Purpose Extracranial-intracranial (EC-IC) bypass surgery remains controversial due to high complication rates reported in major trials. This study evaluates whether optimised perioperative protocols and surgical expertise can achieve substantially improved safety profiles in patients with symptomatic chronic internal carotid artery occlusion (CICAO) and chronic middle cerebral artery occlusion (CMCAO), addressing the critical gap between theoretical benefit and clinical reality. Materials and methods This retrospective single-centre study analysed 256 consecutive patients with symptomatic CICAO (n = 162) or CMCAO (n = 94) who underwent superficial temporal artery-middle cerebral artery bypass between October 2006 and February 2021. All procedures were performed by a single experienced surgeon using standardised protocols, including continuation of antiplatelet therapy throughout the perioperative period, maintaining baseline blood pressure levels, and strict postoperative blood pressure control below 140 mmHg. Patients underwent comprehensive evaluation with magnetic resonance imaging, digital subtraction angiography, and computed tomography perfusion. Primary outcomes included 30-day stroke or death and recurrent stroke during 24-month follow-up. Results The mean temporary intraoperative occlusion time was 23.5 minutes. Remarkably, the 30-day haemorrhagic stroke rate was 0.8% (2/256) with no ischaemic strokes, representing a dramatic improvement over historical controls. During 24-month follow-up, recurrent stroke occurred in 1.5% (4/256) of patients. Patients with CMCAO demonstrated superior outcomes compared to CICAO patients, with total stroke rates of 1.0% versus 3.1%, respectively. Conclusions Under expert surgical technique with optimised perioperative protocols, EC-IC bypass achieves exceptional safety profiles with complication rates substantially lower than previous major trials. The dramatic reduction from the historical 15% to 0.8% perioperative stroke rates demonstrates that surgical excellence and protocol optimisation can transform outcomes in cerebral revascularisation. These findings suggest that the poor results in previous trials may reflect technical and management factors rather than fundamental procedure limitations, warranting reconsideration of EC-IC bypass for carefully selected patients, particularly those with CMCAO.

Background: Giant cavernous internal carotid artery (ICA) aneurysms present with therapeutic challenges, especially if associated with a persistent primitive trigeminal artery (PPTA). Although flow diverters (FDs) are commonly used, the PPTA can maintain collateral inflow to the aneurysm sac, preventing complete thrombosis. Case Description: A 74-year-old woman presented with progressive oculomotor nerve palsy and visual decline. High-flow external carotid-middle cerebral artery bypass with distal ICA occlusion beyond the aneurysm was performed. The bypass remained patent without infarction, and partial aneurysm thrombosis occurred, whereas PPTA flow was preserved. Conclusion: This case emphasizes the importance of individual microsurgical strategies if FD treatment may be ineffective due to complex embryonic vascular anatomy.

Apollo microcatheter-assisted transvenous embolization for brain arteriovenous malformation with a tortuous stenotic drainage vein and “Caput Medusa” sign: a case report

Tandem lesions, where extracranial and intracranial vascular pathology coexists, have a poor prognosis and are a significant cause of acute ischemic stroke (AIS) with large vessel occlusion (LVO); they present unique challenges in diagnosis and endovascular treatment. This retrospective study analyzed demographic parameters, risk factors, qualification procedures, fibrinolytic therapy, interventional management, complications, technical aspects, and clinical outcomes in tandem-occlusion anterior circulation stroke (TOS) patients treated at a Thrombectomy Capable Stroke Center (TCSC) in Wejherowo from 2020 to 2024. Acute stroke patients with TOS were compared to two groups: patients with isolated intracranial artery occlusion (iLVO) and patients with isolated extracranial internal carotid artery (iICA) lesion. A total number of 193 patients who underwent endovascular therapy (EVT) were involved. The comparison between selected populations was performed to analyze frequency, risk factors, procedure complexity, complications, and clinical outcome. In the observed group the prevalence of tandem lesions was 17.1%, isolated extracranial internal carotid artery (ICA) occlusion was 11.4%, and isolated intracranial artery occlusion-71.5%. Tandem and ICA occlusion patients were younger (66.21 ± ± 9.8 vs. 70.34 ± 12.16; p < 0.01) and had a higher prevalence of smoking (45% vs. 26.1%; p < 0.05) compared to the intracranial LVO group. The latter had a higher rate of atrial fibrillation (21.2% vs. 60.9%; p < 0.001). Time intervals, including onset-to- -reperfusion (301.66 vs. 246.15 minutes; p < 0.01) and related to it: groin-to-first pass, groin-to-recanalization were significantly prolonged in the tandem group. Clinical outcomes, as measured by the National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS), were worse in the tandem group compared to both the intracranial LVO (mRS 0-2: 24.2% vs. 44.9%; p < 0,01; NIHSS: 9.96 vs. 7.01; p < 0.01) and isolated extracranial ICA occlusion groups (mRS 0-2: 24.2% vs. 59.1%; p < 001; NIHSS: 9.96 vs. 4.53; p < 0.01). There were no significant differences in complication rates between the groups. In the analyzed cohort of interventionally treated AIS patients, the presence of tandem lesions was correlated with poor clinical outcomes and associated with the presence of atherosclerosis risk factors. Endovascular procedures in these cases were more complex and involved extended time intervals. Conversely, patients with isolated intracranial lesions were generally older, with atrial fibrillation being the primary risk factor. In these patients, endovascular procedure times were shorter and resulted in more favorable clinical outcomes.

The optimal treatment strategy for isolated internal carotid artery occlusion (IICAO) presenting as acute ischemic stroke (AIS) remains uncertain because these patients were largely excluded from pivotal thrombectomy trials. We compared endovascular treatment (EVT) with best medical treatment (BMT) for IICAO, assessing functional independence, mortality, and safety, and explored outcomes by occlusion site (cervical vs intracranial). Following PRISMA guidelines (PROSPERO CRD420251004624), PubMed, Embase, and Cochrane Library were searched through September 2025. Eligible studies enrolled adults with IICAO treated with EVT or BMT and reported ≥1 predefined outcome: modified Rankin Scale (mRS) 0-2 at 90days, 90-day mortality, or symptomatic intracranial hemorrhage (sICH). Data were pooled using Mantel-Haenszel random-effects models, reporting odds ratios (ORs) with 95% confidence intervals (CIs). Risk of bias was assessed with ROBINS-I. Five studies including 1531 patients (878 EVT; 653 BMT) met inclusion criteria. EVT patients were younger and had more severe strokes. Pooled analysis showed no significant difference in 90-day functional independence between EVT and BMT (OR 1.78; 95% CI 0.99-3.21; I2 = 71%), and adjusted analyses attenuated the effect (OR 1.22; 95% CI 0.82-1.82). No significant differences were found for 90-day mortality (OR 0.84; 95% CI 0.64-1.09; I2 = 0%) or sICH (OR 1.48; 95% CI 0.72-3.07; I2 = 0%). Subgroup analyses by occlusion site yielded similar neutral results. Current evidence does not demonstrate superiority of EVT over BMT for IICAO, though a possible benefit for intracranial occlusions cannot be excluded. These findings remain hypothesis-generating and emphasize the need for dedicated randomized trials.

Introduction: Endovascular thrombectomy (EVT) for large vessel occlusion (LVO) stroke is supported by high-quality evidence, but patients with metastatic cancer have histocally been excluded from clinical trials. Thus, the safety and efficacy of EVT compared to best medical management (BMM) for LVO patients with metastatic cancer remains unclear. The objective of this retrospective cohort study is to assess outcomes of EVT for LVO stroke patients with concomitant metastatic cancer compared with BMM. Methods: The study population included adult patients with LVO stroke (internal carotid, middle cerebral, or basilar artery occlusion) and metastatic cancer from the 2016 to 2022 Nationwide Readmissions Database. Patients with brain tumors, lymphoma, leukemia, National Institutes of Health Stroke Scale (NIHSS) less than 6, or missing data were excluded. Propensity score matching was performed using 1-to-1 nearest-neighbor matching. The primary outcome was functional independence at hospital discharge. Secondary outcomes included discharge to home, hospital length of stay, in-hospital mortality, and 180-day mortality. Outcomes were also assessed in subgroups of patients who died during the initial hospitalization or within six months. Results: Of 5629 included patients, 3590 remained after propensity score matching (1833 EVT, 1757 BMM). Median age was 70 years for both groups; 52% were women. Compared to BMM, EVT was associated with higher rates of functional independence (17.8% vs 8.7%; P&lt;.001) and discharge to home (42.3% vs 34.1%; P=0.001), with no significant difference in in-hospital mortality (22.8% vs 24.3%; P=0.49), hospital length of stay (median 7 vs 6 days; P=0.34), or 180-day mortality (28.4% vs 28.5%; P=0.98). Among patients who suffered in-hospital mortality (n=845), there was no significant difference in length of stay (LOS) (median 5 vs 4 days, p=0.52). Among patients who survived the index hospitalization but later died within 180 days (N=134), EVT was associated with higher rates of interim functional independence (33.8% vs 12.3%, p=0.014). Conclusions: Among LVO stroke patients with metastatic cancer, EVT was associated with significantly higher rates of functional independence without change in mortality or LOS.

Background: Excessive hyperemia and failed microvascular reperfusion have been linked to poor outcomes after successful endovascular therapy (EVT) for large-vessel occlusion stroke. We tested whether post-EVT transcranial doppler (TCD) indices of focal hyperemia or increased microvascular resistance in the reperfused MCA territory were associated with outcomes. Methods: This was a single-center retrospective study of adults with MCA or intracranial ICA occlusion who underwent adequate TCD 24–72 h after successful EVT (eTICI ≥2b50) from 8/2023 to 3/2025. Bilateral MCA mean flow velocity (MFV), peak systolic velocity (PSV), end-diastolic velocity (EDV), and pulsatility index (PI) were measured; stroke ipsilateral/contralateral ratios (MFV-R, PSV-R, EDV-R, PI-R) were computed. Focal hyperemia (MFV-R or PSV-R &gt;1) and increased microvascular resistance (EDV-R&lt;1 or PI-R&gt;1) were tested for association with: early neurological improvement (ENI; DNIHSS≥4), early neurological deterioration (END; DNIHSS ≥4), hemorrhagic transformation (HT), and poor 90-day outcome (mRS 5–6). Multivariable logistic regression adjusted for age, sex, time from stroke onset to arrival, NIHSS, ASPECTS, IV thrombolysis, and eTICI. Results: A total of 165 patients were included (median age 73; 50% women; median NIHSS 17; 83% MCA occlusion; 23% IVT; 61% eTICI 2c–3). On unadjusted comparisons, ENI patients (n= 127, 77%) had higher MFV-R (p=0.04) and EDV-R (p=0.02), and lower PI-R (p=0.02); mRS 5–6 patients (n=39, 24%) had lower EDV-R (p=0.02) and a trend toward higher PI-R (p=0.05). In adjusted models, higher PI-R predicted lower odds of ENI (OR 0.08; 95% CI 0.01–0.82; p=0.03), higher odds of END (OR 27.3; 1.3–567.3; p=0.03), and higher odds of mRS 5-6 (OR 11.9; 1.4–98.3; p=0.02). Higher EDV-R associated with lower mRS 5-6 (OR 0.3; 0.1–0.9; p=0.03) and trended toward ENI (OR 2.8; 0.9–8.2; p=0.07). Higher PSV-R was associated with END (OR 7.3; 1.1–50.2; p=0.04). MFV-R trended toward lower odds of mRS 5-6 (OR 0.3; 0.09–1.1; p=0.07). No indices were associated with HT. Conclusions: Early TCD evidence of increased focal microvascular resistance after successful EVT independently correlated with worse early and 90-day outcomes, while relative hyperemia did not predict harm and may favor early improvement. These findings support the pragmatic use of TCD to monitor incomplete microvascular reperfusion, and its applications toward individualized blood pressure management post-EVT in future prospective studies.

Invasive aspergillosis-related internal carotid artery occlusion diagnosed by thrombus pathology after mechanical thrombectomy.

Background: Infective endocarditis (IE) could cause cerebral infarction through septic embolization, presenting challenges in both diagnosis and treatment. Because intravenous thrombolysis is contraindicated in suspected IE-related stroke, careful evaluation of cerebral perfusion and infarct extent is crucial for selecting appropriate therapy. Case Description: A 45-year-old woman was admitted to the emergency department with fever and disturbance of consciousness. Imaging revealed a cerebral infarction due to right internal carotid artery (ICA) occlusion. Echocardiography demonstrated a vegetation on the mitral valve, suggesting IE as the embolic source. As the onset time was unclear and no diffusion-weighted image-fluid-attenuated inversion recovery mismatch was observed, intravenous alteplase was considered inappropriate. Although the neurological deficit was mild, computed tomography perfusion (CTP) imaging showed extensive hypoperfusion in the right ICA-middle cerebral artery territory with a limited infarct core. Mechanical thrombectomy was therefore performed. The procedure was technically challenging, requiring a switch from aspiration thrombectomy to a combined stent retriever technique, ultimately achieving successful recanalization (thrombolysis in cerebral infarction grade 2b). Histopathological examination of the retrieved thrombus revealed fibrin-rich material containing bacterial colonies, and blood cultures were positive for Staphylococcus aureus . Subsequently, the mitral vegetation enlarged, necessitating urgent mitral valve replacement. Conclusion: This case illustrates the usefulness of CTP imaging in guiding treatment decisions for low National Institutes of Health Stroke Scale large-vessel occlusion associated with IE. It also emphasizes that histopathological examination of retrieved thrombi could provide valuable insights into the underlying infectious etiology and inform subsequent management strategies.

Acute intracranial internal carotid artery (ICA) occlusion has high clot burden and poor outcomes. No consensus exists on optimal first-line mechanical thrombectomy (MT) using direct aspiration first pass technique (ADAPT), stent retriever (SR) alone, or combined thrombectomy (non-ADAPT). We compared outcomes between ADAPT and non-ADAPT strategies for ICA occlusion. Data were collected from a comprehensive stroke center between January 2019 and August 2024. Patients with intracranial ICA occlusions were divided into ADAPT and non-ADAPT groups. Demographic, clinical, angiographic, and clinical outcomes (National Institute of Health Stroke Scale [NIHSS] score at 24 hours and modified Rankin Scale [mRS] score at 3 months) were compared. Good functional outcome was defined as a mRS score of 0-2. Of 85 patients (mean age, 75 years; 47% females), 60 (70.6%) received ADAPT and 25 (29.4%) non-ADAPT (18 with aspiration and SR combined and 7 with SR alone). ADAPT achieved successful recanalization with shorter procedure time (median, 32 minutes vs. 60 minutes, P=0.001), higher modified Treatment In Cerebral Ischemia (mTICI) recanalization rates (final mTICI 2c-3, 75% vs. 52%; P=0.038; mTICI 2b-3, 98.3% vs. 88%; P=0.074), and better outcomes at 3 months (mRS ≤2, 47% vs. 22%; P=0.039). Multivariate analysis showed NIHSS at discharge as the only significant predictor of good functional outcome at 3 months (odds ratio [OR] 0.68, P<0.001), while ADAPT exhibited a trend toward significance (OR 5.10, P=0.075). ADAPT exceeded other strategies for intracranial ICA occlusion as first-line technique, achieving faster recanalization and potentially impacting long-term functional outcome.

Abstract Pediatric intracranial aneurysms are exceptionally rare, especially in children under five years of age, and often differ from adult forms in etiology, morphology, and clinical presentation. They are more likely to be fusiform, giant, or thrombosed and frequently associated with congenital vascular anomalies or underlying genetic disorders. Early recognition is critical to prevent irreversible neurological damage or life-threatening complications. We report the case of a 4-year-old boy who presented with progressive left-sided ptosis, ophthalmoplegia, and optic atrophy. Neuroimaging revealed a partially thrombosed giant aneurysm of the left internal carotid artery (ICA), a patent fusiform aneurysm of the right ICA, and extensive arterial tortuosity with segmental ectasia and tortuosity. Additional findings included enlarged posterior fossa subarachnoid spaces, subcutaneous frontal veinous ectasia with transdiploic venous drainage, and arteriovenous shunts in the external carotid territory. Despite café-au-lait macules, the patient did not meet the diagnostic criteria for neurofibromatosis type 1. Digital subtraction angiography confirmed cervical occlusion of the left ICA and collateral compensation via the anterior communicating artery. The vascular pattern raised suspicion for a hereditary connective tissue disorder, such as Loeys–Dietz or vascular Ehlers–Danlos syndrome. PHACES-like vasculopathy was also considered due to the posterior fossa findings and cerebrovascular anomalies. Given the absence of rupture, preserved cerebral perfusion, and high interventional risk related to diffuse vascular tortuosity, a conservative approach with close clinical and radiological follow-up was adopted. Multidisciplinary input guided the decision-making process. Genetic testing could not be performed due to resource limitations. This case underscores the importance and role of neurovascular imaging and a broad differential diagnosis when evaluating cranial neuropathies in children. The presence of bilateral aneurysms, arterial tortuosity, and extracranial vascular anomalies should prompt investigation for syndromic arteriopathies. Multidisciplinary management and long-term monitoring are essential in such complex pediatric presentations.

To assess the potential benefit of artificial intelligence (AI) based imaging software in supporting mechanical thrombectomy (MT) transfer decisions in patients with acute ischemic stroke (AIS) referred from low-volume primary stroke centers (PSCs). Many MT-eligible patients are initially managed in PSCs, which often lack advanced imaging capabilities, stroke imaging expertise, and efficient interhospital image transfer systems. Artificial intelligence-based tools for automated large vessel occlusion (LVO) detection have shown promising results in improving stroke workflow metrics, yet data from low-volume PSCs remain limited. This study presents a multicenter, retrospective analysis of 109 AIS patients transferred for anterior circulation LVO MT from five low-volume PSCs in Poland over a 53-month period (≤ 1 MT transfer/center/month). Standard imaging was retrospectively assessed using Brainomix 360 (Brainomix USA Inc., Chicago, USA) to assess early ischemic changes, collateral status, and LVO location. Two blinded vascular neurologists independently simulated transfer decisions based on post-processed imaging. Large vessel occlusion detection sensitivity and potential changes in transfer eligibility were analyzed. The workflow time parameters were compared to the comprehensive stroke center (CSC) cohort with a routine AI-assisted evaluation (n = 69). The maximal expected time benefit from AI implementation was also estimated. Artificial intelligence-based sensitivity for anterior circulation LVO detection was 83.5% [95% confidence interval (CI) 76.5-90.5], significantly higher for M1 than for internal carotid artery (ICA) occlusions (95.2% vs. 63.9%, p < 0.01). Among included patients, 78.9% (95% CI 70.3-85.5) were simulated as eligible and could potentially benefit from shorter workflow times. This is supported by the significantly shorter computed tomography angiography (CTA) to endovascular treatment (EVT) notification time in the CSC cohort with routine AI-assisted imaging compared with the low-volume PSC (11 vs. 48 min, p < 0.01). The median maximal potential reduction in door-in-door-out (DIDO) time was estimated at 30 min [interquartile range (IQR) 4-45). In contrast, 4.6% (95% CI 2.0-10.3) individuals were reclassified as ineligible due to extensive early ischemic changes and poor collaterals, potentially avoiding futile transfer. Artificial intelligence-assisted imaging may significantly improve transfer decisions and workflow efficiency in low-volume PSCs, particularly in settings without real-time radiological interpretation. Its broader adoption may strengthen MT eligibility assessment within regional stroke networks.

Abstract Background Occlusion of the internal carotid artery can lead to ischemic stroke. Currently, first-line treatment options for ischemic stroke include antiplatelet agents, lipid-regulating drugs, plaque-stabilizing medications, and comprehensive management of risk factors. Nevertheless, advancements in medical technology and materials have introduced various methods to reopen occluded internal carotid arteries. However, there remains a lack of high-level evidence-based support for these interventions. Case presentation In this case report, we present a patient with chronic tandem internal carotid artery occlusion who presented with a month history of blurred vision in the left eye, which had worsened over the preceding 24 h. The occluded vessel was successfully recanalized via endovascular intervention, leading to improve the patient’s visual symptoms. Conclusion For patients with chronic tandem occlusion of the internal carotid artery, endovascular treatment can be considered, but its success rate needs to be evaluated comprehensively based on multiple factors to achieve individualized and precise treatment. In the future, it is necessary to conduct randomized controlled trials to further compare the efficacy and safety of endovascular treatment combined with drug therapy and drug therapy alone for symptomatic non-acute internal carotid artery occlusion patients.

Patients with internal carotid artery occlusion (ICAO) present with a heavy thrombosis burden and bad lateral circulation, which are associated with unfavorable outcomes following endovascular therapy (EVT). In this study, authors explored the risk factors associated with poor outcomes in patients with ICAO undergoing EVT and developed and validated a dynamic nomogram for predicting poor outcomes. Five hundred seventy-seven patients from the multicenter, randomized, double-blind, placebo-controlled MARVEL (Methylprednisolone as Adjunctive to Endovascular Treatment for Acute Large Vessel Occlusion) trial were included in the current retrospective study. The patients, all of whom had ICAO and received EVT between February 2022 and June 2023, were split into training (60%) and internal validation (40%) cohorts. Additionally, 281 patients from the Endovascular Treatment for Acute Anterior Circulation Ischemic Stroke registry (ACTUAL registry) served as the external validation cohort. Least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression analyses were applied to identify risk factors to establish a dynamic nomogram prediction model. Five risk factors were independently associated with poor outcome, including age (OR 0.951, 95% CI 0.935-0.968, p < 0.001), baseline Alberta Stroke Programme Early CT Score (OR 1.176, 95% CI 1.075-1.286, p < 0.001), baseline National Institutes of Health Stroke Scale score (OR 0.850, 95% CI 0.801-0.901, p < 0.001), baseline American Society of Interventional and Therapeutic Neuroradiology and Society of Interventional Radiology grade (OR 1.646, 95% CI 1.388-1.951, p < 0.001), and baseline glucose levels (OR 0.891, 95% CI 0.827-0.959, p = 0.002). The prediction model, based on these five factors, showed moderate performance with an area under the curve of 0.786 (95% CI 0.728-0.844) in the internal validation and 0.795 (95% CI 0.743-0.847) in the external validation, with the calibration curve closely aligning with the ideal diagonal line. This predictive model can accurately forecast poor outcomes for patients with ICAO undergoing EVT, serving as a useful adjunct in operative decision-making for both physicians and patient families.

Bilateral giant petrocavernous internal carotid artery (ICA) aneurysms are extremely rare, and its natural history, treatment response, and prognosis are unknown. Herein, we present the second case of a bilateral giant petrocavernous aneurysm treated with an external carotid artery-radial artery-M2 segment of the middle cerebral artery (ECA-RA-M2) bypass and ICA ligation. A 12-year-old female diagnosed with bilateral petrocavernous ICA aneurysms presented with headache, vomiting, and ptosis on the left eye. Endovascular treatment was not feasible due to financial limitations; hence, she underwent gradual ICA occlusion with a Poppen clamp followed by Hunterian ligation of the left ICA. Six years later, she returned with progressive blurring of vision on the right eye. CT angiography showed significant enlargement of the right ICA aneurysm (25.8 to 51.6mm) with partial thrombosis. Endovascular treatment was not feasible due to aneurysm length. Hence, a right pterional craniotomy with an ECA-RA-M2 bypass was performed. Intraoperative pressure monitoring confirmed graft patency but inadequate flow. To mitigate ischemic risk, the right ICA was gradually occluded with a Poppen clamp before definitive Hunterian ligation. Postoperative angiography confirmed bypass patency and complete aneurysm exclusion. The patient was discharged without new neurologic deficits; visual status remained stable. Pediatric bilateral petrocavernous ICA aneurysms are exceedingly rare, with limited data to guide therapy. This case illustrates contralateral aneurysm enlargement following unilateral ICA sacrifice, underscoring the hemodynamic burden on the remaining ICA. Long-term surveillance and individualized, multidisciplinary, treatment planning are critical in managing complex aneurysms in this population.

Recent outcomes of intravenous tissue plasminogen activator (t-PA) alone in the era of mechanical thrombectomy: A sub-analysis of the Kanagawa Intravenous and Endovascular Treatment (K-NET) registry.

The TICI score determines the reperfusion grade on DSA after endovascular treatment (EVT) in patients with acute ischemic stroke. Despite successful macrovascular reperfusion, almost one-half of patients have poor clinical outcomes. In addition to the large vessels, DSA also depicts the passage of contrast in the capillaries. We aim to study differences in DSA perfusion parameters generated from the time-intensity curves that might differentiate between good and poor clinical outcome in patients who achieved successful reperfusion. Patients from the MR CLEAN Registry with an ICA, M1, and M2 occlusion, and successful reperfusion extended TICI (eTICI ≥2b) were selected. Perfusion parameters of the capillary pixels were computed on post-EVT DSA by deconvolving the time-intensity curve with the arterial input function obtained from the ICA. We extracted 4 perfusion parameters: CBV, CBF, time-to-maximum (Tmax), and mean transit time (MTT). The association between the perfusion parameters and favorable functional outcome at 90 days (0-2 mRS) was analyzed using logistic regression with adjustments for prognostic patient characteristics including eTICI. In total, 743 of 5768 patients were included. There was no association between eTICI scores and favorable functional outcome. In contrast, a shorter MTT and Tmax were associated with favorable functional outcome (adjusted OR, 1.25 [95% CI, 1.03-1.51], 1.39 [95% CI, 1.06-1,82]). DSA-CBV and DSA-CBF were not significantly associated with mRS. Quantifying DSA perfusion parameters provides additional information about reperfusion status and could contribute to differentiating between favorable and unfavorable functional outcomes. The code for producing the quantitative digital subtraction perfusion angiography is publicly available at: https://github.com/RuishengSu/perfDSA.

Prediction of Malignant Acute Middle Cerebral Artery Infarction Via Dual-Energy Computed Tomography-Derived Parameters.

Spontaneous recanalization (SR) of an internal carotid artery (ICA) is a rare phenomenon. Cases reported in literature described the evolution of dissection or atherothrombotic / cardioembolic acute occlusions. No case of post-endarterectomy ICA occlusion resolved by SR has never been reported. Herein, we describe the case of a 64-year old male patient who presented an ipsilateral ischemic stroke due to the ICA occlusion in the second post-operative day of a carotid endarterectomy (CEA) and SR 6months later, without anticoagulant therapy administration. The aim of this report was to increase awareness of this unusual entity and to highlight the usefulness of duplex ultrasound (DUS) surveillance of ICA eventual postoperative occlusions in order to detect accidental recanalization and to propose an adjunctive treatment whenever needed.

Objectives: Endovascular thrombectomy is widely recognized as the standard treatment for acute ischemic stroke caused by large vessel occlusion. However, the efficacy and safety of intravenous thrombolysis before endovascular thrombectomy in acute ischemic stroke patients with tandem lesions remain a subject of ongoing debate. Tandem lesions are characterized by concurrent intracranial large vessel occlusion and extracranial internal carotid artery stenosis or occlusion. The dual pathology of tandem lesions complicates therapeutic strategies. Herein, a systemic review is conducted to assess the efficacy and safety of intravenous thrombolysis combined with endovascular thrombectomy versus direct endovascular thrombectomy alone in patients with tandem lesions. Methods: Relevant literature was searched in PubMed, Embase, and the Cochrane Library from their inception to May 1, 2024. Five observational studies involving 1445 patients were included. Primary outcomes included 3-month clinical outcomes, reperfusion success rate, incidence of asymptomatic cerebral hemorrhage, and mortality rate. Results: Compared with direct endovascular thrombectomy alone, intravenous thrombolysis plus endovascular thrombectomy significantly improved 3-month clinical outcomes (odds ratio [OR] = 1.51, 95% confidence interval [CI]: 1.16–1.95), elevated reperfusion success rate (OR = 1.60, 95% CI: 1.21–2.11), and reduced 3-month mortality (OR = 0.69, 95% CI: 0.52–0.93). However, no significant difference was observed in the incidence of asymptomatic cerebral hemorrhage (OR = 0.93, 95% CI: 0.66–1.31) between the two treatment modalities. Additionally, three studies compared the therapeutic efficacy of tenecteplase and alteplase, revealing no significant differences in 3-month clinical outcomes, reperfusion success rates, incidence of asymptomatic cerebral hemorrhage, and mortality between the two thrombolytic agents. Subgroup analyses suggested that the benefits of intravenous thrombolysis plus endovascular thrombectomy were consistent across different patient populations, including age, baseline stroke severity, and time-to-treatment intervals. Conclusion: Intravenous thrombolysis combined with endovascular thrombectomy significantly improves clinical outcomes and reduces mortality in acute ischemic stroke patients with tandem lesions, without increasing the risk of asymptomatic cerebral hemorrhage. However, the current evidence is primarily derived from observational studies, which may involve selection bias and confounding factors. Further randomized controlled trials are warranted to validate these results and to explore the impact of patient-specific and surgical factors on clinical outcomes. This study was conducted in accordance with the Preferred Reporting Items for Systematic Evaluation and Meta-Analysis (PRISMA) statement, and the study protocol was registered with PROSPERO (registration No. CRD42024570536).