Daniele Giuseppe Romano

The management of suspected ischemic stroke has evolved significantly, largely due to advancements in imaging technologies such as Computed Tomography Perfusion (CTP). This narrative review aims to delineate the practical applications and limitations of CTP in acute stroke evaluation, particularly in challenging scenarios. It is organized around illustrative clinical and imaging cases regarding small subcortical infarctions, posterior fossa ischemia, abnormal reference hemispheres, chronic steno-occlusive disease, the simultaneous involvement of multiple vascular territories, luxury perfusion, diaschisis, and systemic hemodynamic abnormalities. We discuss the core–penumbra paradigm, emphasizing the need for accurate interpretation of perfusion maps to guide therapeutic decisions. While automated CTP analyses enhance diagnostic efficiency, they can overlook critical patient-specific factors and exhibit variability in performance across different software platforms. Limitations in detecting small infarcts, particularly in lacunar strokes, highlight the necessity for qualitative visual assessments alongside quantitative data. Individualized case evaluations are crucial, as discrepancies between automated readings and qualitative interpretations can influence the management of single cases. Furthermore, we propose an integrated approach that combines automated assessments with human expertise to improve diagnostic precision and treatment efficacy. Future research should focus on refining CTP methodologies and enhancing their applicability in diverse clinical contexts to optimize patient management in acute ischemic stroke situations.

BACKGROUND AND OBJECTIVES: Aspiration catheters are an integral component of mechanical thrombectomy for acute ischemic stroke (AIS). Following early series demonstrating increasing procedural efficiency and improved outcomes with use of large-bore (LB) aspiration catheters, there is increased interest in the use of emerging superlarge-bore (SLB) catheters. METHODS: We retrospectively analyzed AIS patients with large vessel occlusion treated at 34 international centers (2018-2025) using SLB or LB aspiration catheters on the first attempt. We used propensity score matching (1:6) to define a balanced cohort based on baseline and technical confounders between the catheter groups. Safety, efficacy, and technical outcomes were compared, with the primary outcome being the first pass effect (FPE). RESULTS: A total of 2032 patients treated with aspiration as the frontline technique were included (SLB n = 107; LB n = 1925). After propensity score matching (SLB n = 107; LB n = 642), there was no significant difference in FPE between the SLB and LB groups (56.1% vs 54.8%; odds ratio [OR] 1.05, P = .8). Secondary efficacy outcomes were similarly comparable, including functional independence at 90 days (50.0% vs 46.9%; OR 1.13, P = .586), successful recanalization (modified thrombolysis in cerebral infarction ≥2b) (96.3% vs 93.5%; OR 1.78, P = .3), and median time to modified thrombolysis in cerebral infarction ≥2b (22.0 vs 22.8 minutes; β = −5.94, P = .7). Safety outcomes were also comparable, including intraprocedural complications (10.3% vs 8.2%, P = .5), symptomatic intracranial hemorrhage (8.7% vs 6.6%, P = .4), embolization to new territory (15.9% vs 13.1%, P = .4), and 90-day mortality (21.6% vs 27.1%, P = .3). Using a 10% noninferiority margin, LB aspiration catheters met the prespecified noninferiority criterion compared with SLB aspiration catheters for successful recanalization and FPE. Our findings remained consistent in the subgroup restricted to internal carotid artery and M1 occlusions. CONCLUSION: The use of SLB aspiration catheters showed comparable safety and efficacy with standard LB catheters for mechanical thrombectomy in AIS.

Background: Intracranial artery dissection (IADS) is an uncommon cause of acute ischemic stroke (AIS). In hyperacute settings, stenting is constrained by the need for intensive antiplatelet therapy. This study evaluated the antithrombogenic hydrophilic polymer–coated pEGASUS-HPC self-expanding stent for IADS-related AIS. Methods: This multicenter retrospective cohort study across seven stroke centers included consecutive patients with AIS and occlusion or severe flow-limiting stenosis caused by symptomatic IADS, who were treated with the pEGASUS-HPC. The outcomes were technical and angiographic success (device opening; mTICI score ≥2b when reperfusion was targeted), peri-procedural complications, mRS score, and follow-up patency. Results: In 36 treated patients (mean age 62.0 ± 19.6 years; 63.9% men), 91.7% of the dissections were spontaneous, and 80.6% were occlusive. Mechanical thrombectomy preceded stenting in 26/29 occlusive cases. Full stent opening occurred in 94.4%, and 100% reperfusion success was achieved in targeted vessels. Most patients received periprocedural intravenous antiplatelet bridging (75.0%) and were discharged on DAPT (77.8%). Whereas no intraprocedural complications occurred, four postprocedural events occurred during admission (11.1%), of which two were clinically significant and two were minor and asymptomatic. The mean NIHSS score improved from 11.8 at admission to 4.9 at discharge, and the mean discharge mRS score was 2.1. Clinical follow-up (mRS) was available in 33/36 patients (91.7%), with favorable functional outcome (mRS 0–2) in 27/33 (81.8%). Imaging follow-up at the early window (mean 94 days) was available in 27/36 (75.0%). In-stent stenosis ≥ 50% occurred in 14.8% and 4.2% of patients at early and mid-term follow-up, respectively, whereas no device occlusions or recurrent strokes occurred through mid-term follow-up. Long-term imaging follow-up (15/36, 41.7%) showed no new in-stent stenosis. Conclusions: pEGASUS-HPC stenting for IADS-related AIS was technically feasible and achieved high reperfusion rates and a low overall complication burden, thus supporting prospective evaluation with standardized antiplatelet protocols.

Background: Vertebrogenic low back pain (LBP) is a distinct subtype of chronic LBP (cLBP) arising from nociceptive sensitization of the basivertebral nerve (BVN) within pathologically altered vertebral endplates. Modic type 1 and type 2 changes on MRI are primary imaging biomarkers for patient selection. Basivertebral nerve ablation (BVNA), a minimally invasive intraosseous radiofrequency procedure, has emerged as a targeted treatment for this condition. This narrative review aims to synthesize current evidence on the pathophysiology of vertebrogenic LBP, patient selection criteria, procedural outcomes, safety profile, and cost-effectiveness of BVNA. Methods: We conducted this narrative review of the literature, encompassing randomized controlled trials (including the SMART and INTRACEPT studies), prospective registries, and real-world cohort studies evaluating BVNA for vertebrogenic LBP. Clinical and imaging-based selection criteria, procedural techniques, outcome measures, adverse events, opioid utilization, and healthcare utilization data were examined. Results: Evidence demonstrates consistent and durable reductions in pain and disability following BVNA, with a favorable safety profile. Complication rates are low, with vertebral compression fracture and procedure-related radicular pain reported as the most frequent adverse events. BVNA is associated with reduced opioid consumption and decreased overall healthcare utilization. Moreover, emerging data suggest efficacy beyond originally defined inclusion criteria, including cases of osteoporosis, multilevel Modic changes, adult spinal deformity, and complex comorbid presentations. Conclusions: BVNA represents an effective and safe treatment option within the multimodal management of vertebrogenic LBP. Current evidence supports a gradual expansion of procedural indications, with implications for healthcare resource optimization and opioid stewardship.

Chronic subdural hematoma (CSDH) is traditionally described as a post-traumatic blood collection within the subdural space; however, both its anatomical localization and pathophysiology have been increasingly questioned. Ultrastructural and histopathological evidence demonstrates that no true subdural space exists under physiological conditions and that CSDH originates instead within the dural border cell (DBC) layer, a mechanically fragile and biologically active meningeal interface. Accordingly, chronic “subdural” hematoma may be more accurately interpreted as an intradural border cell lesion. Beyond anatomy, CSDH is a dynamic, self-sustaining disease driven by chronic inflammation, pathological angiogenesis, vascular immaturity, and localized hemostatic dysregulation. Hypoxia-induced HIF-1α/VEGF activation promotes fragile, hyperpermeable neovessels, while local hyperfibrinolysis and kallikrein–kinin activation prevent stable clot formation, driving recurrent microbleeding and plasma exudation. Consequently, hematoma persistence and recurrence represent a biological failure rather than a purely technical surgical shortcoming. This conceptual shift provides a coherent rationale for dural-targeted therapies, including middle meningeal artery embolization and pharmacological modulation of angiogenesis and fibrinolysis. Reframing CSDH as a chronic intradural and biologically active disorder has important implications for terminology, classification, and the development of mechanism-oriented, multidisciplinary management strategies.

BACKGROUND AND OBJECTIVE: Flow diverter devices have revolutionized the treatment of intracranial aneurysms, but evidence on newer-generation devices remains limited. The Surpass Evolve (SE) was designed to improve deliverability and vessel wall apposition compared with its predecessors. This registry aimed to evaluate the feasibility, safety, and efficacy of SE in a large, real-world multicenter cohort with long-term follow-up. METHODS: Between May 2019 and December 2022, 275 consecutive aneurysms in 272 patients were treated with the SE flow diverter across 28 Italian centers. Clinical and imaging follow-up was completed by January 2024. Mid-term (≤6 months) and long-term (≤24 months) follow-ups, including clinical assessment, angiography, and cross-sectional imaging (computed tomography/magnetic resonance), were systematically collected and independently reviewed by a central Core Lab. RESULTS: The mean maximum diameter of the aneurysm was 11.2 mm, and the mean neck size was 5.4 mm. A total of 258 aneurysms were unruptured (93.8%), and 17 (6.2%) were ruptured. The majority arose from the anterior circulation (87.6%), with 12.4% in the posterior circulation. Device deployment was unsuccessful in 5/278 procedures (1.8%), and misdeployment occurred in 28/278 (10%). The overall device-related mortality was 0.7%, and the morbidity was 5.4%. At mid-term follow-up, complete or near-complete occlusion was achieved in 66% of aneurysms, increasing to 92% at long-term. According to mass criteria, 82% of aneurysms were considered cured, whereas sac enlargement occurred in 0.5% and 17% remained unchanged in volume. CONCLUSION: Our experience using SE for endovascular treatment of intracranial aneurysms showed a high safety and efficacy profile, substantially equivalent to that of the other flow diverter devices commonly used.

BACKGROUND: While rescue stenting (RS) is a recognized bailout strategy following failed endovascular thrombectomy for acute ischemic stroke with large vessel occlusion, first-line stenting (FLS) has emerged as a potential alternative to avoid vascular injury and improve outcomes. However, direct comparisons between these strategies remain limited. We conducted a comparative analysis of FLS versus RS using data from a large, multicenter international registry to evaluate their relative safety and effectiveness. METHODS: We conducted a comparative analysis of FLS versus RS using data from the RESISTANT registry (Registry of Endovascular Salvage for Intracranial Stenting in Thrombectomy-Refractory Stroke), a multicenter, international, retrospective cohort of patients with acute ischemic stroke treated with intracranial stenting during endovascular thrombectomy (2016–2023). Patients were categorized by stenting strategy: FLS (stent placed without prior thrombectomy) or RS (stent placed after failed thrombectomy). The primary effectiveness outcome was functional independence (modified Rankin Scale score, 0–2) at 90 days; the primary safety outcome was symptomatic intracranial hemorrhage. Propensity score inverse probability of treatment weighting was used to adjust for baseline differences. RESULTS: Among 827 patients, 723 were in the RS cohort (median age, 67 [interquartile range, 59–77] years; 64.2% male) and 104 in the FLS cohort (median age, 65.5 [interquartile range, 58.8–77] years; 72.1% male). Using FLS as the reference strategy, inverse probability of treatment weighting–adjusted analyses did not detect significant differences in functional independence (odds ratio [OR], 0.64 [95% CI, 0.38–1.07]) or symptomatic intracranial hemorrhage (OR, 0.93 [95% CI, 0.34–2.59]). No significant differences were observed in secondary outcomes, including successful reperfusion, mortality, or procedural complications. In the anterior circulation cohort (n=589), outcomes were likewise comparable (functional independence: OR, 0.62 [95% CI, 0.60–1.25]; symptomatic intracranial hemorrhage: OR, 0.81 [95% CI, 0.30–2.18]). Similarly, in the posterior circulation cohort (n=234), no significant differences were found (functional independence: OR, 0.82 [95% CI, 0.32–2.10]; symptomatic intracranial hemorrhage: OR, 0.81 [95% CI, 0.30–2.18]). CONCLUSIONS: In this study, no significant differences in safety or effectiveness were detected between FLS and RS strategies during endovascular thrombectomy for acute ischemic stroke. Prospective, randomized trials are needed to better define optimal treatment approaches.

Purpose: The optimal anesthetic approach for intracranial stenting in acute stroke remains unclear. We compared outcomes of patients under general anesthesia (GA) versus local anesthesia or conscious sedation. Methods: The RESISTANT registry is a multicenter observational study on acute intracranial stenting during thrombectomy. Patients treated between January 2016 and June 2023 were included and stratified into GA and local anestesia/conscious sedation groups. The primary outcome was an adjusted shift analysis of the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included mRS 0–2 at 90 days and final modified Thrombolysis in Cerebral Infarction (mTICI) 2c/3 scores. Safety outcomes were symptomatic intracranial hemorrhage (sICH) and mortality. Adjusted ordinal and logistic regression with mixed-effects models were performed. Results: Of 876 patients, 445 (50.8%) received GA. Median age was 67 years [59–77]; 567 (64.8%) were men. No differences were found in 90-day mRS (adjusted common OR = 1.256 [0.887–1.780], p = 0.199). Rates of functional independence (39.0% vs 44.5%; aOR = 0.956 [0.606–1.507], p = 0.846), mTICI 2c/3 (68.9% vs 68.7%; aOR = 0.941 [0.602–1.471], p = 0.790), and sICH (8.0% vs 8.6%; aOR = 0.769 [0.374–1.584], p = 0.477) were comparable. In-hospital (23.0% vs 12.0%; aOR = 2.39 [1.35–4.22], p = 0.003) and 90-day mortality (33.3% vs 21.1%; aOR = 2.017 [1.227–3.315], p = 0.006) were higher in the GA group. Conclusion: In patients undergoing intracranial stenting during thrombectomy, anesthesia modality was not associated with better outcomes. GA was linked to higher mortality, likely due to indication bias.

Low-back pain (LBP) is a leading cause of disability worldwide. When symptoms persist beyond 4–6 weeks, when red flags are suspected, or when precise patient selection for procedures is needed, imaging—primarily MRI (Magnetic Resonance Imaging)—becomes pivotal. The purpose is to provide a pragmatic, radiology-first roadmap that aligns an imaging phenotype with anatomical targets and appropriate image-guided interventions, integrating MRI-based phenotyping with image-guided interventions for subacute and chronic LBP. In this narrative review, we define operational MRI criteria to distinguish radicular from non-radicular phenotypes and to contextualize endplate/Modic and facet/sacroiliac degenerative changes. We then summarize selection and technique for major procedures: epidural and periradicular injections (including selective nerve root blocks), facet interventions with medial branch radiofrequency ablation (RFA), sacroiliac joint injections and lateral branch RFA, basivertebral nerve ablation (BVNA) for vertebrogenic pain, percutaneous disc decompression, minimally invasive lumbar decompression (MILD), and vertebral augmentation for painful fractures. For each target, we outline preferred and alternative guidance modalities (fluoroscopy, CT, or ultrasound), key safety checks, and realistic effect sizes and durability, emphasizing when to avoid low-value or poorly indicated procedures. This review proposes a phenotype-driven reporting template and a care-pathway table linking MRI patterns to diagnostic blocks and definitive image-guided treatments, with the aim of reducing cascade testing and therapeutic ambiguity. A standardized phenotype → target → tool approach can make MRI reports more actionable and help clinicians choose the right image-guided intervention for the right patient, improving outcomes while prioritizing safety and value.

BACKGROUND: In the case of failed reperfusion or severe stenosis during endovascular treatment of acute stroke, intracranial stenting is a growing practice. We aimed to study clinical and radiological outcomes in a large multicenter cohort. METHODS: The RESISTANT registry (Registry of Endovascular Salvage for Intracranial Stenting in Thrombectomy-Refractory Stroke; 2016–2023) is a multicenter single-arm retrospective registry of patients with acute stroke who underwent intracranial stenting during endovascular treatment across 36 international centers. The primary end point was functional outcome at 90 days. Secondary end points were final successful reperfusion (modified Thrombolysis in Cerebral Infarction, 2b-3) and stent patency at 24 hours. Safety outcomes included procedural complications, symptomatic intracranial hemorrhage, and in-hospital mortality. Logistic regression models including those variables that achieved statistical significance, along with age, baseline National Institutes of Health Stroke Scale, and baseline modified Rankin Scale, were used to define independent predictors. RESULTS: Among 904 patients enrolled, 876 fulfilled inclusion criteria. Median age was 67.0 (interquartile range, 59.0–77.0) years, 567 (64.8%) were men, and the median National Institutes of Health Stroke Scale score was 12.0 (interquartile range, 7.0–19.0). Anterior circulation was involved in 624 (71.6%), and the rate of tandem extracranial/intracranial occlusion was 4.9%. Stenting was performed in 469 patients (53.5%), owing to failed reperfusion (expanded Thrombolysis in Cerebral Infarction, 0-2a), and in 320 patients (36.5%) because of residual severe stenosis. After stenting, immediate successful recanalization was achieved in 777 (89.5%). At 90 days, the rate of modified Rankin Scale score of 0 to 2 was 41.2%. The number of thrombectomy attempts (adjusted odds ratio, 0.810 [95% CI, 0.707–0.929]; P =0.003) and the final successful recanalization (adjusted odds ratio, 19.394 [95% CI, 5.486–68.560]; P <0.001) were associated with good functional outcome. During admission, the reocclusion rate was 12.2%, most of them within 48 hours. Symptomatic intracranial hemorrhage was diagnosed in 8.4% of patients; no variables were independently associated with a higher probability. CONCLUSIONS: Acute intracranial stenting was a feasible therapy for patients with failed reperfusion or severe stenosis. Successful reperfusion and a lower number of thrombectomy attempts predicted functional outcome. Prospective studies are warranted to confirm efficacy and safety.