Filip Cihlář

Background: Endovascular management of acute stroke caused by a tandem lesion in the anterior circulation is currently a discussed area. Acute insertion of a carotid stent in the absence of antiaggregation premedication often leads to acute stent occlusion with clinical impact. Conversely, early antiplatelet therapy after intravenous thrombolysis can lead to hemorrhagic complications. Early reocclusion may also occur if the carotid artery is left with residual stenosis for elective treatment. Our aim was to analyze the clinical outcome of patients with tandem lesions (TL). Results: 1350 patients were included in the study. 225 patients underwent MT for a tandem lesion (age 70.8 ± 11.3 years, 52.4% men). Successful recanalization (TICI ≥ 2b) was achieved in 83.1% (79.9% at non TL group, p = 0,269). A good clinical outcome(mRS ≤ 2) was achieved by 54.7% of patients (43.4% at non TL group, p = 0,002). A relatively good clinical outcome (mRS ≤ 3) was achieved by 61.8% of patients (50% at non TL group, p = 0,001). Mortality (90 days) was 25.3% (34.6% at non TL group, p = 0,007). Conclusions: A tandem lesion in the anterior circulation is a frequently feared finding in acute cerebrovascular accident. However, endovascular treatment can have a significantly good clinical result here as well. In our cohort, this is the subgroup with the best prognosis.

Objectives: The goal of this study is to establish the incidence of high on-treatment platelet reactivity (HTPR) to aspirin and clopidogrel in patients undergoing carotid stenting and to evaluate the efficacy of ticagrelor and ticlopidine in patients with HTPR to clopidogrel. Methods: In a single institutional setting spanning eight years, every consecutive patient who underwent carotid artery stenting was incorporated into a study. Subsequently, a retrospective analysis of their platelet function was executed. Prevalence of high on-treatment reactivity to aspirin, clopidogrel, ticlopidine and ticagrelor was assessed. Platelet function testing was conducted by light transmission aggregometry and Multiplate^®. Results: A total of 216 patients were tested for antiplatelet therapy efficacy. The high on-treatment reactivity to clopidogrel was observed in 68 patients (31.4%). No patients with high on-treatment reactivity to ticagrelor or ticlopidine were observed. There was a significant reduction in platelet reactivity with ticagrelor (p < 0.000) and ticlopidine (p < 0.000) in patients with HTPR to clopidogrel. Conclusions: High on-treatment platelet reactivity to clopidogrel is common in patients undergoing carotid artery stenting. Ticagrelor is a viable alternative to overcome HTPR to clopidogrel. These findings suggest that platelet function testing can identify patients who may benefit from tailored antiplatelet therapy in reducing thromboembolic complications after carotid stenting.

Given the paucity of high-quality safety/efficacy data on acute stroke therapies in patients with premorbid disability, they risk being routinely excluded from such therapies. We examined utilization of endovascular thrombectomy (EVT), associated workflow, and poststroke outcomes among patients with vs without premorbid disability. We used national registry data on thrombolysis/EVT for the Czech Republic from 1 January 2016 to 31 December 2020. Premorbid disability was defined as prestroke modified Rankin Scale score (mRS) ≥3. We compared proportions of patients with vs without premorbid disability who received EVT and examined workflow times. We compared ΔmRS-change in mRS from prestroke to 3 months-in patients with vs without premorbid disability, in addition to intracerebral hemorrhage (ICH), mortality, and discharge NIHSS (National Institutes of Health Stroke Scale score), adjusting for age, sex, baseline NIHSS, and comorbidities, and verified using propensity score weighting (PSW) and matching for differences in treatment assignment. We stratified by age group (interaction = 0.73). EVT recipients with premorbid disability did not differ significantly for several outcomes including ΔmRS (aIRR: 0.99, 95% CI 0.84-1.17) but were more likely to have 3-month mRS 5-6 (70.1% vs 39.5% without premorbid disability, aOR: 1.85, 95% CI 1.12-3.04). Patients with premorbid disability were less likely to receive EVT, had slower treatment times, and had worse outcomes compared with patients without premorbid disability. However, regardless of premorbid disability, patients fared better with EVT vs medical management and one-third with prestroke disability returned to their prestroke status.

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Treatment of complex aneurysms often requires additional surgical tools including the use of the extra-intracranial (EC-IC) bypass. The following report depicts the utilization of the EC-IC bypass in treating a dissecting aneurysm several hours after a salvage emergent evacuation of an acute subdural hematoma via decompressive craniectomy (DC). Preserving the superficial temporal artery during the DC provided a donor artery for the bypass surgery.

Cerebral vasospasm and subsequent delayed ischemic neurological deficit is a typical sequela of acute subarachnoid hemorrhage after aneurysm rupture. The occurrence of vasospasms after uncomplicated surgery of an unruptured aneurysm without history of suspected rupture is extremely rare. The pathogenesis and severity of cerebral vasospasms is typically correlated with the amount of blood breakdown products extravasated during subarachnoid hemorrhage. In rare cases, where vasospasms occur after unruptured aneurysm surgery, the pathogenesis is most likely multifactorial and unclear. We present two cases of vasospasms following uncomplicated clipping of middle cerebral artery (MCA) aneurysms and a review of literature. Early diagnosis and therapy of this rare complication are necessary to achieve optimal clinical outcomes.