Juvenile nasopharyngeal angiofibroma (JNA) is a benign tumor of the nasal cavity that predominantly affects young boys. Surgical removal remains the gold standard for the management of this disease. Preoperative intra-arterial embolization (PIAE) is useful for reductions in intraoperative blood loss and surgical complications. In our series of 79 patients who underwent preoperative embolization from 1999 to 2020, demographics, procedural aspects, surgical management and follow-up outcome were analyzed. Embolization was performed in a similar fashion for all patients, with a superselective microcatheterization of external carotid artery (ECA) feeders and an injection of polyvinyl alcohol (PVA) particles, followed, in some cases, by the deployment of coils . Procedural success was reached in 100% of cases, with no complications such as bleeding or thromboembolic occlusion, and surgical intraoperative blood loss was significantly decreased. In conclusion, PIAE is a safe and effective technique in JNA treatment, minimizing intraoperative bleeding.

Spontaneous intracranial hypotension (SIH) occurs due to a leakage of the cerebrospinal fluid (CSF) lowering the pressure of subarachnoid space, mostly caused by a dural breach or discogenic microspur. As a result of less support provided by CSF pressure, intracranial structures are stretched downward, leading to a constellation of more or less typical MRI findings, including venous congestion, subdural effusions, brainstem sagging and low-lying cerebellar tonsils. Clinic examination and an MRI are usually enough to allow for the diagnosis; however, finding the location of the dural tear is challenging. SIH shares some MRI features with Chiari malformation type I (CM1), especially low-lying cerebellar tonsils. Since SIH is likely underdiagnosed, these findings could be interpreted as signs of CM1, leading to a misdiagnosis and an incorrect treatment pathway. Medical treatment, including steroids, bed rest, hydration caffeine, and a blind epidural blood patch, have been used in this condition with variable success rates. For some years, CSF venous fistulas have been described as the cause of SIH, and a specific diagnostic and therapeutic pathway have been proposed. The current literature on SIH with a focus on diagnosis, treatment, and differential diagnosis with CM1, is reviewed and discussed.

Spontaneous intracranial hypotension (SIH) is due to a leakage of CSF lowering the pressure of subarachnoid space, mostly caused by a dural breach or discogenic microspur. Clinical and MRI are usually typical enough to allow diagnosis, while finding the location of the dural breach is challenging. Since some years, CSF venous fistulas have been described as the cause of SIH, and a specific diagnostic and therapeutic path has been proposed. Here we report the first two successfully treated patients in Italy. Both had chronic and non specific symptoms, with severe reduction of quality of life; clinical symptoms improved after endovascular occlusion of the responsible vein.

Purpose: Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke (AIS) due to large vessel occlusion (LVO). The choice of a transradial approach (TRA) for anterior circulation LVOs is still debatable; the use of a specific tricoaxial system could help mitigate numerous issues related to transradial MT.Materials and Methods: From November 2022 to November 2023, 22 patients underwent TRA-MT for anterior circulation LVOs, both as first-line and rescue from transfemoral approach (TFA) failure, with the same triaxial setup consisting of a 7F introducer sheath, 7F guide catheter, and aspiration catheters ranging from 5.5F to 5F in relation to the occlusion site. Choice of thrombectomy technique was at operator discretion. Patients’ demographic data, clinical presentation, treatment details, complications, rate of crossover to TFA, successful revascularization (modified thrombolysis in cerebral infarction [mTICI] score ≥2b), and good clinical outcome at 3 months (modified Rankin scale [mRS] 0-2) were reported.Results: Of 20 patients selected, 10 (50%) had occlusion of M1 segment of middle cerebral artery (MCA), 6 (30%) of internal carotid artery (ICA) terminus, and 4 (20%) with M2 MCA occlusions; 12/20 (60%) were right-sided occlusions and 8/20 (40%) were left-sided. The mean National Institutes of Health Stroke Scale score was 9.25 at admission. Successful revascularization to mTICI 2b-3 was achieved in 18/20 patients (90%). Intracranial complications were reported in 2 (10%) patients. Rate of radial artery occlusion at 24 hours was 10,6%; no access-site haemorrhagic complications were reported. Symptomatic intracranial hemorrhage occurred in 2 (10%) patients. mRS score 0-2 at 3 months was 50%.Conclusion: The high technical effectiveness and good safety profile of this specific tricoaxial setup for TRA-MT in AIS, even for large proximal LVOs, could constitute a viable alternative to TFA-MT in selected cases.

BACKGROUND: In the case of failed reperfusion or severe stenosis during endovascular treatment of acute stroke, intracranial stenting is a growing practice. We aimed to study clinical and radiological outcomes in a large multicenter cohort. METHODS: The RESISTANT registry (Registry of Endovascular Salvage for Intracranial Stenting in Thrombectomy-Refractory Stroke; 2016–2023) is a multicenter single-arm retrospective registry of patients with acute stroke who underwent intracranial stenting during endovascular treatment across 36 international centers. The primary end point was functional outcome at 90 days. Secondary end points were final successful reperfusion (modified Thrombolysis in Cerebral Infarction, 2b-3) and stent patency at 24 hours. Safety outcomes included procedural complications, symptomatic intracranial hemorrhage, and in-hospital mortality. Logistic regression models including those variables that achieved statistical significance, along with age, baseline National Institutes of Health Stroke Scale, and baseline modified Rankin Scale, were used to define independent predictors. RESULTS: Among 904 patients enrolled, 876 fulfilled inclusion criteria. Median age was 67.0 (interquartile range, 59.0–77.0) years, 567 (64.8%) were men, and the median National Institutes of Health Stroke Scale score was 12.0 (interquartile range, 7.0–19.0). Anterior circulation was involved in 624 (71.6%), and the rate of tandem extracranial/intracranial occlusion was 4.9%. Stenting was performed in 469 patients (53.5%), owing to failed reperfusion (expanded Thrombolysis in Cerebral Infarction, 0-2a), and in 320 patients (36.5%) because of residual severe stenosis. After stenting, immediate successful recanalization was achieved in 777 (89.5%). At 90 days, the rate of modified Rankin Scale score of 0 to 2 was 41.2%. The number of thrombectomy attempts (adjusted odds ratio, 0.810 [95% CI, 0.707–0.929]; P =0.003) and the final successful recanalization (adjusted odds ratio, 19.394 [95% CI, 5.486–68.560]; P <0.001) were associated with good functional outcome. During admission, the reocclusion rate was 12.2%, most of them within 48 hours. Symptomatic intracranial hemorrhage was diagnosed in 8.4% of patients; no variables were independently associated with a higher probability. CONCLUSIONS: Acute intracranial stenting was a feasible therapy for patients with failed reperfusion or severe stenosis. Successful reperfusion and a lower number of thrombectomy attempts predicted functional outcome. Prospective studies are warranted to confirm efficacy and safety.