Tomas Klail

Background: The asymmetry of cortical veins in susceptibility weighted imaging (SWI) in MRI might be a biomarker for migraine aura and cortical spreading depression (CSD). The aim of this study was to assess in humans if SWI asymmetry can be found in patients who have migraine attacks without aura. Methods: We included patients (n = 100 per group) from the emergency room setting when they (i) presented with an acute neurological deficit or headache; (ii) had a discharge diagnosis of a migraine aura, a migraine without an aura, or neither (controls without stroke or epilepsy); and (iii) had a brain MRI with SWI in the acute setting. Results: In the migraine with aura group, SWI asymmetry was found in 26% (95% CI 18–35) compared to patients with migraine without aura (3%, [95% CI 1–8], p < 0.001) and controls 7% [95% CI 3–14], p < 0.001). There was no difference between patients with migraine without aura and controls (p = 0.19). Conclusions: The distinct SWI changes in migraine with and without aura suggest that CSD might not be involved in the pathophysiology of migraine without aura.

Purpose: Internal carotid artery dissection (ICA-D) frequently leads to ischemic stroke in individuals under 50 years. There is mounting evidence on the role of the styloid process (SP) in ICA-D, particularly SP length and the SP–ICA distance. Despite having clear guidelines on the treatment of SP-related Eagle syndrome and ICA-D, the concept of SP-related ICA-D is relatively new and no therapeutic guidelines exist. Methods: A narrative literature search was performed to identify all articles pertaining to the diagnosis and treatment of ICA-D linked to an ipsilateral elongated SP or short SP-ICA distance. The treatments were evaluated in terms of symptom recurrence after the treatment. As illustrative examples of clinical management, we present an in-house case series of patients with suspected ICA-D related to SP. Results: Treatment efficacy was assessed, with an in-house case series provided. Seventy-five reports and case studies involving 84 patients were analyzed. Conservative treatments were common (52%) but had a high symptom recurrence rate (33%). It is noteworthy that no patients treated initially with styloidectomy exhibited symptom recurrence. Conclusion: In case of a correctly diagnosed SP-related ICA-D, a styloidectomy may offer a curative option, but more research is needed for clear indications and standardized guidelines to prevent recurrent symptoms or strokes.

Cerebral perforators are end-arteries that vascularize specific deep territories in the cerebral hemispheres and brainstem. Due to improved imaging quality, these aneurysms are increasingly diagnosed in clinical routine. High resolution 3D angiographic images are mandatory and in some occasions fusion images might be helpful to detect these aneurysms. Basilar artery perforator aneurysms (or BAPAs) are one of the most common subtypes of perforator aneurysms and might cause subarachnoid hemorrhage along the brainstem (perimesencephalic hemorrhage). Due to the limited evidence, the management of BAPAs may pose a challenge in clinical routine. While some aneurysms can be managed conservatively, a few might require treatment to prevent rebleeding. We present the cases of two patients with BAPAs managed at our center in order to increase the awareness on these potentially underdiagnosed aneurysms.

Background: Acute basilar artery occlusion (BAO) is a severe disease that is associated with an 85% mortality rate if untreated. Several studies have analyzed the use of mechanical thrombectomy (MT) in the different scenarios of BAO. However, the results remain conflicting and the role of MT as standard of care for vertebrobasilar tandem occlusions (VBTO) has not been confirmed. Our goal was to assess technical feasibility, safety, and functional outcome of endovascular treatment of VBTO in comparison to isolated BAO (IBAO). Methods: We retrospectively reviewed all prospectively collected patients with acute BAO from six tertiary centers between September 2016 and November 2021. Patients were subsequently divided into two groups: VBTO and IBAO. Baseline data, procedural details, and outcomes were compared between groups. Results: A total of 190 patients were included, 55 presenting with a VBTO and 135 with IBAO. Successful recanalization was equally common in both groups (89.1% and 86.0%). Rates of favorable functional outcome (modified Rankin Scale: 0–2) were higher in patients with VBTO compared to IBAO (36.4% vs. 25.2%, p = 0.048) and mortality was lower (29.1% vs. 33.3%). However, these associations faded after adjustment for confounders (adjusted odds ratio [aOR] 0.86, 95% CI 0.35–2.05; aOR 0.93, 95% CI 0.35–2.45). Rates of symptomatic intracranial hemorrhage did not differ between the groups (VBTO: 7.3% vs. IBAO: 4.2%; p = 0.496). Conclusion: Endovascular treatment of VBTO is technically feasible and safe with similar rates of successful recanalization, favorable functional outcome, and mortality to those in patients with IBAO.