William J. P. Ertl

Background: Temporalis muscle thickness (TMT) measured on routine neuroimaging has emerged as a radiological marker of sarcopenia, but its prognostic value in acute ischemic stroke is not well defined. This systematic review examined whether TMT is associated with functional status, swallowing outcomes, and mortality after acute ischemic stroke. Methods: A PRISMA-guided systematic review identified observational studies (2000–2025) reporting TMT and at least one clinical outcome in adults with acute ischemic stroke. PubMed, MEDLINE, Embase, Web of Science, and Scopus were searched. Two reviewers independently screened records and extracted data. Risk of bias was assessed using ROBINS-I and the Newcastle–Ottawa Scale, with justification relative to prognostic-factor tools. Due to heterogeneity in TMT definitions and outcome measures, findings were synthesized narratively. Results: Four cohorts, including 1361 patients, met the inclusion criteria. Mean age was 69.7 years, and 53.9% were male. Study-level mean TMT ranged from 5.2 to 6.35 mm; among the 704 patients in cohorts that reported TMT-defined sarcopenia status, prevalence was 51.8% (365/704). Across studies, lower TMT or TMT-defined sarcopenia was associated with poorer functional outcomes and higher mortality, independent of age and stroke severity. In one thrombectomy cohort, each 1-mm increase in TMT increased the odds of functional independence (adjusted OR 1.14, 95% CI 1.03–1.27). In contrast, each 1-mm increase reduced 90-day mortality (adjusted OR 0.71, 95% CI 0.54–0.93). Lower TMT also predicted prolonged nasogastric tube dependence. Conclusions: TMT is a simple CT- or MRI-based measure that is consistently associated with disability, dysphagia, and survival after acute ischemic stroke. Current evidence is observational and supports further prospective validation and measurement standardization rather than immediate routine decision-making use.

Background: Symptomatic carotid atherosclerotic stenosis is a major cause of ischemic stroke. In patients with heavily calcified plaque and limited physiologic reserve for open revascularization, conventional carotid artery stenting may fail because rigid calcium prevents adequate luminal expansion. Intravascular lithotripsy (IVL) is an adjunctive plaque-modification strategy for selected calcified carotid lesions, although evidence remains limited and carotid IVL is investigational. Case presentation: An 83-year-old man with hyperlipidemia, hypertension, hypothyroidism, protein S deficiency, prior myocardial infarction, and lower-extremity deep vein thrombosis on apixaban presented with acute ischemic stroke manifested by dysarthria, global aphasia, and right hemiparesis. Brain MRI showed acute left-hemisphere borderzone infarcts involving deep white matter and basal ganglia, consistent with ipsilateral carotid atheroembolism and/or relative hypoperfusion. CTA and cerebral angiography demonstrated approximately 60% left internal carotid artery stenosis, with heavy concentric calcification spanning a lesion length greater than 10 mm at the carotid bifurcation. Management and outcome: After multidisciplinary review of carotid endarterectomy, TCAR, and transfemoral options, IVL-assisted carotid angioplasty and stenting under continuous embolic protection was selected given advanced age, prior myocardial infarction, acute neurologic impairment, and limited functional reserve. Using distal embolic protection and proximal balloon-guide flow arrest, IVL was performed across the calcified plaque, followed by deployment of a new-generation integrated 3-in-1 carotid stent. Angiographic stenosis improved from approximately 60% to approximately 20% by NASCET methodology without periprocedural stroke, vasospasm, dissection, hemodynamic instability, or access-site complication. Admission NIHSS was 29; discharge NIHSS and mRS were 6 and 3, respectively. At approximately 1-month follow-up he was alert and oriented ×3 with fluent language and good comprehension. No further antithrombotic regimen switch occurred during outpatient follow-up, and no perioperative complications were reported. Conclusion: In this elderly patient with acute ischemic stroke and heavily calcified symptomatic carotid stenosis, IVL with angioplasty and a 3-in-1 carotid stent achieved early technical success without periprocedural complication and with short-term clinical stability. This case supports further investigation of IVL-based carotid revascularization in carefully selected patients who are poor candidates for open surgery and highlights the need for standardized follow-up, neurologic outcome reporting, and prospective evaluation of long-term patency and stroke prevention.

Background: Carotid artery stenosis may contribute to cognitive impairment through chronic hypoperfusion and subclinical ischemic injury. Although carotid endarterectomy (CEA) and carotid artery stenting (CAS) reduce stroke risk, their cognitive effects remain unclear. We conducted a systematic review and meta-analysis to evaluate cognitive outcomes after these interventions. Methods: Following PRISMA guidelines, we searched PubMed, Embase, Web of Science, and the Cochrane Library from January 2000 to November 2025. Eligible studies reported cognitive outcomes after CEA or CAS, either alone or in direct comparison. Random-effects meta-analyses were performed for Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) outcomes. Single-arm studies were analyzed using standardized mean change, and head-to-head studies using mean difference. Outcomes were stratified by intervention type and follow-up interval (0–6 months and >6 months). Domain-specific cognitive outcomes were summarized qualitatively. Risk of bias was assessed using RoB-2, ROBINS-I, and the Newcastle-Ottawa Scale. Results: Sixty-eight studies including 4,659 patients met inclusion criteria; 27 contributed to meta-analysis and 41 to qualitative synthesis. MMSE showed no significant early change after either intervention, while CAS showed significant improvement at >6 months. MoCA improved significantly after both CEA and CAS at early and late follow-up, although heterogeneity was high. Head-to-head analyses found no significant difference between CEA and CAS for MMSE or MoCA, but these comparisons were limited by small sample sizes. Domain-specific outcomes were mostly stable, with improvements most often reported in memory, attention, executive function, and processing speed. Conclusions: Carotid revascularization may be associated with improved cognitive outcomes, particularly on MoCA, but results are heterogeneous and largely observational. Comparative evidence does not show a clear cognitive advantage of CEA or CAS. Future studies should use standardized cognitive testing and adequately powered direct comparisons.