[This corrects the article DOI: 10.1371/journal.pone.0342739.].

BACKGROUND AND OBJECTIVES:The benefit of IV thrombolysis (IVT) with alteplase before endovascular thrombectomy (EVT) compared with EVT alone has been shown to be limited and time dependent. Data on tenecteplase, its recommended alternative, are limited. We aimed to assess the efficacy and safety of IVT with tenecteplase plus mechanical thrombectomy (TNK + EVT) compared with EVT in patients with large vessel occlusion stroke and determine whether its potential benefit decreases with treatment time. METHODS:We conducted a retrospective pooled analysis of 2 nationwide, real-world registries of patients with anterior circulation large vessel occlusion stroke within 4.5 hours of known symptom onset and with no contraindication to thrombolysis, treated with TNK + EVT (TETRIS) or EVT (ETIS). The efficacy outcome was the 3-month modified Rankin Scale (mRS) score, analyzed in ordinal and dichotomized (mRS score ≤2) approaches. We used propensity score-weighted logistic regression to assess associations between treatment groups and outcomes of interest. RESULTS:Among 1,890 patients who were analyzed (TNK + EVT: n = 798; EVT: n = 1,092; median age 73 years [interquartile range 61-82]; 49.6% women), the median expected onset-to-thrombolysis time was 146 minutes [interquartile range 119-180]. More than half of patients (n = 1,063; 56.2%) were admitted first to a primary stroke center. All baseline characteristics were balanced between treatment groups after overlap weighting. Overall, TNK + EVT was associated with better 3-month functional outcome over the full mRS (weighted common odds ratio [OR] 1.53 [95% CI 1.29-1.82]; p < 0.001) and regarding functional independence (propensity score overlap weighting [PSOW]-OR 1.50 [95% CI 1.23-1.84]; p < 0.001). This benefit did not differ statistically between patients admitted first to a primary or comprehensive stroke center (p-interaction = 0.12). There was no significant effect of the expected onset-to-thrombolysis time on the association between TNK + EVT and better functional outcome (p-interaction = 0.11). There were no significant differences in parenchymal hematoma (PSOW-OR 1.29 [95% CI 0.94-1.79]; p = 0.12) and symptomatic intracerebral hemorrhage (PSOW-OR 1.13 [95% CI 0.69-1.86]; p = 0.61) rates. DISCUSSION:Among patients treated within 4.5 hours of symptom onset, TNK + EVT was associated with better functional outcome than EVT, without safety concerns. This benefit does not seem to be time dependent. These findings support the routine use of tenecteplase before EVT in the early time window. CLASSIFICATION OF EVIDENCE:This study provides Class II evidence that, in patients with stroke due to anterior circulation large vessel occlusion, IV tenecteplase plus thrombectomy is associated with better functional outcomes at 3 months compared with thrombectomy alone. TRIALS REGISTRATION INFORMATION:NCT03776877 (ETIS registry) and NCT05534360 (TETRIS registry).

Background and Purpose Whether perfusion-diffusion mismatch modifies treatment effect of mechanical thrombectomy (MT) for large strokes is poorly known. To address this question, we conducted a post hoc secondary analysis of the Large Stroke Therapy Evaluation (LASTE) randomized controlled trial (RCT). Methods The LASTE RCT compared MT plus best medical treatment (BMT) to BMT alone in patients with large infarct (Alberta Stroke Program Early CT Score 0–5) in the 0–7-hour timewindow. This secondary analysis was restricted to patients with available baseline MR perfusionweighted imaging. We investigated the potential heterogeneity of MT treatment according to the presence of perfusion-diffusion mismatch, defined as a mismatch ratio ≥1.2, calculated as the time-to-maximum >6 seconds cerebral volume divided by ischemic core volume. The primary outcome was better functional outcome (favorable shift in the distribution of modified Rankin Scale [mRS] at 90 days, analyzed using generalized odds ratio [GenOR]). Results A total of 102/324 patients were included, among whom 55 (54%) had a perfusiondiffusion mismatch. No significant treatment effect heterogeneity by diffusion-perfusion mismatch was observed for the primary outcome (GenOR for better functional outcome: 1.70 [95% confidence interval, CI, 0.95 to 3.05] and 1.04 [95% CI, 0.57 to 1.87] in patients with and without mismatch, respectively; ratio of GenORs: 1.63 [95% CI, 0.71 to 3.74]; P for heterogeneity=0.24) or for the secondary efficacy and safety outcomes. Conclusions Our study found no evidence of heterogeneity of treatment effect with respect to benefit or safety in patients with unrestricted infarct size at baseline treated with MT by presence of perfusion-diffusion mismatch. An individual participant-data meta-analysis of RCT is needed for definitive conclusions.

BACKGROUND AND PURPOSE:The optimal anesthetic regimen for the endovascular treatment (EVT) of stroke due to large-vessel occlusion remains unclear. Patients with large infarct cores on initial imaging constitute a specific subpopulation. The aim of this study was to investigate the impact of the anesthesia type during EVT on outcomes in this subpopulation. MATERIALS AND METHODS:Data were extracted from the multicenter, randomized, controlled LASTE trial (n = 30 centers in France and Spain) that compared EVT plus best medical treatment versus best medical treatment alone in patients with a large infarct core (ASPECTS = 0-5). In this post hoc analysis, only patients who underwent EVT were included. We defined 2 study groups: general anesthesia (GA) and conscious sedation and/or local anesthesia (CS-LA). The primary end point was the functional outcome, assessed with the mRS at 3 months. Secondary end points included early neurologic status, infarct extension at day 1, symptomatic intracranial hemorrhage, and mortality. End points were investigated using univariate and multivariate analyses adjusted for prespecified confounders. RESULTS:For this post hoc analysis, we included 159 patients: 45 in the GA group and 114 in the CS-LA group. The functional outcome at 3 months was not different between groups: median mRS score = 5; interquartile range [IQR]: 3-6 in the GA group and 4; IQR: 3-6 in the CS-LA group (adjusted OR =0 .78; 95% CI, 0.52-1.18). However, in the GA group, the NIHSS score significantly worsened between admission and day 1 (mean difference = -3.8 [-6.6 to -1.0]; P = .007), infarct volume extension was more severe (mean difference: -26.5 mL [-50.2 to -2.9]; P = .028), and parenchymal hematoma was more frequently detected. Between-group differences in early neurologic improvement, symptomatic intracranial hemorrhage, and mortality were not significant. CONCLUSIONS:In this post hoc analysis of the LASTE trial data, we detected potential signals of a GA detrimental effect in patients with large infarct cores on baseline imaging. Larger studies are necessary to confirm this finding.

IMPORTANCE:Central retinal artery occlusion (CRAO) is a disabling subtype of acute ischemic stroke. It is not known whether intravenous (IV) thrombolysis delivered within 4.5 hours of time last known well (LKW) improves visual outcomes. STUDY DESIGN:Systematic review and individual participant data meta-analysis. OBJECTIVE:The objective of this study is to determine whether IV thrombolysis improves visual outcomes among patients with acute non-arteritic CRAO when administered within 4.5 hours of time LKW compared with placebo, no IV thrombolysis, and/or anti-thrombotic therapy. EVIDENCE REVIEW PLAN:This study is prospectively registered through PROSPERO (#1154900). We will include randomized controlled trials (RCTs) that enroll patients with non-arteritic CRAO presenting within 4.5 hours of time LKW. We will not include non-controlled interventional studies or retrospective studies. We will search MEDLINE, Embase, the Cochrane Library, Web of Science, and the ClinicalTrials.gov registry from inception through the date of commencement of the systematic review. We will assess the risk of bias using the Cochrane Risk of Bias Tool 2.0. We will contact the corresponding author(s) of any studies identified that meet the study selection criteria. We will inspect, harmonize, and collate trial datasets. The primary end point will be attainment of a final best corrected visual acuity (BCVA) equal to or better than 20/63 (logarithm of the minimum angle of resolution [logMAR] of ≤0.5). Secondary end points will include shift analyses of key visual acuity outcome categories according to the World Health Organization (WHO) International Classification of Disease (ICD)-11, final BCVA considered as a continuous variable, final BCVA equal to or better than 20/100 (logMAR of ≤0.7), final BCVA equal to or better than 20/200 (logMAR of ≤1), a quantitative measure of visual field function (where available), global disability (modified Rankin Scale score [mRS]), and key safety end points (including symptomatic intracranial hemorrhage [sICH] and other systemic hemorrhage). We will fit a series of mixed logistic and linear regression models with trial, and trial by treatment interaction terms as random effects. To probe for sources of heterogeneity, we will pursue a series of subgroup and sensitivity analyses. Finally, a GRADE assessment will be presented. CONCLUSIONS AND RELEVANCE:Completion of the proposed study will permit a synopsis of the interventional literature on IV thrombolysis for CRAO, generate a pooled estimate of the treatment effect, and allow exploration of sources of heterogeneity. Such results may be of interest to healthcare professionals, guideline development bodies, policymakers, payors, and future patients with CRAO. REGISTRATION:This systematic review is prospectively registered: PROSPERO #1154900.

Objectives Few data are available regarding the functional prognosis of adults with primary central nervous system vasculitis (PCNSV). We developed and validated a prognostic model for 12-month functional independence in adults with PCNSV. Methods We conducted a multicentre, international cohort study of adults with PCNSV (COVAC’). The primary end point was functional independence 12 months after the start of corticosteroids or immunosuppressants, defined as a modified Rankin Scale of 0–2. We identified baseline features independently associated with functional independence using multivariable analyses. We assessed discrimination using AUC-ROC and externally validated the model in a geographically distinct, single-centre cohort from India. Results Among the 206 patients included with PCNSV (mean age: 48 years; 41% female), 67 (33%) were diagnosed based on a positive biopsy. At 12 months, 135 (66%) patients were functionally independent and 12 (6%) had died. Favourable prognostic factors were ≥1 intracranial stenosis on CT- or MR-angiogram (OR = 2.99, 95% CI: 1.23–7.68) and headache (OR = 2.67, 95% CI: 1.31–5.59). Unfavourable prognostic factors were an altered level of consciousness (OR = 0.09, 95% CI: 0.02–0.31), ≥1 acute brain infarct (OR = 0.12, 95% CI: 0.04–0.33) and cognitive impairment (OR = 0.22, 95% CI: 0.10–0.46). A prognostic model including these five variables had an AUC of 0.80 (95% CI: 0.74–0.87) in the derivation cohort and 0.67 (95% CI: 0.54–0.81) in the validation cohort. Conclusions Baseline clinical and imaging variables may predict 12-month functional independence in adults with PCNSV. These results may support physicians in prognostication and risk stratification of adults with PCNSV.

Importance Evidence regarding efficacy and safety of thrombectomy in acute ischemic stroke (AIS) due to medium or distal vessel occlusions (MDVOs) is lacking. Objective To evaluate the benefit of thrombectomy, in addition to medical treatment over medical treatment alone, in patients with an AIS related to a primary and isolated MDVO. Design, Setting, and Participants Randomized clinical trial conducted at 22 stroke centers in France from November 2021 to April 2025, with planned enrollment of 488 patients. The trial has been stopped after the planned interim analysis on the recommendation of the data and safety monitoring board for futility and increased rate of symptomatic intracranial hemorrhage with thrombectomy. Eligible adult patients had an AIS due to a primary MDVO within 8 hours of symptom onset or within 24 hours of last seen well if no hyperintense signal was present on fluid-attenuated inversion recovery imaging. Intervention Thrombectomy in addition to medical treatment (n = 123) or medical treatment alone (n = 121). Main Outcomes and Measures The primary end point was a good clinical outcome at 3 months, defined as a modified Rankin Scale score of 0 to 2, assessed by an independent, blinded assessor. Secondary end points included mortality rate at 3 months and adverse and serious adverse events. Results Of the 244 patients randomized (median age, 75 years [IQR, 67-81]; 56% male; median National Institutes of Health Stroke Scale score, 8 [IQR, 6-12]), 100 of the 123 patients in the thrombectomy group (81%) received thrombectomy and none of the 121 patients in the control group received thrombectomy; 217 (89%) completed follow-up. At 3 months, 72 of 116 patients (62%) in the thrombectomy group had a good clinical outcome vs 81 of 119 patients (68%) in the control group (odds ratio, 0.73 [95% CI, 0.40-1.31]; P = .29; adjusted absolute difference, −6.8% [95% CI, −19.4% to 5.7%]). The incidence of symptomatic intracranial hemorrhages was higher among the 100 patients who actually received thrombectomy than in those who did not (11% vs 3%, P = .008), as was incidence of subarachnoid hemorrhages (13% vs 2%, P < .001) and embolus migration (5% vs 1%, P = .04). Mortality rate did not significantly differ between the 2 groups (6% vs 8%; P = .49). Conclusions and Relevance Thrombectomy did not lead to a higher rate of good clinical outcome at 3 months compared with medical treatment alone in patients with acute ischemic stroke related to an MDVO. Hemorrhagic complications were more frequent after thrombectomy. Trial Registration ClinicalTrials.gov Identifier: NCT05030142

Introduction L’activité physique (AP) est un facteur déclenchant mécanique (FDM), associé aux dissections artérielles cervicales (DAC) spontanées dans 40 % des cas. Sa reprise en post-DAC ne fait l’objet d’aucune recommandation. Objectifs Étude de la reprise d’une AP (professionnelle ou de loisir) dans les suites d’une DAC et risque de récurrence. Méthodes Étude épidémiologique, monocentrique, non contrôlée, rétrospective et prospective.Critères d’inclusion : patients âgés de dix-huit à cinquante-cinq ans, admis au CHU de Nantes entre le 1/01/2016 et le 31/12/2022 pour une DAC extra-crânienne spontanée et symptomatique, datant de moins de 4 semaines. La reprise d’une activité physique et son délai après la DAC ont été recueillis prospectivement par entretien téléphonique structuré, ainsi que la survenue d’évènement neurovasculaire, en particulier dissection récidivante. Résultats Cent-cinq patients ont été inclus, parmi lesquels 40 % avaient un FDM identifié.Soixante-treize pour cents des patients reprennent une AP (professionnelle ou de loisir) après la DAC.Sur une durée médiane de 5,9 ans, 11 récurrences de DAC sont survenues (10 patients), représentant une incidence annuelle de 1,9 %.Cinq récurrences sont survenues dans le groupe de patients reprenant une AP et six dans le groupe de patients ne reprenant pas d’AP. Discussion La reprise d’une AP dans les suites d’une DAC ne semble pas augmenter le risque de récurrence.L’hypothèse d’une vasculopathie transitoire, suggérée par une proportion significative de DAC multiples et la fréquence des récurrences augmentée les premiers mois qui suivent la DAC, incite à proposer un délai de sécurité de 3–4 mois avant la reprise de l’AP. Conclusion Absence d’argument en faveur d’une majoration du risque de récidive lors de la reprise de l’AP en post-DAC, dans notre étude. Celle-ci semble possible passée la phase aigüe, sans restriction.

BACKGROUND:Reversible cerebral vasoconstriction syndrome (RCVS) is a neurovascular disorder with unclear pathophysiology, particularly concerning systemic endothelial function. Understanding arterial stiffness could shed light on potential systemic vascular involvement in RCVS. OBJECTIVE:This study aimed to investigate systemic endothelial dysfunction in patients with RCVS by assessing arterial stiffness using pulse wave velocity (PWV). METHODS:We conducted a prospective, age- and sex-matched, 1:1 case-control study from January 2020 to January 2023 at Nantes University Hospital. Patients diagnosed with definite RCVS according to ICHD-3 criteria were enrolled as cases; controls were matched individuals without RCVS. All participants underwent PWV measurement as a noninvasive marker of arterial stiffness. Follow-up PWV assessments were performed in RCVS patients at 1 and 3 months after onset. RESULTS:Sixty-two subjects with a mean age of 49.8 years (70% female) were included. One-third of RCVS cases had secondary triggers. Mean systolic and diastolic blood pressures were 130.8 ± 24.0 mmHg and 80.6 ± 1.4 mmHg, respectively, with 29% of patients presenting acute hypertension. No systemic organ dysfunction was observed in cardiac, renal, or hepatic assessments. PWV values at the acute stage showed no significant difference between patients and controls (7.0 vs. 6.4 m.s-1, p = 0.8701). PWV increased transiently from 7.7 to 9.2 m.s-1 at 1 month but returned to 8.1 m.s-1 by 3 months, without statistically significant overall changes (p = 0.5331). CONCLUSION:Systemic arterial stiffness, as measured by PWV, remains normal and stable throughout the course of RCVS even during the acute phase and recovery. TRIAL REGISTRATION:ClinicalTrials.gov, NCT04463212.

BACKGROUND AND OBJECTIVES:Fractional flow reserve (FFR) is a validated tool for assessing epicardial coronary stenosis. In myocardial infarction (MI), microvascular dysfunction may impair hyperemic flow, potentially affecting the interpretation of FFR measurement. The FLOVITA Study (NCT04818918) aimed to assess the impact of prior myocardial necrosis on absolute coronary blood flow and resistance using pressure wire-based continuous thermodilution. METHODS:This prospective pilot study included 40 patients undergoing coronary physiological assessment of the left anterior descending (LAD) artery between May 2021 and February 2024. Patients were stratified into two groups: recent anterior ST-elevation MI (n = 23) and controls without history or imaging evidence of MI (n = 17). Absolute coronary blood flow and microvascular resistance were measured using pressure wire-derived continuous thermodilution. This novel technique allows direct, operator-independent quantification of coronary flow and microvascular resistance, offering high reproducibility. Multivariable linear regression identified factors associated with absolute coronary blood flow. RESULTS:LAD absolute blood flow was significantly lower in the MI group compared to controls (0.169 ± 0.005 vs. 0.215 ± 0.05 L/min; p = 0.006), despite similar FFR values and macrovascular resistance. Infarct size and microvascular resistance were independently associated with reduced flow. Each 10% increase in infarct size was associated with a 0.01 L/min reduction in LAD flow (p = 0.026), while a 100 WU increase in microvascular resistance corresponded to a 0.02 L/min decrease (p < 0.001). CONCLUSION:The FLOVITA study is a proof-of-concept analysis suggesting that MI significantly reduces coronary blood flow through increased microvascular resistance. These findings underscore the importance of accounting for microvascular dysfunction when interpreting post-MI coronary physiology. Registered with ClinicalTrials.gov under the identifier NCT04818918.

Reversible cerebral vasoconstriction syndrome (RCVS) is a rare condition whose exact underlying mechanisms remain undetermined. Herein, we report two exceptional family cases suggesting that a potential genetic factor might be involved in this condition. A mother and her daughter presented with recurrent thunderclap headaches and reversible vasoconstriction of the right middle cerebral artery in the first family. Clinical features suggestive of RCVS associated with a discrete subdural hemorrhage was observed in a mother and her daughter in a second family. These familial observations of RCVS suggest the existence of a genetic factor promoting the emergence of this condition.

BACKGROUND:Central retinal artery occlusion (CRAO) is a subtype of ischaemic stroke that results in acute monocular vision loss. Although open-label studies and meta-analyses have suggested that early intravenous thrombolysis might improve visual acuity, no randomised controlled trials have yet confirmed this benefit. We aimed to compare the safety and efficacy of intravenous alteplase with oral aspirin in patients with CRAO treated within 4·5 h of onset of severe vision loss. METHODS:THEIA was a multicentre, double-dummy, patient-blinded, assessor-blinded, randomised, controlled, phase 3 trial conducted across 16 hospitals with stroke units in France. Adults (aged ≥18 years) presenting with sudden, severe, and persistent monocular vision loss (Snellen <20/400) due to suspected non-arteritic acute CRAO were eligible for inclusion. Participants were randomly assigned (1:1), stratified by centre, to receive either 0·9 mg/kg of bodyweight intravenous alteplase and oral placebo (alteplase group) or 300 mg oral aspirin and intravenous saline placebo (aspirin group) within 4·5 h of symptom onset. Patients, outcome assessors, and the study sponsor were masked to treatment allocation; treating nurses and neurologists were unmasked. The primary efficacy outcome was improvement in visual acuity of at least 0·3 logarithm of the minimum angle of resolution (LogMAR) from baseline to 1 month, analysed in the full analysis set, which included all patients who received the complete intervention and a visual acuity assessment at baseline. Safety outcomes included serious adverse events, particularly intracranial and extracranial bleeding, analysed in all randomly assigned participants. This study is registered at ClinicalTrials.gov (NCT03197194) and is completed. FINDINGS:Between June 8, 2018, and Oct 2, 2023, 70 patients (mean age 70 years [SD 9]; 25 [36%] women and 45 [64%] men) were enrolled and randomly assigned to either the alteplase group (35 [50%]) or the aspirin group (35 [50%]). In total, 65 (93%) patients received the allocated treatment: 34 (97%) in the alteplase group and 31 (89%) in the aspirin group. Mean time from symptom onset to treatment initiation was 232·4 min (SD 43·6). Among 56 patients with available data on the primary endpoint, 19 (66%) of 29 patients in the alteplase group and 13 (48%) of 27 patients in the aspirin group showed an improvement in visual acuity of at least 0·3 LogMAR at 1 month (unadjusted risk difference 17·4 [95% CI -11·8 to 46·5]; adjusted odds ratio 1·1 [95% CI 0·07 to 18·39]; p=0·95). One asymptomatic intracranial haemorrhage related to study treatment was reported in the alteplase group. 14 serious adverse events unrelated to treatment occurred in 11 patients overall (six [17%] in the aspirin group and five [14%] in the alteplase group). No symptomatic haemorrhages or major bleeding related to study treatment were reported. INTERPRETATION:Intravenous alteplase administered within 4·5 h of CRAO onset was not associated with a significant improvement in visual acuity compared with aspirin, despite a higher rate of improvement in the alteplase group. However, the study was likely underpowered to detect a statistical difference. Although no safety concerns related to alteplase were identified, the overall modest recovery rates underscore the need for individual patient-level data meta-analyses with forthcoming randomised controlled trials to clarify the potential benefit of thrombolysis or aspirin in patients with acute CRAO. FUNDING:French Ministry of Health and Boehringer Ingelheim, France.

BACKGROUND:Carotid web is a rare and likely underrecognized cause of ischemic stroke, particularly in young patients. Given the high risk of recurrence, diagnostic delays may have serious consequences. This study aimed to assess the incidence and impact of delayed carotid web diagnosis after a first ischemic event. METHODS:We conducted a retrospective analysis using data from the French ongoing multicenter prospective CAROWEB (Carotid Web registry). We included patients with a first-ever ischemic stroke or transient ischemic attack in the anterior circulation, attributed to an ipsilateral carotid web with no other identifiable cause, between September 2013 and April 2023. Patients with missing data on the date of the first ischemic event or carotid web diagnosis, or with prior stroke history, were excluded. Participants were categorized into early diagnosis (≤30 days) and delayed diagnosis (>30 days) groups. Factors associated with diagnostic delay were investigated through univariable and multivariable analyses. Stroke recurrence was evaluated using Kaplan-Meier survival analysis. RESULTS:Of 280 patients in the registry, 225 met the inclusion criteria. A delayed diagnosis occurred in 57 patients (25.3%). Independent predictors of diagnostic delay included lower initial National Institutes of Health Stroke Scale score (odds ratio, 0.92; P=0.002), stroke occurring before 2019 (odds ratio, 0.19; P<0.001), and the absence of computed tomography angiography in the initial work-up (odds ratio, 0.20; P<0.001). Stroke recurrence was significantly higher in the delayed group (3.6 versus 0.38 per 100 patient-years). After adjusting for the National Institutes of Health Stroke Scale and year of stroke onset, delayed diagnosis was associated with a 5-fold increased risk of recurrence (adjusted hazard ratio, 5.02; P=0.014). CONCLUSIONS:Delayed carotid web diagnosis remains common, especially in minor strokes, in the absence of early computed tomography angiography, and in events before 2019. Such delays are associated with a significantly increased risk of stroke recurrence, highlighting the need for early vascular imaging in ischemic stroke evaluation. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT04431609.

BACKGROUND:The predictive value of very high coronary artery calcium (CAC) scores for guiding invasive angiography in suspected obstructive coronary artery disease (oCAD) remains uncertain. AIM:To assess the positive predictive value (PPV) of high CAC thresholds (>1000 and > 2000 Agatston Units [AU]) for oCAD in real-life patients. METHODS:We prospectively included 300 consecutive adults referred for coronary angiography primarily because of high or very high CAC scores (January 2020-December 2022). Obstructive CAD was defined according to European guideline criteria, combining anatomical and functional assessment. RESULTS:The cohort was 81 % male, mean age 68.9 ± 8.2 years; 24 % were symptomatic. The average clinical pre-test probability, calculated using the Risk Factor-Clinical Likelihood (RF-CL) model, was 0.20 ± 0.07. oCAD was found in 42 % of patients (38 % revascularized). The mean Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score was 12. For CAC >1000 AU, specificity and PPV were 40 % and 50 % (95 % CI 44-57); for CAC >2000 AU, they increased to 86 % and 66 % (95 % CI 54-75) respectively. No threshold achieved the 85 % benchmark to justify angiography as a stand-alone strategy. Multivariate analysis confirmed very high CAC scores as strong modulators of oCAD risk (OR 2.7 for ≥1000 AU; OR 3.6 for ≥2000 AU). CONCLUSION:Even at extreme thresholds (>2000 AU), CAC alone did not reliably identify oCAD in patients with low to moderate RF-CL. CAC remains valuable for refining pre-test probability and guiding the selection of appropriate non-invasive testing.

OBJECTIVE:Peripheral arterial dissections are uncommon, with cervical artery dissections being the most prevalent. Comparative data on the evolution of renal, splanchnic, and coronary dissections are scarce. This study aimed to characterise and assess the prognosis of non-aortic arterial dissections based on their anatomical territories. METHODS:Patients with dissection of cervical, coronary, renal, or splanchnic arteries from 2017 - 2022 that were documented at Nantes University Hospital were included retrospectively. RESULTS:A total of 185 patients were included. Compared with other arterial territories, patients with coronary or vertebral dissections were more frequently females (p = .006), patients with vertebral or renal dissections were younger (p = .009), and patients with splanchnic dissections had more heritable connective tissue disorders (HCTDs) (p = .002); these differences were statistically significant for each comparison with the other groups. Cardiovascular risk factors did not statistically significantly differ according to the territory dissected. Ischaemic complications represented 44.8%, 91.7%, 88.2%, and 20.0% for cervical, coronary, renal, and splanchnic dissections, respectively (p < .001). The median follow up was 19 months (range 1 - 177 months). For all territories, symptomatic recurrence of dissection was observed in 10.3%, and the median time to recurrence was 34 months. Symptomatic dissection recurrence rates for patients with a single dissection at diagnosis and for multiple dissections were 6.8% and 22.2%, respectively (p = .030). In the multiple territories dissection group, there were more females (83.3% vs. 34.2%; p < .001), more HCTDs were identified (11.1% vs. 1.9%; p = .024), and patients were younger (p = .049). CONCLUSION:Patients' clinical phenotypes differed according to the territory initially dissected, with a higher frequency of HCTDs in splanchnic dissections. Dissections affecting several beds or territories at diagnosis were associated with a higher rate of recurrence. These data need to be confirmed in large prospective studies.

Introduction: Predicting the probability of functional independence in patients with primary angiitis of the central nervous system (PACNS) may help guide treatment decisions and prognostication. We sought to develop a prediction model for functional independence in adults with PACNS. Methods: Adults with PACNS were included from an international, multicenter, retrospective, observational cohort (COVAC). Clinical and imaging variables were collected prior to immunosuppressant treatment. Univariable and multivariable logistic regression models were used to identify baseline variables associated with functional independence (modified Rankin Score 0-2), measured 12 months after diagnosis. Results: Among the 194 patients included, 60 (31%) were diagnosed with PACNS based on a positive biopsy. At 12 months, 124 (65%) patients were functionally independent and 12 (6%) were dead. In multivariable logistic regression models, variables predictive of functional independence at 12 months were presence of ≥ 1 intracranial stenosis on CT- or MR-angiogram (aOR 3.33, 95% CI: 1.34-8.77, p=0.01), headache (aOR 2.66, 95% CI: 1.29-5.62, p<0.01), and absence of an altered level of consciousness (aOR 0.09, 95% CI: 0.02-0.28, p<0.001), an acute brain infarct (aOR 0.13, 95% CI: 0.04-0.34, p<0.001), or cognitive impairment (aOR 0.32, 95% CI: 0.15-0.68, p<0.01). A predictive model including these five variables showed good discrimination (c-statistic: 0.79, 95% CI: 0.72-0.86). Purely lymphocytic PACNS (n=34) was not associated with higher odds of functional independence than granulomatous or necrotizing PACNS (n=26) (OR 0.97, 95% CI: 0.33-2.83, p=0.96). Conclusions: This study identified baseline clinical and imaging variables that may predict functional independence in adults with PACNS. Validation of these results is required in an independent cohort.

Complication after carotid artery revascularization is mainly represented by stroke. Reversible cerebral vasoconstriction syndrome triggering by carotid artery revascularization is exceptional but it is an unrecognized aetiology of stroke. It could be associated with brain edema and henceforth, a posterior reversible encephalopathy syndrome can be confused with post-carotid artery revascularization cerebral hyperperfusion syndrome. We reported three cases about reversible cerebral vasoconstriction syndrome following revascularization therapy whose one had also a posterior reversible encephalopathy syndrome. This complication occurred within two weeks after carotid artery revascularization. All took nimodipine and all had a functional improvement at 3-months follow-up. Reversible cerebral vasoconstriction syndrome with posterior reversible encephalopathy syndrome after carotid artery revascularization may mimic cerebral hyperperfusion syndrome. After a comprehensive review, nineteen cases of reversible cerebral vasoconstriction syndrome post-carotid artery revascularization have been reported in the literature mainly after symptoms. It occurs mainly in women around sixty years of age. The onset is expected four days after revascularization.

Introduction: Data on prior use of Tenecteplase versus Alteplase in acute stroke management by mechanical thrombectomy are controversial. Our primary objective was to make a comprehensive comparative assessment of clinical and angiographic efficacy and safety outcomes in a large prospective observational study. Methods: We included stroke patients who were eligible for intravenous thrombolysis and endovascular thrombectomy between 2019 and 2021, from an ongoing registry in twenty comprehensive stroke centers in France. We divided patients into two groups based on the thrombolytic agent used (Alteplase vs Tenecteplase). We then compared their treatment times, and their angiographic (TICI scale), clinical (mRS at three months and sICH) and safety outcomes after controlling for potential confounders using propensity score methods. Results: We evaluated 1131 patients having undergone thrombectomy for the final analysis, 250 received Tenecteplase and 881 Alteplase. Both groups were of the same median age (75 vs 74 respectively), and had the same baseline NIHSS score (16) and ASPECTS (8). There was no significant difference for First Pass Effect (OR 0.93, 95 % CI 0.76-1.14, p = 0.75), time required for reperfusion (OR 0.03, 95 % CI 0.09-0.16, p = 0.49), or for final reperfusion status. Clinically, functional independence at 90 days was similar in both groups (OR 0.82, 95 % CI 0.61-1.10, p = 0.18) with the same risk of sICH (OR 1.36, 95 % CI 0.77-2.41, p = 0.28). However, Tenecteplase patients had shorter imaging-to-groin puncture times (99 vs 142 min, p < 0.05). Conclusions: Tenecteplase showed no better clinical or angiographic impact on thrombectomy compared to Alteplase. Nevertheless, it appeared associated with a shorter thrombolysis-to-groin puncture time. (c) 2024 Elsevier Masson SAS. All rights reserved.

Background: Impingement of an elongated styloid process (ESP) or calcified stylohyoid ligament on surrounding neck structures defines Eagle syndrome. The vascular variant, also called stylocarotid syndrome, results from impingement of vascular structures and remains poorly known among physicians.Research Design: We report our own experience and review the literature in order to clarify the diagnostic and therapeutic management. Patients with vascular events in relation to an ESP and hospitalized at our institution were extracted from our databank and retrospectively reviewed. We also performed a comprehensive review of the literature on Eagle syndrome using PubMed (R) and Google Scholar, analysing the presentation, management, and follow-up.Results: We report five cases of the vascular variant of Eagle syndrome: one carotid perforation, one focal arteriopathy, one with both acute and chronic dissection and two acute internal carotid dissection. Vascular compression, whether permanent or transient, is also reported in the literature. Management varies, although styloidectomy is deemed appropriate for symptomatic compression, while stenting is preferred in cases of perforation.Conclusions: A common definition of Eagle syndrome is required for better diagnosis and management. The choice of styloidectomy is understandable for compression but remains to be investigated in other cases.