Background and purpose Intra-arterial treatment (IAT) is effective when performed within 6h of symptom onset in selected stroke patients (T<6H'). Its safety and efficacy is unclear when the patient has had symptoms for more than 6h (T>6H') or for an unknown time (unclear-onset stroke, UOS), or woke up with a stroke (wake-up stroke, WUS). In this study we compared the safety of IAT in these four patient groups. Methods Eight-hundred and fifty-nine patients treated with IAT were enrolled. The main outcome parameters were clinical outcome [excellent: modified Rankin Scale (mRS) 0 or 1; or favorable: mRS 02] or mortality 3months after treatment. Further outcome parameters were the rates of vessel recanalization, and cerebral and systemic hemorrhage. Results Six-hundred and fifty-four patients were treated before (T<6H) and 205 after 6h or an unknown time (128 T>6H, 55 WUS and 22 UOS). NIHSS scores were higher in UOS patients than in T<6H patients, vertebrobasilar occlusion was more common in T>6H and UOS patients, and middle cerebral artery occlusions less common in T>6H than in T<6H patients. Other baseline characteristics were similar. There was no significant difference in clinical outcome and the rate of hemorrhage in multivariable regression analysis. Conclusions Clinical outcome of our four groups of patients was similar with no increase of hemorrhage rates in patients treated after awakening, after an unknown time or more than 6h. Our preliminary data suggest that treatment of such patients may be performed safely. If confirmed in randomized trials, this would have major clinical implications.

Background and purposeEndovascular therapy is used increasingly for treatment of acute symptomatic internal carotid artery (ICA) occlusion, although randomized trials are lacking. Predictors of outcome are therefore of special interest.MethodsFrom 1992 to 2010 we treated 201 patients with acute ICA occlusion with intra‐arterial pharmacological thrombolysis (32), endovascular mechanical therapy (78) or a combination of both (91). All data were assessed prospectively.ResultsThere were 76/38% patients with tandem occlusions [ICA plus middle (MCA) or anterior cerebral arteries (ACA)], 18/9% without concomitant occlusions of major intracranial arteries (ICA plus branch occlusion) and 107/53% with functional ICA‐T occlusions (ICA plus MCA and ACA). Median baseline National Institute of Health Stroke Scale (NIHSS) score was 17. Good recanalization (Thrombolysis in Myocardial Infarction 2–3) was achieved in (157/201) 78% patients and good reperfusion (Thrombolysis in Cerebral Infarction 2–3) in (151/182) 83%. Better recanalization rates were obtained with mechanical approaches, with/without thrombolytics (78/91 = 86% and 64/78 = 82%) compared with pharmacological thrombolysis only (15/32 = 47%; P < 0.001). Twelve patients (6%) suffered symptomatic intracranial haemorrhages. The 3‐month outcome was favourable [modified Rankin score (mRS) 0–2] in 54/28% patients and moderate (mRS 0–3) in 90/46%; 60/31% patients died. Only 17/16% patients with functional ICA‐T occlusions had favourable outcomes compared with 32/44% with tandem occlusions and 5/31% with ICA plus cerebral branch occlusions (P = 0.001). In multivariate analysis age [odds ratio (OR) = 0.96, 95% confidence interval (CI) = 0.93–0.98], NIHSS on admission (OR = 0.9, 95% CI = 0.83–0.98) and functional ICA‐T occlusion (OR = 0.35, 95% CI = 0.16–0.77) were non‐modifiable predictors, and vessel recanalization was the only modifiable predictor of outcome (OR = 9.30, 95% CI = 2.03–42.63).ConclusionsThe outcome of acute symptomatic ICA occlusion is poor. However, recanalization is associated with better outcome, and recanalization rates with mechanical techniques were superior to merely pharmacological recanalization attempts.

Introduction Anatomical MR contrasts (such as T1 and T2) fail to identify occult lesions and diffuse demyelination which are known to occur in multiple sclerosis (MS). Diffusion tensor imaging (DTI) can potentially discern axonal loss in white-matter tissue and serve as a marker for loss of tissue integrity (demyelination, axonal degeneration) [1,2]. Poor image quality and the limited resolution in spinal cord DWI has so far impeded focal evaluation of spinal cord tissue i.e. the differentiation between grey and white matter. Furthermore, adequate image quality was achievable only at the cervical level of the spinal cord. Recent improvements in MR pulse sequence design have overcome these problems, thereby providing a new instrument for the assessment of multiple sclerosis. We tested the newly available technique in a comprehensive clinical MS study and measured diffusivity values of the spinal cord at three levels. Methods Imaging was performed on a 3 T Philips Achieva (Philips Healthcare, Best, the Netherlands) using a dedicated spine coil. DTI data of 18 volunteers and 41 patients with relapsing remitting MS (RRMS), secondary progressive MS (SPMS) or primary progressive MS (PPMS) (Table 1) were acquired at cervical (~C5) and thoracic level (~T5) as well as at the lumbar enlargement of the spinal cord. In each region 6 transverse slices were acquired using an outer volume suppressed reduced field of view single-shot EPI sequence [3,4] (NEX = 6/12 for b = 0/b = 750 s/mm2, acquisition matrix = 176x44, FOV = 120x30 mm, z=5mm, TR = 4000 ms, TE = 49 ms, 60% partial-Fourier acquisition). After subsequent image co-registration fractional anisotropy (FA) and apparent diffusion coefficient (ADC) maps were calculated. Diffusivity values were evaluated in the posterior white matter (PWM) (Fig. A). Only normal appearing spinal cord tissue, i.e. spinal cord tissue without T2-hyperintense lesions, was evaluated. ROI sizes were kept constant for all evaluated subjects.

BACKGROUND AND PURPOSE:Retrievable stents combine the high recanalization rate of stents and the capability of removing the thrombus offered by mechanical thrombectomy devices. We hypothesized that retrievable stents shorten time to recanalization in the multimodal approach for endovascular stroke treatment.MATERIALS AND METHODS:Forty consecutive patients with acute ischemic stroke and undergoing endovascular therapy were included. Treatment included thromboaspiration, thrombus disruption, thrombolysis, PTA, and stent placement. In 17 patients, a retrievable stent was used (group A) in addition to multimodal therapy. The remaining 23 patients constituted group B. Baseline characteristics, occlusion sites, urokinase dose, recanalization rate, and time to recanalization were compared between the groups.RESULTS:Median NIHSS scores were higher in group A compared with group B on admission (19 versus 12.5; P = .018) but were not significantly different at day 1 (14 versus 10; P = .6). Intra-arterial thrombolysis was used in significantly fewer patients of group A than group B (53% versus 87%, respectively; P = .017), and median urokinase dose was lower in group A than in group B (250,000 IU versus 700,000 IU; P = .006). Time to recanalization was significantly shorter in group A compared with group B (median time to recanalization 52.5 minutes versus 90 minutes, respectively; P = .001). Recanalization rate was higher in group A than group B (94% versus 78%; P = .17).CONCLUSIONS:Addition of retrievable stents to the multimodal endovascular approach for acute ischemic stroke treatment significantly reduces time to recanalization and further increases the recanalization rate.