (SEP) and motor evoked (MEP) potentials. Corticobulbar motor evoked potentials and flash-visual evoked potentials were recorded depending on the topography of the lesion. Intraarterial provocative tests (PT) with amobarbital and lidocaine were also performed. All patients except one were under total intravenous anaesthesia. Clinical outcome was assessed prospectively and correlated with IOM events. Results In 5/21 (24%) procedures, significant IOM events were detected. We observed temporary MEPs changes in 4 cases, recovered after interrupting embolization or performing corrective measures, without postoperative neurological deficits. In one case, persistent SEP and MEP deterioration were detected secondary to a frontal hematoma leading to mild sensory-motor deficit in the right upper extremity after the procedure (3 months mRankin Scale 2). Overall, 18 provocative tests were performed, 14 in brain and 4 in spinal cord pathology. They included 13 lidocaine and 5 amobarbital injections. Two positive results (11%) occurred after the injection of lidocaine (right MCA aneurysm and left frontal AVM). No false negative results were detected. Conclusion The implementation of both IOM methodologies and PT during therapeutic interventional neuroradiology is feasible and may contribute to detect early neurological damage in time to prevent irreversible neurological deficits.

Introduccion. El holter implantable permite detectar fibrilacion auricular paroxistica (FAP) oculta en pacientes con ictus criptogenico, pero se desconoce que algoritmo de seleccion tiene un mayor rendimiento y la duracion optima de monitorizacion. Objetivo. Conocer la frecuencia y el tiempo hasta detectar la FAP mediante un holter implantable Reveal XT ® en pacientes con ictus criptogenico seleccionados por sospecha elevada de embolismo cerebral. Pacientes y metodos. Criterios de seleccion: ausencia de etiologia del ictus tras el estudio completo incluyendo un ecocardiograma transesofagico, monitorizacion ECG y holter de 24 horas, asi como confirmacion de oclusion aguda embolica de la arteria intracraneal por duplex transcraneal o bien alta sospecha de embolismo por caracteristicas de neuroimagen. Tras implantar el holter Reveal XT se formo a los pacientes para que emprendieran transmisiones todos los meses o ante sintomas. Se reviso la informacion online mensualmente y se realizaron visitas clinicas en las unidades de Neurologia y Cardiologia. Resultados. Se incluyeron 101 pacientes con ictus criptogenico y al menos un mes de seguimiento: edad media de 67 anos, 54 mujeres (53,5%). Tiempo medio de seguimiento: 281 ± 212 dias. Se detecto FAP oculta en 34 pacientes (33,7%) y falsos positivos en 23 (22,8%). Mediana desde el implante hasta la deteccion de la arritmia: 102 dias (rango: 26-240 dias). En un 70% de los pacientes se registraron multiples episodios de FAP. El 75% de los eventos se detectaron durante los primeros seis meses de monitorizacion. Conclusiones. El algoritmo de seleccion de pacientes con ictus criptogenico segun sospecha de embolismo cerebral se asocio a una elevada frecuencia (33,7%) de FAP oculta con holter implantable. Uno de cada cuatro eventos sucedio tras los primeros seis meses de monitorizacion.

Background: Metabolic syndrome and insulin resistance may hamper the beneficial effect of intravenous thrombolysis in acute ischemic stroke. We investigated the temporal profile and prognostic value of 11

Objetivo. Estudiar la frecuencia, seguridad y eficacia de la trombolisis intravenosa guiada por tomografia computarizada de perfusion (TCP) mediante la identificacion de tejido cerebral rescatable en ictus isquemicos a priori excluidos por criterios tradicionales (SITS-MOST y ECASS-3). Pacientes y metodos. Incluimos ictus isquemicos no lacunares consecutivos. Tras tomografia convencional, se realizo TCP en los siguientes supuestos: inicio 4,5-6 h, desconocido o al despertar, signos precoces de infarto extenso, ictus menor o grave, e inicio con crisis epileptica o perdida de conciencia. Se indico alteplasa intravenosa 0,9 mg/kg si: ausencia de infarto establecido en tomografia simple, core en mapa de volumen sanguineo cerebral menor de un tercio del territorio de la arteria cerebral media, mismatch > 20% entre mapas de tiempo de transito medio y volumen sanguineo cerebral, y consentimiento informado. Las variables pronosticas fueron parametros de seguridad-eficacia del SIST-MOST. Resultados. De mayo de 2009 a abril de 2010, 66 pacientes con ictus isquemico a priori no candidatos para trombolisis intravenosa fueron estudiados con TCP. Las indicaciones fueron: > 4,5 h en 18 pacientes, ictus del despertar o inicio desconocido en 25, signos precoces extensos en 6, inicio con crisis epilepticas en 11, e ictus menor (escala del ictus del National Institute of Health < 4) en seis. Veintinueve (44%) recibieron trombolisis intravenosa de acuerdo con los hallazgos de la TCP. De ellos, 2 (6,9%) sufrieron transformacion hemorragica sintomatica y 18 (62,1%) alcanzaron un Rankin igual o menor a 2 al tercer mes. Conclusion. Una alta proporcion de pacientes con ictus isquemico, excluibles a priori segun criterios tradicionales, podria recibir trombolisis intravenosa de manera eficaz-segura utilizando protocolo de TCP. No obstante, estos hallazgos necesitarian confirmacion en ensayos clinicos aleatorizados.