BACKGROUND AND PURPOSE: The aspiration technique has gained a prominent role in mechanical thrombectomy. The thrombectomy goal is successful revascularization (modified TICI ≥ 2b) and first-pass effect. The purpose of this study was to evaluate the impact of the vessel-catheter ratio on the modified TICI ≥ 2b and first-pass effect. MATERIALS AND METHODS: This was a retrospective, single-center, cohort study. From January 2018 to April 2020, 111/206 (53.9%) were eligible after applying the exclusion criteria. Culprit vessel diameters were measured by 2 neuroradiologists, and the intraclass correlation coefficient was calculated. The receiver operating characteristic curve was used for assessing the vessel-catheter ratio cutoff for modified TICI ≥ 2b and the first-pass effect. Time to groin puncture and fibrinolysis were weighted using logistic regression. All possible intervals (interval size, 0.1; sliding interval, 0.01) of the vessel-catheter ratio were plotted, and the best and worst intervals were compared using the χ² test. RESULTS: Modified TICI ≥ 2b outcome was achieved in 75/111 (67.5%), and first-pass effect was achieved in 53/75 (70.6%). The MCA diameter was 2.1 mm with an intraclass correlation coefficient of 0.92. The optimal vessel-catheter ratio cutoffs for modified TICI ≥ 2b were ≤1.51 (accuracy = 0.67; 95% CI, 0.58–0.76; P = 0.001), and for first-pass effect, they were significant (≤1.33; P = .31). The modified TICI ≥ 2b odds ratio and relative risk were 9.2 (95% CI, 2.4–36.2; P = 0.002) and 3.2 (95% CI, 1.2–8.7; P = .024). The odds ratio remained significant after logistic regression (7.4; 95% CI, 1.7–32.5; P = .008). First-pass effect odds ratio and relative risk were not significant (2.1 and 1.5; P > .05, respectively). The modified TICI ≥ 2b best and worst vessel-catheter ratio intervals were not significantly different (55.6% versus 85.7%, P = .12). The first-pass effect best vessel-catheter ratio interval was significantly higher compared with the worst one (78.6% versus 40.0%, P = .03). CONCLUSIONS: The aspiration catheter should be selected according to culprit vessel diameter. The optimal vessel-catheter ratio cutoffs were ≤1.51 for modified TICI ≥ 2b with an odds ratio of 9.2 and a relative risk of 3.2.

Background: The major endovascular mechanic thrombectomy (MT) techniques are: Stent-Retriever (SR), aspiration first pass technique (ADAPT) and Solumbra (Aspiration + SR), which are interchangeable (defined as switching strategy (SS)). The purpose of this study is to report the added value of switching from ADAPT to Solumbra in unsuccessful revascularization stroke patients. Methods: This is a retrospective, single center, pragmatic, cohort study. From December 2017 to November 2019, 935 consecutive patients were admitted to the Stroke Unit and 176/935 (18.8%) were eligible for MT. In 135/176 (76.7%) patients, ADAPT was used as the first-line strategy. SS was defined as the difference between first technique adopted and the final technique. Revascularization was evaluated with modified Thrombolysis In Cerebral Infarction (TICI) with success defined as mTICI ≥ 2b. Procedural time (PT) and time to reperfusion (TTR) were recorded. Results: Stroke involved: Anterior circulation in 121/135 (89.6%) patients and posterior circulation in 14/135 (10.4%) patients. ADAPT was the most common first-line technique vs. both SR and Solumbra (135/176 (76.7%) vs. 10/176 (5.7%) vs. 31/176 (17.6%), respectively). In 28/135 (20.7%) patients, the mTICI was ≤ 2a requiring switch to Solumbra. The vessel’s diameter positively predicted SS result (odd ratio (OR) 1.12, confidence of interval (CI) 95% 1.03–1.22; p = 0.006). The mean number of passes before SS was 2.0 ± 1.2. ADAPT to Solumbra improved successful revascularization by 13.3% (107/135 (79.3%) vs. 125/135 (92.6%)). PT was superior for SS comparing with ADAPT (71.1 min (CI 95% 53.2–109.0) vs. 40.0 min (CI 95% 35.0–45.2); p = 0.0004), although, TTR was similar (324.1 min (CI 95% 311.4–387.0) vs. 311.4 min (CI 95% 285.5–338.7); p = 0.23). Conclusion: Successful revascularization was improved by 13.3% after switching form ADAPT to Solumbra (final mTICI ≥ 2b was 92.6%). Vessel’s diameter positively predicted recourse to SS.

A wide range of acute neurological disorders may present with symptoms similar to a stroke, so-called 'stroke mimics'. Migraine aura and seizures account for the most extensive stroke mimics population. A large number of patients with a definite stroke mimics diagnosis (most commonly those with psychiatric disorders or seizures) had been treated with IV alteplase without adverse related events. We report a case of a man aged 70 years admitted to the emergency room because of acute onset of delirium and a loss of strength in the left arm (National Institutes of Health Stroke Scale {NIHSS}: 10), severe hyponatremia (127 mEq/L), and no evidence of intracranial arterial occlusion at CT scan. He was eligible for intravenous thrombolysis and, after treatment, neurological symptoms improved (NIHSS: 2). The subsequent appearance of “clonus” in the left lower limb, the persistence of hyponatremia, and the presence of electroencephalogram (EEG) abnormalities led to the clinical suspicion of focal motor-onset seizure with impaired awareness. The patient was treated successfully with anti-seizure medications (ASMs): lacosamide 200 mg IV during the acute setting care, followed by oral lacosamide 200 mg bis in die (BID). Since two other focal seizures occurred, brivaracetam 25 mg BID has been added in therapy with subsequent clinical discontinuance and EEG normalization. Two consecutive magnetic resonance imaging (MRI) examinations showed several cortical lesions restricted in high signal in diffusion‐weighted imaging (DWI) which corresponding to T2‐weighted and fluid‐attenuated inversion recovery (FLAIR) hyperintensities, but without lesions evidence in apparent diffusion coefficient (ADC) map. These radiological changes disappeared at a follow-up MRI performed 20 days after the symptoms’ onset. The patient fully recovered was discharged home without developing pharmacological adverse events. In this case, MRI provided an opportunity for early identification of seizure-related alterations. Hence, we discuss how prospective MRI studies during seizures and interictal period would contribute to defining the relationship between the electroclinical characteristics and MRI alteration patterns, and therefore, the potential role of MRI in the differential diagnosis between seizures and stroke mimic.

Background: This review critically analyzed recent publications on large-core Randomized Controlled Trials (RCTs). Six RCTs demonstrated the superiority of mechanical thrombectomy over the best medical treatment in patients with low ASPECTs. However, the use of ASPECTs to define the ischemic core has limitations in detecting ischemic changes beyond the middle cerebral artery (MCA) territory. This review evaluates the implications of this choice on the external validity of the trials. Methods: The study evaluated ASPECTS reliability by examining the anatomical details of occlusion location, collateral blood flow, and perfusion imaging. An analysis comparing the HERMES collaboration with six RCTs on large-core infarcts was conducted to investigate how the occlusion site affects infarct size and salvageable brain tissue, as well as to support pathophysiological assessment. Key Message: RCTs indicated a trend toward more proximal occlusions in large-core trials compared to HERMES collaboration, unpredictably increasing the mismatch between the ischemic core and salvageable tissue. ASPECTS inadequately depicted ischemic changes outside the proximal MCA occlusion, causing potential misinterpretations. Perfusion imaging identified core volume and salvageable areas better than ASPECTS alone by including all at-risk tissues, not just the MCA. This review advocates redefining infarct core assessment in large-core RCTs, prioritizing perfusion imaging over ASPECTS. It emphasizes the significance of the occlusion site in large-core stroke for clinical decisions and calls for research to refine the imaging criteria for thrombectomy eligibility.

Background: For stage I non-small cell lung cancer surgery remains the cornerstone of the treatment and the use of minimally invasive technique is desirable. The lack of tactile feedback in RATS is a well-known drawback of this approach, so the precise identification of the disease is crucial for performing the lung resection. Methods: We present our retrospective case history, accounting for 82 patients, divided into two groups based on marking technique: 99^mTc-MAA (99^mTechnetium Albumin Macroaggregates) only (Tech group) (22 cases, 26,5%) and 99^mTc-MAA + Indocianine green (Tech+ICG group) (61 cases, 73,49%). Results: In Tech group there were 11 males (50%) ad 11 females (50%), median nodule diameter was 21,5mm (IQR 16), median distance of the nodule from visceral pleura was 18 mm (IQR 21). Eighteen out of 22 nodules (81,82%) were subsolid. Three conversions were reported, all due to failure to identify the nodule (13,63%). Mean operative time was 111,6 ± 45,6 min. At the histopathological examination resulted 13 lung adenocarcinomas, 1 squamous cells carcinomas, 2 minimally invasive lung adenocarcinomas, 2 lung adenocarcinomas in situ, 3 metastases from another tumor and 1 benign nodule. In Tech+ICG group there were 27 males (44,26%) and 34 females (55,73%), median nodule diameter was 18mm (IQR 14), median distance of the nodule from visceral pleura was 24mm (IQR 15). Forty-six out of 61 nodules were subsolid (75,4%). Four conversion was reported, due to failure in nodule identification (6,55%). Operative time was 105,6 ± 36,8 min. At the histopathological examination resulted 12 lung adenocarcinomas, 7 squamous cells carcinoma, 9 minimally invasive lung adenocarcinomas, 12 lung adenocarcinomas in situ, 1 typical carcinoid, 7 atypical adenomatous hyperplasias, 7 metastases from another tumor and 6 benign nodules. The two groups are homogeneous in terms of median nodule diameter (p = 0,676), median distance from visceral pleura (p = 0,114), SUV max (p = 0,894), operative time (p = 0,512), nodule characteristics (solid vs subsolid) (p = 0,724). Conclusions: Both techniques appear to be safe and reproducible. Further standardized studies are needed to validate and confirm the results obtained from our case series.