Extracranial Occlusion Research Articles

Evaluating the Management and Outcomes of Acute Extracranial Occlusions of Internal Carotid Arteries with Patent Intracranial Vasculature

Evaluating the Management and Outcomes of Acute Extracranial Occlusions of Internal Carotid Arteries with Patent Intracranial Vasculature

Exploring vertebral artery stump syndrome: An overlooked cause of posterior ischemic strokes. A narrative review of current management options

IntroductionStump syndrome is defined as a clinical syndrome resulting from a distal intracranial vessel embolic stroke due to an extracranial vessel occlusion. Similar to the anterior circulation, the recurrence of ischemic strokes in territories supplied by the posterior circulation in the presence of vertebral artery occlusion is termed Vertebral Artery Stump Syndrome (VASS). Material and MethodsWe conducted a literature review, identifying 72 patients with transient ischemic attacks (TIAs) or ischemic strokes attributed to VASS, according to Kawano criteria. We categorized all patients in two groups focusing on the therapeutic management those who underwent primary medical treatment and those who received endovascular or surgical treatment either in acute or chronic phase. ResultsIn the anticoagulant therapy group, only 1 patient had a stroke recurrence. Among the 4 on antiplatelets, all had recurrences, but 3 benefited from switching to anticoagulants or endovascular therapy. In the endovascular therapy group, worse outcomes were linked to acute large vessel occlusion. Endovascular treatment of the vertebral artery, in a chronic phase, was explored in literature for recurrent TIAs or minor strokes suggesting that this could be a viable therapeutic alternative when medical treatment failed in preventing recurrence of ischemic stroke. ConclusionsSome studies suggest that anticoagulant medical therapy may be beneficial for VASS and endovascular therapy has also been reported for selected patients. However, data on treatment outcomes and prognosis are still underreported, making treatment decisions challenging. Randomized Controlled Trials are needed to establish the optimal treatment approach.

Effect of Endovascular Thrombectomy for Acute Ischemic Stroke on Cognitive Outcomes: A Secondary Analysis of the ESCAPE Trial.

The effect of endovascular therapy (EVT) for large vessel occlusion stroke on cognitive outcomes is not well understood. We evaluated the effect of EVT on cognitive function in the Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times (ESCAPE) trial. Patient data from the ESCAPE randomized trial were analyzed. Cognitive assessments completed at 90 days after stroke were the Montreal Cognitive Assessment (MoCA), the Sunnybrook Neglect Assessment Procedure (SNAP), the Boston Naming Test (BNT), Trail-making test A (Trails A), and Trail-making test B (Trails B). We used logistic regression to evaluate the association between EVT and favorable cognitive outcome on the 5 separate tests, adjusting for demographic and clinical factors. We used generalized estimating equations and ordinal regression to determine the odds of favorable outcome with EVT on global cognition incorporating the 5 tests. We added final infarct volume (FIV) to the models to assess the relationship of FIV with cognitive outcome. The ESCAPE trial included 315 patients, 165 randomized to EVT and 150 randomized to control. There was higher odds of favorable outcome with EVT for MoCA (adjusted odds ratio [aOR] 2.32, 95% CI 1.30-4.16), SNAP (aOR 3.85, 95% CI 2.00-7.45), BNT (aOR 2.33, 95% CI 1.30-4.17), trails A (aOR 3.50, 95% CI 1.93-6.36), and trails B (aOR 2.56, 95% CI 1.46-4.48). There was higher odds of favorable outcome with EVT on global binary (aOR 2.57, 95% CI 1.67-3.94) and ordinal analyses (aOR 2.83, 95% CI 1.68-4.76) of cognitive function. After adding FIV to the models, both FIV and EVT were significantly associated with cognitive outcome. There was a significant correlation between global cognitive performance and mRS at day 90 (r = -0.78, p < 0.001), with the largest reductions in favorable cognitive outcome from mRS score 4 to 5 and from mRS 2 to 3. In this secondary analysis of the ESCAPE trial, EVT was associated with favorable outcome on 5 separate cognitive tests and in global analyses of cognitive benefit. These results provide novel evidence for the effect of EVT on cognition and support the global benefit of treatment with EVT. This study provides Class II evidence that in patients with acute ischemic stroke due to intracranial internal carotid artery (ICA) or M1 segment MCA occlusion, including tandem extracranial ICA occlusions, EVT compared with best medical therapy increased odds of favorable cognitive outcome.

Abstract 53: Patients With Tandem Lesions Undergoing Thrombectomy Have Increased In-Hospital Stroke Recurrence Risk

Introduction: Mechanical Thrombectomy improves outcomes in patients with acute ischemic stroke due to large vessel occlusion. Nearly 15% of patients have a tandem extracranial and intracranial occlusion. There is limited data on in-hospital outcomes in patients with acute tandem lesions undergoing thrombectomy. Methods: We included patients hospitalized with acute ischemic stroke and large vessel occlusion undergoing thrombectomy at our comprehensive stroke center over a 7-year period. Data on demographics and baseline risk factors, occlusion site, and acute treatment was pulled from the stroke registry. Records were reviewed for the study outcome which was recurrent ischemic stroke during the in-hospital period, defined as new or worsening neurological symptoms due to new infarct or extension of the infarct. All outcomes were confirmed by a second neurologist. Patients were followed for 90-days and received a 90-day call to determine their modified rankin scale. We defined good functional outcome as 90-day mRS 0-2. We used fisher’s exact test and t-tests to compare categorical and continuous variables and built binary logistic regression model to compare 90-day mRS across the two groups (tandem vs. non-tandem lesions), adjusting for age and NIHSS scale. Results: We identified a total of 1347 patients (mean age 72 years, 51% women) who underwent thrombectomy and 226 (16.7%) had tandem lesions and 108/226 (47.8%) underwent acute stenting. Patients with tandem lesions were more likely to be men (60.6% vs. 46.6%,), have hyperlipidemia (60.9% vs. 52.1%), coronary artery disease (25.3% vs. 19.0%), smokers (35.9% vs. 20.5%) and less likely to have atrial fibrillation (20.0% vs. 46.2%) and history of congestive heart failure (8.0% vs. 16.8%), all p&lt;0.05. Patients tandem occlusions were more likely to have in-hospital recurrent ischemic stroke (8.0% vs. 4.1%, p = 0.012). Acute stenting was not associated with improved functional outcome at 90-days (aOR 0.86, 95% CI 0.41-1.82, p = 0.703). Conclusion: In this large cohort of thrombectomy patients, patients with tandem lesions had increased in-hospital recurrent stroke and acute stenting in this sub-group was not associated with improved functional outcome at 90-days.

Repeated ischemic strokes due to infectious arteritis of both internal carotid and basilar arteries as a complication of sphenoiditis and otitis

The article presents a case of a 54-year-old female patient who, over the course of 2 years, suffered 5 cerebrovascular accidents (CVA) due to infectious arteritis of both internal carotid arteries (ICA) and basilar artery as a complication of sphenoiditis and otitis. According to neuroimaging data, the steno-occlusive process in the ICA developed gradually, starting with the intracranial ICA narrowing with the contrast enhancement by vessel wall, the development of its occlusion six months later, and the detection of the extracranial ICA occlusion with the formation of «flame sign» at its mouth a year later. Repeated examination of the cerebrospinal liquid at an early stage of the disease revealed cytosis up to 367/3 and protein 0.66 g/l. The correct diagnosis was established only after 3 years with a retrospective analysis of clinical, neuroimaging, and laboratory data. Therefore, targeted antibiotic therapy was not carried out, which led to the progression of ICA occlusion and repeated strokes. Infectious arteritis should be taken into account in the differential diagnosis of the causes of the ICA occlusive process.

Assessment of Collateral Pathways in Carotid Occlusion: Investigating the Clinical Significance of Ultrasound and TCCS

Background: Carotid occlusion is a severe condition closely associated with ischemic stroke. The prompt identification of patients presenting with extracranial carotid artery occlusion and the evaluation of collateral circulation compensation in these individuals bear significant clinical importance for subsequent patient management. Ultrasound offers significant advantages in the diagnosis of extracranial carotid artery stenosis and occlusion, while Transcranial Color-Coded Sonography (TCCS) is increasingly pivotal in assessing intracranial artery stenosis and determining blood flow direction. The objective of our study was to assess the concordance between ultrasound combined with TCCS and digital subtraction angiography (DSA) in evaluating extracranial carotid occlusion and intracranial collateral circulation.&#x0D; Methods: Patients with severe stenosis in the extracranial carotid artery were recruited for our study. All patients suspected of having occlusion in the extracranial carotid arteries underwent ultrasound, transcranial color-coded sonography (TCCS), and digital subtraction angiography (DSA). Sensitivity, specificity, positive predictive value, negative predictive value, overall accuracy, and kappa value were employed to assess the effectiveness and consistency of ultrasound and TCCS compared to DSA.&#x0D; Results: Ultrasound demonstrated a sensitivity of 85.4%, specificity of 100%, positive predictive value of 100%, negative predictive value of 90.4%, and overall accuracy of 93.9% in the diagnosis of extracranial artery occlusion. The kappa value was calculated as 0.87 (P＜0.001), indicating substantial agreement between ultrasound and DSA measurements for consistency assessment. Transcranial color-coded sonography (TCCS) exhibited a sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of 97.6%, 100%, 100%, 66.7%, and 97.7% respectively in evaluating collateral circulation in patients with carotid artery occlusion. The kappa value was 0.79 (P＜0.001) in assessing the collateral circulation in patients with occluded carotid arteries.&#x0D; Conclusions: Ultrasound proved to be a valuable tool for evaluating patients with occluded carotid arteries, while TCCS emerged as a reliable approach for assessing collateral pathways in individuals with extracranial carotid artery occlusion.

Single vs. Multiphase Computed Tomography angiography in acute internal carotid artery occlusion: An accuracy and interobserver agreement study

ObjectiveAccurate differentiation between the intracranial and extracranial location of the acute internal carotid artery (ICA) occlusion is essential for guiding treatment decisions and mechanical thrombectomy planning. Multiphase Computed Tomography angiography (mCTA) appears to be superior to Single-phase Computed Tomography angiography (sCTA) in the evaluation of acute ICA occlusions. The main objective of our research is to study the accuracy of mCTA compared to sCTA in distinguishing isolated acute intracranial ICA occlusion from extracranial or tandem occlusion. MethodsTwo observers independently analyzed sCTA and mCTA of patients with acute ICA occlusion at two different time points. The location of the occlusion was categorized as intracranial or extracranial for both imaging techniques and then compared with digital subtraction angiography (gold standard). Sensitivity and specificity rates for isolated intracranial ICA occlusion on sCTA and mCTA were calculated. Kappa statistics were used to assess interobserver agreement. ResultsThe sensitivity of sCTA and mCTA was 48.28% (28.36%–68.19%) and 79.31% (62.84%–95.78%) respectively for the diagnosis of isolated intracranial ICA occlusion, with an almost perfect interobserver agreement between both observers (p < 0.001). ConclusionsOur research suggests that mCTA is more accurate than sCTA in distinguishing isolated intracranial occlusions from extracranial or tandem occlusions.

Prediction of 90‐Day Home Time Among Patients With Medium‐Vessel Occlusion Undergoing Endovascular Thrombectomy

Background The benefit of endovascular thrombectomy for medium‐vessel occlusion (MeVO) strokes is unclear. We used 90‐day home time to explore outcomes in patients with MeVO versus large‐vessel occlusions treated with endovascular thrombectomy. Methods Data are from the QuICR (Quality Improvement and Clinical Research) provincial stroke registry and linked administrative data to identify patients who underwent endovascular thrombectomy in our center from January 2015 to December 2020. Imaging data were scored by 2‐physician consensus. We defined MeVO as occlusion beyond and including M2–middle cerebral artery, A2–anterior cerebral artery, or P2–posterior cerebral artery segments. Successful reperfusion was defined as Thrombolysis in Cerebral ischemia grades (≥2b/3). The primary outcome was patient home time (the number of nights a patient is back at their premorbid living situation without an increase in level of care within 90 days of the stroke) using random forest regression. Covariate contribution to home time was determined using partial dependence plots. Results Among 663 patients who underwent endovascular thrombectomy, 139 (20.9%) had MeVO (median age, 71 years; 50.4% women; median National Institutes of Health Stroke Scale, 16). The majority (82%) had good pial collaterals, 10.4% had a tandem extracranial carotid occlusion or stenosis, and 41.7% received intravenous thrombolysis. The most common site of occlusion was M2–middle cerebral artery (58.3%). One hundred eighteen (86.7%) patients achieved successful reperfusion (Thrombolysis in Cerebral Ischemia grades ≥2b/3). Using partial dependence plots, the mean predicted home times were similar in patients with MeVO (45.5 days) versus large‐vessel occlusions (44.6 days). Factors predicting lower 90‐day home time in patients with MeVOs were diabetes (−8.7 days), hypertension (−6.5 days), and atrial fibrillation (−3.5 days). There was no meaningful difference in predicted 90‐day home‐time by sex, baseline National Institutes of Health Stroke Scale, collateral grade, or thrombolysis. Conclusion Patients with MeVO who are selected for endovascular therapy with similar demographic and clinical profiles to large‐vessel occlusions can achieve similar 90‐day home time outcomes to large‐vessel occlusions.

Effect of Antiplatelet Therapy in Acute Ischemic Stroke with Tandem Lesions (P7-5.001)

Effect of Antiplatelet Therapy in Acute Ischemic Stroke with Tandem Lesions (P7-5.001)

Abstract Number ‐ 157: Effect of Antiplatelet Therapy in Acute Ischemic Stroke with Tandem Lesions

Introduction Recent studies have shown beneficial effects of Carotid artery stenting (CAS) in acute ischemic stroke patients with tandem lesions (TL). However, stent placement requires the use of antiplatelet medications to prevent in‐stent thrombosis and re‐occlusion of the artery. This must be balanced with the risk of intracerebral hemorrhage. In this multicenter study, we aimed to investigate the safety and feasibility of using antiplatelet regimens in patients with anterior circulation stroke with TLs. Methods Patient level data were pooled from 17 centers and included patients with intracranial occlusion of ICA or M1/M2 segment of MCA with a concomitant extracranial ICA occlusion or stenosis ≥ 50%. Inclusion criteria were; age ≥ 18 years, EVT for intracranial occlusion, and underwent treatment for extracranial ICA lesions demonstrated on CTA and/or DSA. Patients were divided into groups according to the number of antiplatelets administered at the time of endovascular therapy (EVT) procedure into four groups including; 1) no antiplatelets, 2) single oral antiplatelet, 3) dual antiplatelets, and 4) intravenous antiplatelets (in combination of single or dual antiplatelets). Multivariable logistic regression models with multiple imputations were built to assess the association of primary outcome; symptomatic intracranial hemorrhage (sICH), and secondary outcomes including; modified Rankin Score (mRS) 0–2 at 90 days, and successful reperfusion (mTICI score ≥ 2b). Results A total of 682 patients were included. Of these, 138 (20.2%) did not receive any antiplatelet therapy, while 143 (20.97%) were treated with single oral, 207 (30.35%) with dual oral, and 194 (28.5%) with intravenous combined with single or dual antiplatelets. The rate of favorable outcome was non‐significantly higher in the dual (53%) and IV‐combination (54.4%) antiplatelets, as compared with single (38.9%) and without antiplatelet (38.6%) medications. In the multivariable model, after adjusting, there was no significant differences in the sICH (single: aOR: 1.07, CI: 0.62‐1.84, p = 0.8, dual: aOR: 1.18, CI: 0.70‐1.99, p = 0.55, IV‐combination: aOR: 1.01, CI: 0.57‐1.78, p = 0.98) and functional outcome at 90 days (single: aOR: 1.15, CI: 0.63‐2.12, p = 0.64, dual: aOR: 1.03, CI: 0.55‐1.9, p = 0.9, IV‐combination: aOR: 0.83, CI: 0.42‐1.64, p = 0.59) among the study groups. Interestingly, successful reperfusion (mTICI score ≥ 2b) was significantly higher in dual oral and IV‐combination antiplatelets (single: aOR: 1.14, CI: 0.61‐2.14, p = 0.69, dual: aOR: 4.82, CI: 2.23‐10.42, p = &lt; 0.001, IV‐combination: aOR: 3.65, CI: 1.71‐7.79, p = 0.001). Conclusions Administration of antiplatelet medications during EVT was associated with successful reperfusion without increasing the rate of symptomatic hemorrhage in patients with anterior circulation LVO with TLs. Further large‐scale randomized studies are warranted to validate the optimal antiplatelet regimens during acute carotid artery stenting in patients with TLs.

Abstract Number ‐ 248: Association Between Vertebrobasilar Stenosis, Location, and Quantitative Magnetic Resonance Angiography Flow State

Introduction The relationship between the degree of vertebrobasilar stenosis and QMRA distal‐flow status is uncertain. Our aim was to investigate this relationship. Methods We retrospectively reviewed patients who presented with acute ischemic stroke, had neurovascular imaging demonstrating ≥ 50% stenosis of extracranial or intracranial vertebral or basilar arteries, and QMRA within one year of stroke, between 2009 and 2021 at two institutions. The WASID and CAVATAS methods were used to measure the degree of intracranial and extracranial vertebrobasilar stenosis, respectively. Patients were grouped as: high‐grade (≥ 70% stenosis) in (1) one vertebral artery; (2) two vertebral arteries; or (3) basilar artery; and (4) moderate grade (≤70% stenosis) in either intracranial vertebral and basilar arteries or exclusive extracranial vertebral stenosis or occlusion. QMRA distal‐flow status was used to dichotomize patients into low‐flow and normal‐flow states based on VERiTAS criteria. P‐values were calculated using chi‐squared analysis and Fisher exact test with statistical significance defined as p &lt; 0.05. Results Of the 303 patients undergoing QMRA for vertebrobasilar disease, 69 met study inclusion, consisting of 31 patients with low‐flow and 38 patients with normal‐flow states. High‐grade stenosis was most commonly found in one vertebral artery (34.8%), followed by both vertebral arteries (29.0%), and the basilar artery (27.5%), and moderate stenosis or exclusive extracranial disease made up 21.7% of patients. High‐grade stenosis in at least one vertebral or basilar artery was significantly associated with low‐flow states compared to patients with moderate‐grade stenosis or exclusive extracranial disease (53.7% versus 13.3%, p = 0.007). High‐grade stenosis in both vertebral arteries was significantly more likely to result in a low‐flow state compared to high‐grade stenosis in one vertebral artery (75.0% versus 41.7%, p = 0.001) or to high‐grade stenosis in the basilar artery (75.0% versus 42.1%, p = 0.040). Conclusions Low distal flow status on QMRA is strongly associated with high‐grade intracranial stenosis compared to moderate‐grade or exclusive extracranial stenosis and is nearly twice as frequent with high‐grade intracranial stenosis of both vertebral arteries compared to one. The location, degree of stenosis, and distal‐flow status should be considered as possible entry points for future prospective treatment trials in intracranial atherosclerotic disease.

Early Stent Patency After Endovascular Therapy for Tandem or Isolated Carotid Steno-Occlusive Disease

Early Stent Patency After Endovascular Therapy for Tandem or Isolated Carotid Steno-Occlusive Disease

SPAN2 SCALE: A NEW PREDICTIVE SCALE OF DISABILITY IN MINOR STROKE WITHOUT LARGE-VESSEL OCCLUSION

Background: Currently there is no predictive model in acute minor stroke without large vessel occlusion. Aims: Our objective was to evaluate the independent predictors that correlate with unfavourable outcome and to develop a predictive scale in acute setting. Methods: Retrospective analysis of consecutive acute minor stroke (NIHSS &lt;5) admitted within 4.5 hours to clinical onset who were previously not disabled and without large vessel occlusion on CT angiography (intracranial or extracranial occlusion or stenosis ≥50%). Unfavourable outcome was defined as modified Rankin Scale 3-6 at 90 days. Independent predictors of disability were included in the model. Results: A total of 408 patients with acute minor stroke (NIHSS &lt;5) were analyzed. Large vessel occlusion was detected in 83 (20%), who were excluded. The final analysis included 325 patients, with mean age of 68± 14 years, 59% were men and 14.5% had unfavourable outcome. On multivariate analysis, age &gt;70 years, NIHSS &gt;2, recurrent event, posterior circulation ischemia and previous stroke were associated with unfavourable outcome. Recurrent event was excluded to the model because this variable is not available in acute setting. With the variables detected in the logistic regression, a predictive model was made (SPAN2 scale: previous Stroke, Posterior ischemia, Age &gt;70 or NIHSS &gt;2). The model correctly classified 84% of the patients with unfavourable outcome. A score &gt;2 points on the SPAN2 scale showed a sensitivity 95%, specificity 51%, PPV 25% and NPV 99% of unfavourable outcome at 90 days. Conclusions: SPAN2 scale could be useful to stratify the risk of unfavourable outcome in acute phase of minor stroke without large vessel occlusion. Future studies may validate its usefulness in the selection of patients for thrombolytic therapy.

Emergent carotid endarterectomy and mechanical thrombectomy in tandem occlusion.

Acute tandem occlusions, or occlusions of the extracranial portion of the internal carotid artery (ICA) with concurrent thromboembolism of the intracranial ICA or middle cerebral artery, poses a major clinical challenge, with patients suffering worse outcomes compared to those with single occlusions. Management of these lesions generally includes a combination of mechanical thrombectomy (MT) of the intracranial occlusion and stenting of the extracranial carotid lesion. In this manuscript, we describe a successful surgical method for achieving revascularization of tandem occlusions in the rare circumstance that the proximal lesion cannot be crossed endovascularly to gain intracranial access. Despite using our institution's standard protocol for achieving revascularization of such lesions, the extracranial occlusion could not be crossed endovascularly, and the case was converted to an emergent carotid endarterectomy (CEA) in the operating room. Once the endarterectomy was complete, intraoperative MT was performed before cervical incision closure to revascularization. The patient recovered well postoperatively and was discharged with NIHSS of 2 due to minor facial palsy and minor dysarthria. Thirty-day follow-up revealed resolution of the prior neurologic deficits and an mRS of 1. Emergent CEA should be considered in the rare circumstance of being unable to cross the cervical occlusion during management of acute ischemic stroke with tandem occlusion.

Accuracy of contrast-enhanced ultrasound in diagnosing extracranial carotid occlusion: A meta-analysis.

This study aimed to assess the accuracy of contrast-enhanced ultrasound (CEUS) in detecting extracranial carotid artery occlusion. A systematic literature search was conducted in the Cochrane, PubMed, and EMBASE databases. Prospective or retrospective studies that reported sensitivity and specificity of CEUS for the diagnosis of carotid artery occlusion were selected. Eight studies (354 arteries) were included in the meta-analysis. A bivariate random-effect model was used to estimate overall sensitivity and specificity. The results were also summarized by developing a summary receiver operating characteristic (SROC) curve. The overall sensitivity, specificity, positive, and negative likelihood ratios were 0.99 (95% CI: 0.83-1.00), 0.97 (95% CI: 0.90-0.99), 30.0 (95% CI: 9.8-91.4), and 0.01 (95% CI: 0.00-0.21), respectively; the odds ratio for diagnosis was 4,796 (95% CI: 119-192,584). The diagnostic test accuracy suggests that CEUS is a reliable tool for diagnosis of extracranial carotid artery occlusion.

Abstract TP219: ACE2L: A Novel Scoring Tool With High Sensitivity And Specificity In Predicting Atrial Fibrillation In Cryptogenic Stroke

Introduction/Background: Stroke is a leading cause of serious, long-term disability and death worldwide. Atrial fibrillation (AF) is the most common form of sustained cardiac arrhythmia, and is associated with a high risk of ischemic stroke and thromboembolism. Many cryptogenic strokes may be due to underlying, undetected paroxysmal AF. We performed a retrospective evaluation of patients with a history of ischemic stroke who were subsequently diagnosed with AF in order to develop a novel risk score calculator to help guide management in patients with cryptogenic stroke. Methods: We evaluated patients with a history of ischemic stroke both with and without a subsequent diagnosis of AF. Patients with a pre-existing diagnosis of AF were excluded. 1 point was assigned for each of the following: (1) age &gt; 60; (2) cortical ischemic stroke; (3) embolic appearance on imaging; (4) p-wave terminal force &gt; 5000 μVms; (5) increased left atrial volume index; (6) lack of extracranial large vessel occlusion (LVO). Patients with ipsilateral extracranial LVO and patients with LVO &gt; 70% were excluded. Results: A total of 74 patients with a diagnosis of ischemic stroke were evaluated. Of these, 41 patients had a subsequent diagnosis of AF, and 33 patients did not. A score of 4 or higher correlated with a sensitivity of 86.8% (95% CI: 72.7%, 94.2%), specificity of 100% (95% CI 89.8%, 100%), PPV 100% (95% CI 89.6%, 100%), NPV 87.2% (95% CI 73.3%, 94.4%), negative likelihood ratio 0.13 (95% CI 5.8%, 29.8%), and accuracy 93.1% (95% CI 84.8%, 897%). Conclusions: The novel ACE2L scoring tool demonstrated high sensitivity and specificity in predicting atrial fibrillation in patients with ischemic stroke. This scoring tool utilizes factors readily accessible in the evaluation of acute stroke and is a simple tool that may be used to help guide further management. Future, prospective studies are needed to further validate this scoring tool.

Diagnosis and treatment of acute isolated proximal internal carotid artery occlusions: a narrative review.

The clinical manifestations of proximal (extracranial) internal carotid artery occlusions (pICAOs) may range from asymptomatic to acute, large, and devastating ischemic strokes. The etiology and pathophysiology of the occlusion, intracranial collateral status and patient's premorbid status are among the factors determining the clinical presentation and outcome of pICAOs. Rapid and accurate diagnosis is crucial and may be assisted by the combination of carotid and transcranial duplex sonography, or a computed tomography/magnetic resonance angiography (CTA/MRA). It should be noted that with either imaging modalities, the discrimination of a pseudo-occlusion of the extracranial internal carotid artery (ICA) from a true pICAO may not be straightforward. In the absence of randomized data, the management of acute, symptomatic pICAOs remains individualized and relies largely on expert opinion. Administration of intravenous thrombolysis is reasonable and probably beneficial in the settings of acute ischemic stroke with early presentation. Unfortunately, rates of recanalization are rather low and acute interventional reperfusion therapies emerge as a potentially powerful therapeutic option for patients with persistent and severe symptoms. However, none of the pivotal clinical trials on mechanical thrombectomy for acute ischemic stroke randomized patients with isolated extracranial large vessel occlusions. On the contrary, several lines of evidence from non-randomized studies have shown that acute carotid endarterectomy, or endovascular thrombectomy/stenting of the ICA are feasible and safe, and pοtentially beneficial. The heterogeneity in the pathophysiology and clinical presentation of acute pICAOs renders patient selection for an acute interventional treatment a complicated decision-making process. The present narrative review will outline the pathophysiology, clinical presentation, diagnostic challenges, and possible treatment options for pICAOs.

Cerebrovascular Involvement in Mucormycosis in COVID-19 Pandemic

BackgroundMany countries have seen an unprecedented rise of cases of coronavirus disease 2019 (COVID-19) associated mucormycosis (CAM). Cerebrovascular involvement in CAM has not been studied so far. We describe clinico-radiological manifestations of cerebrovascular complications observed in CAM. MethodsIn this multicentric retrospective observational study from India, patients with CAM who developed cerebrovascular involvement were studied. Their demographics, risk factors, clinical manifestations, imaging, laboratory profile and outcomes were noted. ResultsOut of 49 subjects with cerebrovascular involvement, 71.4% were males while average age was 52.9 years. Ischemic stroke was commonest (91.8%) followed by intracranial haemorrhage (6.1%) and subarachnoid haemorrhage (2%). The incidence of cerebrovascular complications in CAM was found to be 11.8% in one center. Cerebrovascular symptoms appeared a median of 8.3 days from the onset of mucormycosis. Commonest presentation of mucormycosis was rhino-orbito-cerebral syndrome in 98%. Diabetes mellitus was present in 81.7%. Forty percent developed stroke despite being on antiplatelet agent and/or heparin. Amongst subjects with ischemic strokes, location of stroke was unilateral anterior circulation (62.2%); bilateral anterior circulation (17.8%); posterior circulation (11.1%) and combined anterior and posterior circulation (8.9%). Vascular imaging revealed intracranial occlusion in 62.1%; extracranial occlusion in 3.4% and normal vessels in 34.5%. Mortality was 51% during hospital stay. ConclusionsCerebrovascular involvement was seen in 11.8% patients of CAM. Angio-invasive nature of the fungus, prothrombotic state created by COVID-19, and diabetes were important causative factors. Subjects with CAM should be screened for involvement of the brain as well as its vessel. Antiplatelet agents/heparin did not seem to provide complete protection from this type of stroke.

Ischemic stroke on hormonal contraceptives: Characteristics, mechanisms and outcome.

Systemic contraceptives increase the risk of ischemic stroke but little is known about the characteristics, mechanisms and long-term outcome post stroke of patients on hormonal contraception. We sought to To assess characteristics and outcome of acute ischemic stroke (AIS) in young women using systemic hormonal contraceptives (SHC) and compare them to strokes in non-contraceptive users. Using the Acute STroke Registry and Analysis of Lausanne (ASTRAL), we analyzed demographics, risk factors, clinical, radiological and treatment data of consecutive female patients of <50 years between 2003 to 2015. We compared groups with and without SHC in a logistic regression analysis. Of the 179 female patients of <50 years during the observation period, 57 (39.6%) used SHC, 71.9% of whom, a combined oral contraceptive pill. On logistic regression contraceptive users were significantly younger but had comparable stroke severity. They had less migraine with aura and tobacco use, and more hyperlipidaemia. Also, contraceptive users had significantly less intra and extracranial stenosis and occlusion on arterial imaging, but more focal hypoperfusion on CT-perfusion. Undetermined mechanism of stroke was more frequent with SHC users, whereas rare mechanisms were more frequent in non-users. The contraceptive user group had a more favourable adjusted 12-month outcome with significantly fewer ischemic recurrences after stopping systemic contraception in all. Contraceptive users with ischemic strokes are younger and have lesser tobacco use and migraine with aura and more hyperlipidemia. Their stroke mechanism is more often undetermined using a standardised work-up, and their adjusted long-term outcome is more favourable with less stroke recurrence.

The perioperative complications and short-term death in endovascular treatment for acute stroke induced by extracranial carotid occlusion: a systematic review and a meta-analysis.

Endovascular treatment (EVT) has been demonstrated superior to pharmacological thrombolysis in acute ischemic stroke (AIS) induced by extracranial internal carotid artery occlusion. This paper aims to summarize clinical evidence about EVT and assess its efficacy and safety on acute extracranial carotid occlusion. We systematically reviewed all studies that reported endovascular therapy as carotid stenting, stent retriever, aspiration, and angioplasty for acute extracranial carotid occlusion. Literature retrieval was performed in PubMed, Embase, and Cochrane library, dated from January 1st, 2005 to December 31st, 2020. The primary endpoint was a favorable outcome rate. Major secondary endpoints were SICH incidence, 90-day mortality rate, and complications. Meta-analysis and subgroup analysis were conducted to identify predictors for prognosis. This systematic review has been registered in PROSPERO (CRD42020181154) on July 18, 2020. 10 studies with 620 patients were included in total. Endovascular approach presented a favorable outcome rate of 0.47 (0.37, 0.56), an acceptable 90-day mortality rate of 0.16 (0.13, 0.19), and a mild SICH rate of 0.07 (0.05, 0.10). Age and NIHSS at admission were negatively associated with favorable outcome, with odds ratio of 0.95 (0.92, 0.98) and 0.74 (0.62, 0.88) respectively. Lower age (p=0.049) and aspiration thrombectomy (p=0.041) predicted less SICH events. In subgroup in which time window > 6 hours, endovascular therapy presented similar encouraging results, with favorable outcome rate of 0.59 (0.51, 0.66), 90-day mortality rate of 0.11 (0.07, 0.17), and SICH rate of 0.04 (0.02, 0.09). EVT can effectively improve neurological function and reduce 90-day mortality for acute extracranial carotid occlusion patients without increasing the risk of symptomatic intracranial hemorrhage. Endovascular therapy is safe to perform from 6 to 24 hours after symptom onset.