Neutrophil Extracellular Traps (NETs) are DNA extracellular networks decorated with histones and granular proteins produced by activated neutrophils. NETs have been identified as major triggers and ...structural factors of thrombosis. A recent study designated extracellular DNA threads from NETs as a potential therapeutic target for improving tissue-type plasminogen activator (tPA)-induced thrombolysis in acute coronary syndrome. The aim of this study was to assess the presence of NETs in thrombi retrieved during endovascular therapy in patients with acute ischemic stroke (AIS) and their impact on tPA-induced thrombolysis.
We analyzed thrombi from 108 AIS patients treated with endovascular therapy. Thrombi were characterized by hematoxylin/eosin staining, immunostaining, and ex vivo enzymatic assay. Additionally, we assessed ex vivo the impact of deoxyribonuclease 1 (DNAse 1) on thrombolysis of AIS thrombi.
Histological analysis revealed that NETs contributed to the composition of all AIS thrombi especially in their outer layers. Quantitative measurement of thrombus NETs content was not associated with clinical outcome or AIS pathogenesis but correlated significantly with endovascular therapy procedure length and device number of passes. Ex vivo, recombinant DNAse 1 accelerated tPA-induced thrombolysis, whereas DNAse 1 alone was ineffective.
This study suggests that thrombus NETs content may be responsible for reperfusion resistance, including mechanical or pharmacological approaches with intravenous tPA, irrespectively of their etiology. The efficacy of a strategy involving an administration of DNAse 1 in addition to tPA should be explored in the setting of AIS.
URL: http://www.clinicaltrials.gov. Unique identifier: NCT02907736.
Central vein disease (CVD) is a well-known complication of central venous cannulations, indwelling dialysis catheters, and arteriovenous grafts. Brachiocephalic vein (BCV) stenosis or thrombotic ...occlusion can occur in dialysis patients, and the presence of an ipsilateral arteriovenous fistula can cause cerebral venous hypertension due to retrograde flow in the ipsilateral jugular vein. A 53-year-old man receiving hemodialysis (left brachiocephalic hemodialysis fistula) presented with impaired consciousness and seizures related to status epilepticus due to left temporal multifocal hemorrhages. Brain computed tomography and angiogram showed left cortical vein congestion without intracranial arteriovenous shunt. Complementary left brachial angiogram showed a left BCV stenosis and jugular and cerebral high-flow venous reflux with cortical venous reflux from the hemodialysis fistula. The left arm shunt resulted in severe cerebral venous hypertension due to ipsilateral stenosis of the BCV. BCV angioplasty immediately resolved the cerebral reflux. Patients with hemodialysis fistulas are at a higher risk of developing these intracerebral hemorrhage complications.
To determine whether the ABC/2 method could accurately and reliably measure infarct volume and guide thrombectomy decision in acute stroke cases presenting with late or unknown onset.
Four physicians ...who routinely use MRI for acute stroke imaging, blinded to the RAPID results, measured the diffusion-weighted imaging (DWI) infarct volume using the ABC/2 method. Measurements with ABC/2 (the index test) were compared with RAPID (the reference standard) to calculate sensitivity, specificity, and accuracy measures for various volume cutpoints. Thrombectomy decisions based on RAPID and raters' measurements using the criteria from the Diffusion-Weighted Imaging or Computerized Tomography Perfusion Assessment With Clinical Mismatch in the Triage of Wake-Up and Late-Presenting Strokes Undergoing Neurointervention With Trevo (DAWN) trial criteria were compared. Interrater and intrarater agreement was measured using kappa statistics.
Accuracy with the ABC/2 method was greater than 80% for each rater and each volume cut point. Interrater and intrarater agreement was substantial to excellent for each volume cut point. Treatment decisions with ABC/2 volume estimations showed strong interrater and intrarater agreement, and led to similar thrombectomy decisions compared with RAPID in more than 85% of cases.
DWI infarct volume measurement using ABC/2 method shows strong accuracy and reliability and may be an acceptable alternative to RAPID software for the application of DAWN criteria for thrombectomy decision-making.
Purpose
The persistence of the stapedial artery is a rare vascular variant that could explain the origin of the middle meningeal artery from the petrous segment of the internal carotid artery.
The ...anatomic variations are illustrated and a summary of the possible hypothesis of the origin of the middle meningeal artery from the internal carotid artery is discussed, analysing the embryological works of the Carnegie Institute and the vascular development of the middle meningeal.
Methods and results
The authors present a young patient showing a particular vascular variant on diagnostic imaging. These showed a bilateral internal carotid artery that gives origin of the middle meningeal artery in a patient affected by moyamoya disease.
A literature review was performed to analyze the particular variant of the radiologic anatomy.
Conclusion
The internal carotid artery origin of the middle meningeal artery is a wonderful anatomic variant that permits to understand the complex embryological development and then involution of the stapedial artery.
To report the occurrence of non-ischemic cerebral enhancing (NICE) lesions following mechanical thrombectomy (MT) through the retrospective French nationwide registry of NICE lesions. All ...thrombectomy capable stroke centers (TSC) in France were invited to fill out a questionnaire disseminated through a trainee-led research network (JENI-RC:
Jeunes en Neuroradiologie Interventionnelle-Research Collaborative
). NICE lesions were defined according to previous literature as delayed onset punctate, nodular, or annular foci enhancements with peri-lesion edema and vascular distribution in the territory of the MT with no other confounding disease. All 43 TSC French centers responded. Three patients were reported by 3 different centers over a total of 34,824 MT (2015–2020). Patient no. 1 developed symptomatic NICE lesions 8 weeks after MT with combination of aspiration and stentriever for a right middle cerebral artery occlusion. Patient no. 2 developed asymptomatic NICE lesions 5 weeks after MT with direct thromboaspiration for a right middle cerebral artery occlusion. Patient no. 3 developed symptomatic NICE lesions 6 weeks after MT with direct thromboaspiration, and combination of aspiration and stentriever for a basilar artery occlusion. This study provides evidence that NICE lesions following MT are a possible rare complication with a similar presentation as previously described following endovascular aneurysm treatment. Both radiologists and neurologists should be aware of this adverse event and make use of MRI contrast agents in case of unexplained symptoms/images during follow-up after MT.
Background and purpose
Acute ischaemic stroke patients with cerebral small vessel disease (CSVD), including cerebral microbleeds (CMBs) and white matter hyperintensities (WMHs), have worse outcomes. ...The effect was investigated of two blood pressure strategies (intensive vs. standard) and blood pressure variability (BPV) after reperfusion according to CSVD burden in the BP TARGET trial.
Methods
Patients with available magnetic resonance imaging at baseline were included. CMBs were described as absent or present and WMH severity was described according to the Fazekas classification (0–1, absent–mild; 2–3, moderate to severe). Outcomes consisted of any intracerebral hemorrhage (ICH) at 24 h and favorable outcome at 90 days (modified Rankin Scale score between 0 and 2).
Results
In all, 246 patients were included. The intensive systolic blood pressure target was not associated with lower rates of ICH or favorable outcome according to CSVD subgroups (all p values >0.35). Several BPV parameters were associated with increased odds of ICH in patients with CMBs but not in patients without CMBs (diastolic blood pressure coefficient of variation, odds ratio 2.06, 95% confidence interval CI 1.13–3.77, in patients with ≥1 CMB vs. 0.94, 95% CI 0.68–1.31, in patients without CMBs, phet = 0.026). Several diastolic BPV parameters were associated with worse outcomes in patients with severe WMHs but not in patients without WMHs (diastolic blood pressure coefficient of variation, odds ratio 0.32, 95% CI 0.17–0.61, in patients with severe WMHs vs. 1.09, 95% CI 0.67–1.79, in patients without WMHs; phet = 0.003).
Conclusion
No effect of the intensive systolic blood pressure management strategy was found on ICH occurrence or functional outcome according to CSVD burden. BPV was associated with higher odds of ICH in patients with CMBs and worse outcome in patients with moderate‐to‐severe WMHs.
Abstract
Paediatric intracranial dural arteriovenous shunts have clinical presentations and evolutions, with angiographic characteristics that differ from those described in adults. We report our ...experience concerning their therapeutic management, emphasizing the relevance of early diagnosis and appropriate treatment for satisfactory neurocognitive development. Using a prospective database, we reviewed the clinical and radiological data of all children with dural arteriovenous shunts managed between 2002 and 2020. Dural shunts were categorized into three types: dural sinus malformations with arteriovenous shunts; infantile dural arteriovenous shunts; and adult-type dural arteriovenous shunts. Therapeutic strategies and outcomes were analysed depending on lesional subtypes. Modified Rankin Scale for the paediatric population was assessed pre-treatment and at last follow-up. Twenty-eight patients 16 girls (57.1%); 12 boys (42.9%) were included: 17 dural sinus malformation 10 boys (58.8%); seven girls (41.2%), three infantile shunts three girls (100%), eight adult-type shunts four girls (50%); four boys (50%), with a mean age of 19.2 ± 36.6 months at presentation. Twelve (42.9%) had a modified Rankin Scale score of 0–2, four (14.3%) had a score of 3, three (10.7%) had a score of 4 and eight (28.6%) had a score of 5. Embolization was performed in 22 children 78.6%; 12 girls (54.5%); 10 boys (45.5%). Fifteen patients could be cured (68.2%): 11 dural sinus malformations (73.3%), four adult-type lesions (100%) but no infantile shunt. Mean post-treatment follow-up was 39.5 months (max. 139 months): 14 patients (63.6%) presented a modified Rankin Scale score of 0–2 and eight (36.4%) had a score ≥3. In the dural sinus malformation group, the modified Rankin Scale score was improved in 11 patients (73.3%) and unchanged in three (20%). Only one patient with infantile subtype (33.3%) improved clinically. In the adult-subtype group, all children (100%) improved. Of six untreated patients four girls (66.7%); two boys (33.3%), four with adult-subtype shunts showed uneventful evolutions, one with dural sinus malformation died, and therapeutic abortion was conducted in an antenatally diagnosed dural sinus malformation. Paediatric dural fistulas comprise different subtypes with variable clinical courses. Proper diagnosis is mandatory for optimal therapeutic strategies within appropriate therapeutic windows.
Smajda et al. report their experience in paediatric intracranial dural arteriovenous shunts, emphasizing the relevance of early diagnosis and appropriate treatment for satisfactory neurocognitive development. Three different subtypes have to be recognized as they request different therapeutic management.
Graphical Abstract
Graphical Abstract
Background and Purpose:
Optimal blood pressure (BP) targets after endovascular therapy (EVT) for acute ischemic stroke (AIS) still need to be assessed, especially according to the recanalization ...status. Facing the lack of randomized controlled trials addressing this question, we performed a systematic review of studies assessing the post-EVT BP impact on functional outcome and symptomatic intracranial hemorrhage (sICH).
Methods:
Studies published after January 1, 2012 were included in the systematic review. The PRISMA checklist and flow diagram were followed for the design and reporting of this work.
Results:
Five studies were included in the present analysis. Despite a significant heterogeneity among studies which precluded a meta-analysis, systolic BP (SBP) was the most frequently used parameter to describe BP. BP variability (standard deviation, successive variability) after EVT was associated with worse functional outcome, especially in studies without specific BP targets after successful EVT. Lower BP values after successful EVT were associated with lower odds of sICH. Four studies evaluated the post-EVT BP impact on recanalized patients solely, with only one specifically addressing the impact of a TICI 2B vs. 2C. Interestingly, SBP reduction was inversely associated with worse outcomes in TICI 3 patients but not in TICI 2B patients, pointing to the potential value of BP management according to the exact TICI.
Conclusions:
BP post-EVT seems to be associated with worse functional outcomes and sICH. However, given the important heterogeneity depicted among the included studies, no decisive conclusion can be made from this systematic review, thus underlying the urgent need of randomized controlled trials evaluating this question.
Purpose
When dealing with paraclinoid carotid aneurysms, the distinction between intradural and extradural location is a major component for decision-making as only intradural aneurysms carry a risk ...of subarachnoid hemorrhage (SAH). The aim of this study was to test the accuracy and reliability of computed tomography (CT) bony landmarks for the distinction between intradural and extradural paraclinoid aneurysms.
Methods
All patients referred to this institution for a single paraclinoid aneurysm were retrospectively identified. The study included only the patients who presented with diffuse SAH, thus proving the intradural location of the aneurysm. The preoperative images were assessed by two physicians in order to locate the aneurysms using the tuberculum sellae (TS) and the optic strut (OS) landmarks.
Results
A total of 15 patients were included in the study. There were 4 cases (27%) of disagreement with the OS bony landmark and no cases of disagreement with the TS landmark. No aneurysm was consensually considered as extradural by both readers with both bony landmarks; however, five aneurysms (33%) were considered to be extradural by at least one of the physicians with at least one of the two bony landmarks.
Conclusion
The results of the study showed several disagreements when using the OS landmark. More importantly, several aneurysms were considered as extradural with at least one of these two CT bony landmarks, even though they were all associated with an SAH. More reliable and accurate landmarks are warranted.
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