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The management of tandem extracranial internal carotid artery and intracranial large vessel occlusion during endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) has been under-investigated. We sought to investigate outcomes of AIS patients with tandem occlusion (TO) treated with carotid artery stenting (CAS) compared to those not treated with CAS (no-CAS) during EVT.We performed a cohort study using data from AIS patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke. Outcomes were 3 months' mortality, functional outcome, complete and successful recanalization, any intracranial hemorrhage, parenchymal hematoma and symptomatic intracerebral hemorrhage.Among 466 AIS patients with TO, CAS patients were 122 and no-CAS patients were 226 (118 excluded). After adjustment for unbalanced variables, CAS was associated with a lower rate of 3 months' mortality (OR 0.407, 95% CI 0.171-0.969, p = 0.042). After adjustment for pre-defined variables, CAS was associated with a lower rate of 3 months' mortality (aOR 0.430, 95% CI 0.187-0.989, p = 0.047) and a higher rate of complete recanalization (aOR 1.986, 95% CI 1.121-3.518, p = 0.019), successful recanalization (aOR 2.433, 95% CI 1.263-4.686, p = 0.008) and parenchymal hematoma (aOR 2.876, 95% CI 1.173-7.050, p = 0.021). CAS was associated with lower 3 months mortality (OR 0.373, 95% CI 0.141-0.982, p = 0.046) and higher rates of successful recanalization (OR 2.082, 95% CI 1.099-3.942, p = 0.024) after adjustment for variables associated with 3 months' mortality and successful recanalization, respectively.Among AIS patients with TO, CAS during EVT was associated with a higher rate of successful reperfusion and a lower rate of 3 months' mortality.

OBJECTIVEThe introduction of flow-diverter devices (FDDs) has revolutionized the endovascular treatment of intracranial aneurysms. Here the authors present their Italian multicenter experience using the flow re-direction endoluminal device (FRED) in the treatment of cerebral aneurysms, evaluating both short- and long-term safety and efficacy of this device.METHODSBetween February 2013 and December 2014, 169 consecutive aneurysms treated using FRED in 166 patients were entered into this study across 30 Italian centers. Data collected included patient demographics, aneurysm location and characteristics, baseline angiography, adverse event and serious adverse event information, morbidity and mortality rates, and pre- and posttreatment modified Rankin Scale scores, as well as angiographic and cross-sectional CT/MRI follow-up at 3–6 months and/or 12–24 months per institutional standard of care. All images were reviewed and adjudicated by an independent core lab.RESULTSOf the 169 lesions initially entered into the study, 4 were later determined to be extracranial or nonaneurysmal by the core lab and were excluded, leaving 165 aneurysms in 162 patients treated in 163 procedures. Ninety-one (56.2%) patients were asymptomatic with aneurysms found incidentally. Of the 165 aneurysms, 150 (90.9%) were unruptured. One hundred thirty-four (81.2%) were saccular, 27 (16.4%) were fusiform/dissecting, and the remaining 4 (2.4%) were blister-like. One hundred thirty-seven (83.0%) arose from the anterior circulation.FRED deployment was impossible in 2/163 (1.2%) cases, and in an additional 4 cases (2.5%) the device was misdeployed. Overall mortality and morbidity rates were 4.3% and 7.3%, respectively, with rates of mortality and morbidity potentially related to FRED of up to 2.4% and 6.2%, respectively. Neuroimaging follow-up at 3–6 months showed complete or nearly complete occlusion of the aneurysm in 94% of cases, increasing to 96% at 12–24 months’ follow-up. Aneurysmal sac shrinkage was observed in 78% of assessable aneurysms.CONCLUSIONSThis preliminary experience using FRED for endovascular treatment of complex unruptured and ruptured aneurysms showed a high safety and efficacy profile that is comparable to those of other FDDs currently in use.

Background: Risks and complications associated with the treatment of intracranial aneurysms have decreased with the growing use of less in- vasive endovascular techniques. Nevertheless, some risk remains and must be balanced with the risk of aneurysm rupture. Both the risk of rupture and selection of treatment are largely based on factors related to specific characteristics of the particular aneurysm obtained from imaging examinations. Because magnetic resonance angiography (MRA) is noninvasive, lacks use of ionizing radiation, and is less costly, it is largely replacing conventional angiography for the diagnosis and follow-up of intracranial aneurysms. Studies have shown that nonenhanced 3D time-of-flight- (TOF-) MRA is satisfactory for follow-up of aneurysms, and that TOF-MRA performed at 3T provides improved depiction of aneu- rysms compared to 1.5T. Whether the use of MRA with gadolinium contrast provides any added benefit is less clear, with some studies showing that 3D contrast-enhanced MRA (CE-MRA) is better for visualizing aneurysmal morphology, while other studies have shown no such benefit, particularly at 3T. Here we compare 3D TOF-MRA and 3D CE-MRA, both at 3T, for their ability to provide detailed characterization of intracranial aneurysms. Methods: Twenty-nine patients (12 male; 17 female) with known or suspected intracranial aneurysms underwent both unenhanced and contrast-enhanced MRA using an In- tera 3 Tesla magnet (Philips Medical Systems, The Netherlands) with an 8-channel SENSE head coil in a single session. The unenhanced acquisition was carried out with a 3D TOF-MRA sequence (3D FFE, TR 2.3, TE 3.5, FOV 250, matrix 1024x1024, SENSE factor 2.5, 180 slice, 4 chunk, voxel size 0.5x0.5x1 mm), focused on the Circle of Willis and carried out in the axial plane, with fat suppression. Con- trast-enhanced images were acquired with a 3D ultrafast FE sequence (TR 5.9, TE 1.8, FOV 220, matrix 304, re- construction 512, SENSE factor 3, 80 slice, voxel size 0.72x0.72x0.80 mm) in the axial plane, focused on the an- eurysm, using CENTRA for k-space elliptical mapping. A total dose of 0.1 mmol/kg gadobenate dimeglumine (MultiHance; Bracco SpA, Italy) was injected at 2 mL/sec, followed by a 25- mL saline flush injected at the same rate. Both maximum intensity projec- tion (MIP) and volume rendering (VR) techniques were used for image analy- sis. The following features were com- pared for the 2 imaging techniques: the location and length of the aneu- rysm, the sac shape, the presence and measurement of the aneurysm neck, the detection of arterial branches orig- inating from the sac or the neck of the aneurysm, and any other associated circulatory abnormalities. Results: A total of 41 aneurysms were identified with both TOF-MRA and CE-MRA techniques: 20 in the in- ternal carotid artery, 10 vertebrobasi- lar, 7 in the anterior communicating artery, and 4 in the middle cerebral artery. There were no differences be- tween the techniques in terms of detec- tionoftheaneurysms,location,oridentification of the parent artery. There were no differences between TOF-MRA and CE-MRA in terms of assessment of the aneurysm dimensions: 23 were 24 mm. TOF-MRA data detected 12 aneurysms with an irregular sac, whereas CE-MRA acqui- sitions detected 19 irregularly-shaped aneurysms. Both imaging techniques identified 5 fusiform aneurysms with no neck. Of the remaining 36 aneu- rysms, TOF-MRA reconstructions did not enable detection of the neck and therefore, did not permit measurement of the sac/neck ratio, in 10 aneurysms. With CE-MRA, the neck was detected and measured in all 36 nonfusiform aneurysms, permitting calculation of the sac/neck ratio. CE-MRA detected 15 aneurysms with branches origi- nating from the sac and/or the neck, whereas the TOF-MRA sequence ena- bled recognition of branches in only 12 of the 15 aneurysms. Finally, of the 41 aneurysms investigated, abnormali- ties of the Circle of Willis were found in 4 aneurysms with both imaging techniques. In 3 cases, A1 aplasia was found, and in the fourth case, TOF- MRA and CE-MRA both documented aplasia of the left posterior communi- cating artery. The diameter of all 4 of these aneurysms was

BACKGROUND AND PURPOSE: Our aim was to compare contrast-enhanced MR angiography (CE-MRA) and 3D time-of-flight (TOF) MRA at 3T for follow-up of coiled cerebral aneurysms. MATERIALS AND METHODS: Fifty-two patients treated with Guglielmi detachable coils for 54 cerebral aneurysms were evaluated at 3T MRA. 3D TOF MRA (TR/TE = 23/3.5; SENSE factor = 2.5) and CE-MRA by using a 3D ultrafast gradient-echo sequence (TR/TE = 5.9/1.8; SENSE factor = 3) enhanced with 0.1-mmol/kg gadobenate dimeglumine were performed in the same session. Source images, 3D maximum intensity projection, 3D shaded surface display, and/or 3D volume-rendered reconstructions were evaluated in terms of aneurysm occlusion/patency and artifact presence. RESULTS: In terms of clinical classification, the 2 MRA sequences were equivalent for 53 of the 54 treated aneurysms: 21 were considered fully occluded, whereas 16 were considered to have a residual neck and 16 were considered residually patent at follow-up MRA. The remaining aneurysm appeared fully occluded at TOF MRA but had a residual patent neck at CE-MRA. Visualization of residual aneurysm patency was significantly (P = .001) better with CE-MRA compared with TOF MRA for 10 (31.3%) of the 32 treated aneurysms considered residually patent with both sequences. Coil artifacts were present in 5 cases at TOF MRA but in none at CE-MRA. No relationship was apparent between the visualization of patency and either the size of the aneurysm or the interval between embolization and follow-up. CONCLUSION: At follow-up MRA at 3T, unenhanced TOF and CE-MRA sequences are similarly effective at classifying coiled aneurysms as occluded or residually patent. However, CE-MRA is superior to TOF MRA for visualization of residual patency and is associated with fewer artifacts.

BACKGROUND AND PURPOSE: Intravascular treatment of intracranial aneurysms is a relatively new therapeutic technique and long-term controlled angiographic trials are needed to assess persistence of aneurysm occlusion. Our purpose was to evaluate the effectiveness of 3D time-of-flight (3D-TOF) MR angiography as a noninvasive screening tool in the follow-up of cerebral aneurysms treated with Guglielmi detachable coils (GDCs). METHODS: Forty-nine patients with 50 intracranial aneurysms previously treated with GDCs were studied with both DSA and 3D-TOF MR angiography. In 14 cases, a second follow-up examination was performed, for a total of 64 aneurysms evaluated. In 25 aneurysms, both pre- and postcontrast MR angiographic studies were obtained. RESULTS: In seven of 64 aneurysms, the MR angiographic studies were considered to be unreliable owing to the presence of artifacts that obscured part of the parent artery and did not allow an accurate evaluation of the aneurysm neck. These seven aneurysms, however, all were shown to be completely occluded at digital subtraction angiography (DSA). In the remaining 57 aneurysms, DSA revealed complete occlusion in 39 and the presence of residual patency in 18, whereas MR angiography showed complete occlusion in 38 and residual patency in 19. Enhanced MR angiography proved to be useful in evaluating residual patency in large and giant aneurysms and in better depicting the distal branch arteries. CONCLUSION: Although artifacts related to the presence of coils are evident on a considerable number of imaging studies, our findings indicate that MR angiography is useful in the evaluation of residual patency of cerebral aneurysms treated with GDCs and may eventually prove valuable in the follow-up of those cases in which a good initial correlation with DSA was demonstrated.

The feasibility of monitoring the suspended particle concentration (SPC) and fluxes (PF) with Acoustic Doppler Current Profilers (ADCP) was tested in the Venice Lagoon inlets. The backscatter recorded by boat- and bottom-mounted instruments was converted into SPC estimates with a calibration procedure based on multiple water sample collection and ADCP transects. Time series of PF across the inlets were derived from discharge and SPC data allowing for the calculation of a preliminary budget of the exchanges between the lagoon and the open sea.