Sara Pilgram-Pastor

Current international guidelines recommend blood pressure (BP) thresholds for patients eligible for endovascular thrombectomy (EVT). Previous studies have suggested that both low and high admission BPs are associated with poor functional outcome after EVT. However, the association between admission BP and outcomes after EVT remains poorly understood.The aim of this study was to investigate the relationship between admission systolic BP (SBP) and outcomes in patients treated with EVT and to assess whether this association is modified by IV thrombolysis (IVT) treatment and recanalization status. In this observational, international, multicenter cohort study, we used data from the EVA-TRISP registry. Consecutive patients treated with EVT with available admission SBP were included. The primary outcome was 90-day functional outcome. Secondary outcomes included 90-day mortality, 24-hour NIH Stroke Scale (NIHSS), successful recanalization, and symptomatic intracranial hemorrhage (sICH). We used multivariable regression to study the relation between admission SBP and outcomes and to assess effect modification by IVT treatment and recanalization status. We included 10.963 EVT patients. At baseline, the mean age was 72.8 years (SD 13.5), 50.2% were female and the median NIHSS at presentation was 15 (interquartile range 9-19). The association between admission SBP and functional outcome, mortality, and 24-hour NIHSS score was U-shaped, and the nadir was around 150 mm Hg. Below 150 mm Hg, every 10 mm Hg decrease in SBP was associated with higher odds of poor functional outcome (adjusted odds ratio (aOR) 1.07 [95% CI 1.02-1.11]) and mortality (aOR 1.17 [1.12-1.23]). Above 150 mm Hg, every 10 mm Hg increase in SBP was associated with higher odds of poor functional outcome (aOR 1.05 [1.01-1.08]), mortality (aOR 1.04 [1.01-1.09]), and higher 24-hour NIHSS score (β-coefficient 0.28 [0.17-0.40]). We found a positive linear relationship between admission SBP and sICH (1.04 [1.01-1.08]). IVT treatment modified the association between admission SBP and outcomes after EVT. In 5544 EVT-only treated patients, there was no longer a clear association between higher admission SBP values and worse outcome. Lower and higher admission SBP was associated with worse outcomes in the complete cohort. In EVT-only patients, this association was less evident, suggesting that high admission BP alone should not always delay or preclude treatment with EVT in otherwise eligible patients.

BACKGROUND AND PURPOSE: Localizing a cerebrospinal fluid (CSF) leak in spontaneous intracranial hypotension (SIH) patients is of utmost importance when pursuing a targeted therapy. The study aimed to evaluate the accuracy of dynamic myelography techniques in localizing spinal CSF leaks and report the number of examinations required, stratified by leak type and spinal level. MATERIALS AND METHODS: Consecutive SIH patients with a spinal longitudinal extradural CSF collection (SLEC) investigated at our department from January 2013 to February 2025 were screened. All included patients underwent a dynamic myelography work-up to localize the level of spinal CSF leak using conventional dynamic myelography (CDM), and/or dynamic computed tomography myelography (DCTM). RESULTS: In total, 198 SLEC positive SIH patients (mean age: 50 ± 12 years; 67% female, 133/198) were included. In total, 147 patients had a ventral (74%), 49 patients had lateral (25%), and two patients had a primary dorsal (1%) leak. The spinal CSF leak was localized with the first, second, third or fourth dynamic myelography in 97 (49%), 70 (35%), 16 (8%), 11 patients (6%), respectively. The median number of myelography exams (CDM + DCTM) per patient to localize a CSF leak was 2 (IQR 1-2; range 1-8); 1 (IQR 1-2; range 1-5) for ventral, 2 (IQR 1-2; range 1-6) for lateral and 6 (IQR 5-7; range 4-8) for dorsal leaks. In total, 160 patients (81%) were referred for microsurgical closure. The dural leak was identified intraoperatively on the indicated vertebral level in 153 patients (96%), in 2 patients (1.3%) spontaneous sealing occurred, in 5 patients (3%) wrong-level surgery occurred. CONCLUSIONS: Dynamic myelography exams accurately and reliably localize spinal CSF leaks in SIH patients with SLEC. In about half of the patients, the level of the leak can be localized with the first CDM. In case of a repeat dynamic myelography, the technique and patient positioning can be adopted according to the results of the previous exam. Primary dorsal leaks are rare, but due to the low level of suspicion, pose a diagnostic challenge. ABBREVIATIONS: CSF: Cerebrospinal Fluid; CDM: Conventional Dynamic Myelography; DSM: Digital Subtraction Myelography; DAP: Dose-Area Product; DLP: Dose-Length Product; DCTM: Dynamic Computed Tomography Myelography; EBP: Epidural Blood Patch; ICHD: International Classification Of Headache Disorders; IQR: Interquartile Range; PMCT: Post-Myelo CT; SLEC: Spinal Longitudinal Extradural CSF Collection; SIH: Spontaneous Intracranial Hypotension; SD: Standard Deviation; WLS: wrong-level surgery.

BACKGROUND: Moyamoya angiopathy (MMA) is an important cause of juvenile stroke but an overall rare disease among European populations compared with East Asian cohorts. Consecutively, hemorrhagic MMA is described well in East Asian cohorts, but knowledge in non-Asian patients is limited. Literature suggests that disease presentation may vary between those cohorts, also including hemorrhage frequencies. Hence, this article aims to analyze hemorrhagic MMA in European patients. METHODS: We screened for patients of European origin with MMA from a single-center consecutive database of a German hospital specialized on MMA. Those who had a record of intracranial hemorrhage were analyzed individually regarding the type of hemorrhage and use of antiplatelet therapy before and after bleeding onset. To identify associated factors of intracranial hemorrhage, an age- and sex-matched control group was identified from the pool of patients without a history of hemorrhage. Both groups had a comparable follow-up time and were compared in terms of disease presentation, therapeutic interventions, and imaging characteristics, using both univariate tests and multivariate logistic regression analysis. RESULTS: From a pool of 332 patients with MMA we identified 288 of European ancestry. From those, 36 had a record of intracranial hemorrhage (12.5%). Thirty-three patients presenting with 37 events were included for further analysis and case-control-comparison. Most events were intracerebral hemorrhage (n=20; 54%) and subarachnoid hemorrhage (n=11; 30%). 78% developed hemorrhage although no antiplatelet therapy was in use (n=29). Seven patients developed intracranial hemorrhage ipsilateral to prior bypass surgery (21%), while 29 of the control patients had a bypass surgery (88%; P =0.0001). There was no significant difference in terms of unilateral or bilateral disease type, history of hypertension, as well as imaging characteristics (high Suzuki stage and the presence of collateral pathways in conventional angiography, as well as ischemic defects and the presence of microbleeds on cerebral magnetic resonance imaging; P >0.05 in multivariate analysis, respectively). CONCLUSIONS: Bypass surgery was negatively associated with the development of intracranial hemorrhage in MMA in European patients. There was no difference in terms of a history of hypertension between groups, indicating that blood pressure is not the major contributor for rupture of fragile collateral vessels. The investigated imaging characteristics were not associated to hemorrhage onset and, therefore, are not suitable as a tool of screening for patients at risk.

BACKGROUND AND PURPOSE: Flat-panel detector computed tomography (FDCT) immediately after mechanical thrombectomy (MT) can detect complications including early hemorrhagic transformation and subarachnoid hyperdensities (SH). The clinical significance of SH in patients undergoing MT remains unclear. MATERIALS AND METHODS: We studied 223 patients who underwent MT for anterior circulation stroke, had FDCT performed immediately after the procedure, and had follow-up imaging within 24 hours. SH severity was categorized into 5 grades (SH 0: absent to SH IV: extensive). Baseline and procedural characteristics, as well as outcome measures, were analyzed using group comparisons and multivariable logistic regression analyses. RESULTS: Overall, 100/223 (45%) of patients showed SH on immediate post-interventional FDCT. The factors associated with an increased SH risk were: medium vessel occlusion or distal vessel occlusion as compared to a large vessel occlusion, a more distal device position, a higher number of device passes, a larger volume of contrast applied, and worse final reperfusion eTICI. Occurrence of SH grade II-IV was independently associated with worse functional outcomes (aOR for mRS 3-6: 2.2, 95% CI 1.1-4.3), whereas patients with SH grade I had similar outcomes to patients without SH. CONCLUSIONS: Our study identified risk factors for SH, most of which reflect increasingly challenging procedures or more peripheral recanalization attempts. The presence of SH grades II-IV was associated with poorer outcomes, suggesting the need for personalized strategies to reduce its incidence and severity or potentially improve recovery after SH. ABBREVIATIONS: DVO = distal vessel occlusion; FDCT = flat-panel detector computed tomography; LVO = large vessel occlusion; MVO = medium vessel occlusion; MT = mechanical thrombectomy; SH = subarachnoid hyperdensities

Purpose: Flat-panel detector computed tomography (FDCT) is increasingly used in (neuro)interventional angiography suites. This study aimed to compare FDCT perfusion (FDCTP) with conventional multidetector computed tomography perfusion (MDCTP) in patients with acute ischemic stroke. Methods: In this study, 19 patients with large vessel occlusion in the anterior circulation who had undergone mechanical thrombectomy, baseline MDCTP and pre-interventional FDCTP were included. Hypoperfused tissue volumes were manually segmented on time to maximum (Tmax) and time to peak (TTP) maps based on the maximum visible extent. Absolute and relative thresholds were applied to the maximum visible extent on Tmax and relative cerebral blood flow (rCBF) maps to delineate penumbra volumes and volumes with a high likelihood of irreversible infarcted tissue (“core”). Standard comparative metrics were used to evaluate the performance of FDCTP. Results: Strong correlations and robust agreement were found between manually segmented volumes on MDCTP and FDCTP Tmax maps (r = 0.85, 95% CI 0.65–0.94, p < 0.001; ICC = 0.85, 95% CI 0.69–0.94) and TTP maps (r = 0.91, 95% CI 0.78–0.97, p < 0.001; ICC = 0.90, 95% CI 0.78–0.96); however, direct quantitative comparisons using thresholding showed lower correlations and weaker agreement (MDCTP versus FDCTP Tmax 6 s: r = 0.35, 95% CI −0.13–0.69, p = 0.15; ICC = 0.32, 95% CI 0.07–0.75). Normalization techniques improved results for Tmax maps (r = 0.78, 95% CI 0.50–0.91, p < 0.001; ICC = 0.77, 95% CI 0.55–0.91). Bland-Altman analyses indicated a slight systematic underestimation of FDCTP Tmax maximum visible extent volumes and slight overestimation of FDCTP TTP maximum visible extent volumes compared to MDCTP. Conclusion: FDCTP and MDCTP provide qualitatively comparable volumetric results on Tmax and TTP maps; however, direct quantitative measurements of infarct core and hypoperfused tissue volumes showed lower correlations and agreement.

BACKGROUND AND PURPOSE: Potential utility of flat panel CT perfusion imaging (FPCT-PI) performed immediately after mechanical thrombectomy (MT) is unknown. We aimed to assess whether FPCT-PI obtained directly post-MT could provide additional potentially relevant information on tissue reperfusion status. MATERIALS AND METHODS: This was a single-center analysis of all patients with consecutive acute stroke admitted between June 2019 and March 2021 who underwent MT and postinterventional FPCT-PI (n = 26). A core lab blinded to technical details and clinical data performed TICI grading on postinterventional DSA images and qualitatively assessed reperfusion on time-sensitive FPCT-PI maps. According to agreement between DSA and FPCT-PI, all patients were classified into 4 groups: hypoperfusion findings perfectly matched by location (group 1), hypoperfusion findings mismatched by location (group 2), complete reperfusion on DSA with hypoperfusion on FPCT-PI (group 3), and hypoperfusion on DSA with complete reperfusion on FPCT-PI (group 4). RESULTS: Detection of hypoperfusion (present/absent) concurred in 21/26 patients. Of these, reperfusion findings showed perfect agreement on location and size in 16 patients (group 1), while in 5 patients there was a mismatch by location (group 2). Of the remaining 5 patients with disagreement regarding the presence or absence of hypoperfusion, 3 were classified into group 3 and 2 into group 4. FPCT-PI findings could have avoided TICI overestimation in all false-positive operator-rated TICI 3 cases (10/26). CONCLUSIONS: FPCT-PI may provide additional clinically relevant information in a considerable proportion of patients undergoing MT. Hence, FPCT-PI may complement the evaluation of reperfusion efficacy and potentially inform decision-making in the angiography suite.

BACKGROUND AND PURPOSE: Intra-arterial thrombolytics may be used to treat distal vessel occlusions, which cause incomplete reperfusion following mechanical thrombectomy. Because immediate reperfusion after intra-arterial thrombolytics occurs rarely, the aim of this study was to assess the delayed effect of intra-arterial thrombolytics using follow-up perfusion imaging. MATERIALS AND METHODS: We included patients from a prospective stroke registry (February 2015 to September 2022) who had undergone mechanical thrombectomy and had incomplete reperfusion (expanded TICI 2a–2c) and available 24 hour perfusion imaging. Perfusion imaging was rated as delayed reperfusion if time-sensitive perfusion maps did not show wedge-shaped delays suggestive of persisting occlusions corresponding to the post-mechanical thrombectomy angiographic deficit. Patients treated with intra-arterial thrombolytics were compared with controls using multivariable logistic regression and inverse probability of treatment weighting matching for baseline differences and factors associated with delayed reperfusion. RESULTS: The median age of the final study population (n = 459) was 74 years (interquartile range, 63–81 years), and delayed reperfusion occurred in 61% of cases. Patients treated with additional intra-arterial thrombolytics (n = 40) were younger and had worse expanded TICI scores. After matching was performed, intra-arterial thrombolytics was associated with higher rates of delayed reperfusion (adjusted OR = 2.7; 95% CI, 1.1–6.4) and lower rates of new infarction in the residually hypoperfused territory after mechanical thrombectomy (adjusted OR = 0.3; 95% CI, 0.1–0.7). No difference was found in the rates of functional independence (90-day mRS, 0–2; adjusted OR = 1.4; 95% CI, 0.4–4.1). CONCLUSIONS: Rescue intra-arterial thrombolytics is associated with delayed reperfusion of remaining vessel occlusions following incomplete mechanical thrombectomy. The value of intra-arterial thrombolytics as a potential therapy for incomplete reperfusions after mechanical thrombectomy should be assessed in the setting of randomized controlled trials.

Background: We recently reported a worrying 30% rate of early neurological deterioration (END) occurring within 24 hours following intravenous thrombolysis (IVT) in minor stroke with isolated internal carotid artery occlusion (ie, without additional intracranial occlusion), mainly due to artery-to-artery embolism. Here, we hypothesize that in this setting IVT—as compared to no-IVT—may foster END, in particular by favoring artery-to-artery embolism from thrombus fragmentation. Methods: From a large multicenter retrospective database, we compared minor stroke (National Institutes of Health Stroke Scale score 7d ) and 3-month modified Rankin Scale score 0 to 1. Results: Overall, 189 patients were included (IVT=95; antithrombotics=94 [antiplatelets, n=58, anticoagulants, n=36]) from 34 centers. END within 24 hours and END _7d occurred in 46 (24%) and 60 (32%) patients, respectively. Baseline clinical and radiological variables were similar between the 2 groups, except significantly higher National Institutes of Health Stroke Scale (median 3 versus 2) and shorter onset-to-imaging (124 versus 149min) in the IVT group. END within 24 hours was more frequent following IVT (33% versus 16%, adjusted hazard ratio, 2.01 [95% CI, 1.07–3.92]; P =0.03), driven by higher odds of artery-to-artery embolism (20% versus 9%, P =0.09). However, END _7d and 3-month modified Rankin Scale score of 0 to 1 did not significantly differ between the 2 groups (END _7d : adjusted hazard ratio, 1.29 [95% CI, 0.75–2.23]; P =0.37; modified Rankin Scale score of 0–1: adjusted odds ratio, 1.1 [95% CI, 0.6–2.2]; P =0.71). END _7d occurred earlier in the IVT group: median imaging-to-END 2.6 hours (interquartile range, 1.9–10.1) versus 20.4 hours (interquartile range, 7.8–34.4), respectively, P <0.01. Conclusions: In our population of minor strokes with iICAO, although END rate at 7 days and 3-month outcome were similar between the 2 groups, END—particularly END due to artery-to-artery embolism—occurred earlier following IVT. Prospective studies are warranted to further clarify the benefit/risk profile of IVT in this population.

Background: There is paucity of data regarding the effects of delayed reperfusion (DR) on clinical outcomes in patients with incomplete reperfusion following mechanical thrombectomy. We hypothesized that DR has a strong association with clinical outcome in patients with incomplete reperfusion after mechanical thrombectomy (expanded Thrombolysis in Cerebral Infarction, 2a–2c). Methods: Single-institution’s stroke registry retrospective analysis of patients admitted from February 2015 to December 2020. DR was defined as the absence of any perfusion delay on ≈24-hour contrast-enhanced follow-up perfusion imaging, whereas persistent perfusion deficit denotes a perfusion delay corresponding to the catheter angiographic deficit directly after the intervention. The association of perfusion outcome (DR versus persistent perfusion deficit) with the occurrence of new infarcts and 90-day functional independence (modified Rankin Scale score 0–2) was evaluated using logistic regression analyses. Comparison of predictive accuracy was evaluated by calculating area under the curve for models with and without perfusion outcome. Results: In 566 patients (mean age 74, 49.6% female), new infarcts in the incomplete reperfusion areas were less common in DR versus persistent perfusion deficit patients (small punctiform: 17.1% versus 25%, large confluent: 7.9% versus 63.2%; P =0.001). After adjustment for confounders, DR was a strong predictor of functional independence (adjusted odds ratio, 2.37 [95% CI 1.34–4.23]). There was a significant improvement in predictive accuracy of functional independence when perfusion outcome was added to expanded Thrombolysis in Cerebral Infarction alone (area under the curve 0.57 versus 0.62, P =0.01). Conclusions: Occurrence of DR is closely associated with tissue outcome and functional independence. DR may be an independent prognostic parameter, suggesting it as a potential outcome surrogate for medical rescue therapies.