Cerebral stroke secondary to cisplatin-based chemotherapy in young patients undergoing chemotherapy for testicular germ cell tumour (GCT) has been reported only sporadically. Here, we report a 49-year-old man undergoing adjuvant chemotherapy with one cycle of bleomycin, etoposide, and cisplatin for nonseminomatous testicular GCT clinical stage 1b. On the sixth day of treatment, a sudden onset of right-sided hemiparesis and aphasia prompted computed tomography and angiography. An occlusion of the left middle cerebral artery was detected. The patient recovered after immediate thrombolytic therapy, but minor neurological deficits were present 9 months after the event. Among 221 GCT patients undergoing cisplatin-based chemotherapy during 2017-2025, one stroke occurred, revealing a relative incidence of 0.45% in this cohort. A literature survey yielded 31 previous GCT cases with a median age of 35 years, most of them were caused by occlusion of brain supplying arteries. Thrombotic occlusions of brain-supplying arteries secondary to cisplatin-based chemotherapy can arise in otherwise healthy young men with no risk factors for vascular disease. Care givers of GCT patients must be cognizant of such events upon counselling patients before chemotherapy, because this complication of treatment may foil the attempts of restoring health in a basically well curable disease.

Background: Cerebrovascular events are a potentially serious complication of giant cell arteritis (GCA) with intracranial involvement. However, diagnosing GCA in this context remains challenging, as classical clinical features may be absent.Objectives: To identify characteristic cerebellar infarct patterns associated with intracranial GCA and to differentiate them from other common causes of posterior circulation stroke.Design: Multicenter retrospective study.Methods: A total of 125 patients with cerebellar infarctions of various etiologies were included. Among these, 19 patients had confirmed intracranial GCA. Infarct patterns were compared to those seen in strokes of cardioembolic origin (n = 42), arterio-arterial embolism from proximal vertebral artery atherosclerosis (n = 13), local atherosclerotic stenosis of the V4 segment (n = 21), and vertebral artery dissection (n = 30). Infarct topography was assessed using acute-phase diffusion-weighted magnetic resonance imaging. Sensitivity and specificity were calculated for individual imaging features.Results: Distinct imaging signatures were observed in patients with GCA. A "corona-like" infarct pattern, defined by sparing of the medial branch of the proximal posterior inferior cerebellar artery (PICA), demonstrated a sensitivity of 79% and a specificity of 64%. A patchy infarct pattern, characterized by scattered non-confluent lesions, was present in 53% of GCA cases and showed high specificity (93%). When both features were present, specificity increased to 98% and sensitivity was reduced to 47%.Conclusion: Our findings reveal a distinct cerebellar infarct pattern associated with intracranial GCA, characterized by a corona-like configuration and patchy lesions predominantly involving the lateral PICA territory. Recognition of this imaging phenotype may enhance diagnostic accuracy in challenging cases and facilitate the timely initiation of immunosuppressive therapy.

BackgroundA direct aspiration first pass technique (ADAPT) is an effective alternative to stent retriever thrombectomy for patients with large vessel occlusion (LVO). The PERFECT study evaluated direct aspiration with the EMBOVAC large bore aspiration catheter in patients with LVO strokes.MethodsPERFECT was a prospective, post-market, single-arm, multicenter, observational study of patients enrolled across 11 European centers between October 2020 and July 2022. Three direct aspiration passes with EMBOVAC were mandated before switching strategy. The primary endpoint was core-lab assessed successful reperfusion (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2b) post-procedure. Other outcomes included first pass mTICI ≥2c, independent 90-day modified Rankin Scale (mRS) evaluation, and symptomatic intracerebral hemorrhage (sICH) at 24 hours by a clinical events committee.ResultsEMBOVAC was used in 100 patients (mean age 70.4±14.0 years, 59.0% (59/100) female). Final mTICI ≥2b was achieved in 98.0% (97/99), final mTICI ≥2b with no change in frontline therapy or thrombolytics use during the procedure was achieved in 87.9% (87/99), final mTICI ≥2c in 86.9% (86/99), and first pass mTICI ≥2c in 53.5% (53/99). sICH at 24 hours was 0%. The 90-day mRS ≤2 rate was 56.6% (56/99) and all-cause mortality was 12.9%. One device-related serious adverse event occurred within 90 days (1.0%).ConclusionsPERFECT demonstrates that EMBOVAC achieves successful reperfusion rates and favorable clinical outcomes when used in the endovascular treatment of acute ischemic stroke (AIS) using a direct aspiration technique as first line therapy in a real-world setting in patients with AIS secondary to large vessel occlusion.Trial registrationwww.clinicaltrials.govUnique identifier:NCT04531904.

Rescue intracranial stenting is necessary to provide sufficient recanalization after mechanical thrombectomy (MT) in patients with acute large vessel occlusions (LVO) due to an underlying intracranial atherosclerotic disease (ICAD). The CREDO heal is a novel stent that provides a potentially lower thrombogenicity due to surface modification. We present the first multicentric experience with the CREDO heal for acute rescue stenting. Data of 81 patients who underwent rescue stenting after MT at 12 centers in Germany and Spain were prospectively collected and retrospectively evaluated. Final mTICI 2b‑3 was reached in 95.1

Zielsetzung Identifizierung unabhängiger Behandlungsfaktoren, die mit einer hohen Strahlenexposition während der mechanischen Thrombektomie (MT) beim akuten ischämischen Schlaganfall verbunden sind.

Introduction EMBOVAC is a large bore aspiration catheter with an inner diameter of 0.071'. Aim of Study PERFECT (NCT04531904, CERENOVUS) was a prospective, post-market, single-arm study to assess direct aspiration with EMBOVAC as first line therapy in patients with large vessel occlusion and analyse the composition of retrieved thrombus. Methods Subjects were enrolled and followed across 11 European centres between October 2020 and July 2022. A minimum of 3 direct aspiration passes with EMBOVAC were mandated before switching strategy. The primary endpoint was core-lab assessed successful reperfusion (mTICI≥2b) post-procedure. Other outcomes included 90-day mRS by an independent evaluator, symptomatic intracerebral hemorrhage by an independent Clinical Events Committee, and clot analysis by an independent central clot lab. Results Final mTICI≥2b was achieved in 98.0% (97/99) while final mTICI≥2c was reached in 86.9% (86/99) of patients. Final mTICI≥2b without rescue was reached in 87.9% (87/99). First pass mTICI≥2c without rescue was achieved in 53.5% (53/99). mRS≤2 at 90 days was 56.6% (56/99). All-cause mortality at 90 days was 12.9%. No patients experienced sICH at 24 hours post-procedure. One device-related SAE occurred within 90 days. Composition analysis revealed median 54.80% red blood cells and 24.90% fibrin. Conclusion This is the first clinical evaluation of EMBOVAC. Direct aspiration with EMBOVAC as first line therapy resulted in high rates of reperfusion and favorable clinical outcomes. Clot composition analysis can aid in better understanding of the stroke etiology and means for effective clot removal. Disclosure of Interest Acandis (OJ, CL, JF); Microvention (GM, CC, JF); Stryker (GM, CC, JF); Medtronic (GM, CC, JF); Surge2surgery (BG); MIVI (CC); Phenox (CL, JF); Penumbra (CL, JF); GSK (AS); German Ministry of Science & Education and Economy & Innovation, EU, Hamburgische Investitions-/Förderbank, Philips, Bayer, Boehringer Ingelheim, Cerenovus, Covidien, Evasc Neurovascular, MD Clinicals, Medina, Roche, Route92, Tonbridge, Transverse Medical, Tegus Medical, Vastrax (JF); Science Foundation Ireland (KD), KL, HN, BE, AP, SB, AM, MP: nothing to disclose.

Purpose Flow arrest using a balloon guide catheter (BGC) in mechanical thrombectomy (MT) due to large vessel occlusion has been associated with better outcomes. Known limitations of currently commercially available BGCs are incompatibility with large bore aspiration catheters (AC) and lack of distal flexibility. Walrus presents variable stiffness and compatibility with large bore AC. The goal of this study is to describe the first experience with Walrus in a realistic stroke simulation model. Methods A full-length modular vascular model under physiological conditions was used. 8F + -Walrus inner-diameter (ID) 0.087in 95 cm combined with 6F-Sofia AC ID 0.070in 131 cm and an 8F-Flowgate2 BGC ID 0.084in 95 cm with a 5F-Sofia AC ID 0.055in 125 cm were used to perform aspiration MT. User surveys, access to target and occlusion site, technique, time of delivery, anatomical change, and catheter kick-back were assessed. Results Seven neuroradiologists with average of 10 years-experience in MT performed primary aspiration using the above-mentioned combinations in three different anatomies ( N = 41). All operators would likely (29%) or very likely (71%) use again Walrus in combination with large bore AC and the majority (86%) found its navigability easier than with other BGCs. Time to reach final BGC position and catheter kick-back did not differ significantly among anatomies or catheter combinations ( p > 0.05). However, Walrus was more likely to reach ICA petrous segment ( p < 0.05) and intracranial occlusion with AC ( p < 0.01). Conclusion The Walrus combined with large bore AC presented significantly better distal access and navigability for primary aspiration in an in vitro stroke model.

Background and Purpose: Rapid access to acute stroke treatment improves clinical outcomes in patients with ischemic stroke. We aimed to shorten the time to admission and to acute stroke treatment for patients with acute stroke in the Hamburg metropolitan area by collaborative multilevel measures involving all hospitals with stroke units, the Emergency Medical Services (EMS), and health-care authorities. Methods: In 2007, an area-wide stroke care quality project was initiated. The project included mandatory admission of all stroke patients in Hamburg exclusively to hospitals with stroke units, harmonized acute treatment algorithms among all hospitals, repeated training of the EMS staff, a multimedia educational campaign, and a mandatory stroke care quality monitoring system based on structured data assessment and quality indicators for procedural measures. We analyzed data of all patients with acute stroke who received inhospital treatment in the city of Hamburg during the evaluation period from the quality assurance database data and evaluated trends of key quality indicators over time. Results: From 2007 to 2016, a total of 83,395 patients with acute stroke were registered. During this period, the proportion of patients admitted within ≤3 h from symptom onset increased over time from 27.8% in 2007 to 35.2% in 2016 (p < 0.001). The proportion of patients who received rapid thrombolysis (within ≤30 min after admission) increased from 7.7 to 54.1% (p < 0.001). Conclusions: Collaborative stroke care quality projects are suitable and effective to improve acute stroke care.

Identification of independent treatment factors associated with high radiation exposure during endovascular mechanical thrombectomy (EMT) in acute ischemic stroke. This retrospective analysis included all patients treated by means of EMT during the 2‑year period 2017–2018 in a comprehensive stroke center. The EMT were performed by four internal and three external certified neuroradiologists in a clinic overlapping on call system. Radiation exposure as the dependent variable (dose area product DAP, Gy ⋅ cm2) was dichotomized in < 100 Gy ⋅ cm2 and ≥ 100 Gy ⋅ cm2. Independent variables were age (< 75 years vs. ≥ 75 years), time of intervention (during vs. beyond workday), treating neuroradiologist (internal vs. external), occlusion type (“mono” vs. “tandem”), reperfusion success (TICI 0–2A vs. TICI 2B/3), recanalization attempts (≤ 2 vs. > 2) and dose protocol (normal dose in 2017 vs. low dose in 2018). The EMT treatment of 208 patients (111 female, 97 male, mean age 71.6 years) was analyzed. Median DAP was 86.6 Gy ⋅ cm2 and could be reduced from 104.8 Gy ⋅ cm2 (N = 105 in 2017) to 73.3 Gy ⋅ cm2 (N = 103 in 2018) with LD program. Univariable and multivariable binary logistic regression analysis revealed a significantly increased radiation exposure (≥ 100 Gy ⋅ cm2) in tandem occlusion type (P < 0.001), > 2 recanalization attempts (P < 0.001) and normal dose protocol (P = 0.002). Low dose programs can significantly reduce the radiation exposure in EMT. High radiation exposure is significantly associated with more than two recanalization attempts and in cases of tandem occlusions.

Background: Dissections of the cervical brain-supplying arteries are a leading cause of ischemic stroke in young adults, with an annual incidence of 2.5-3 / 100 000 for carotid artery dissection and 1-1.5 / 100 000 for vertebral artery dissection. It can be assumed that many cases go unreported. We present the clinical features here to help physicians diagnose this disease entity as rapidly as possible. Methods: This review is based on pertinent publications retrieved by a selective search in PubMed. Results: Spontaneous dissection of the internal carotid or vertebral artery is characterized by a hematoma in the vessel wall. It often arises in connection with minor injuries; underlying weakness of the arterial wall (possibly only temporary) may be a predisposing factor. Acute unilateral pain is the main presenting symptom. In internal carotid dissection, the site of the pain is temporal in 46% of cases, and frontal in 19%; in vertebral artery dissection, it is nuchal and occipital in 80%. Pain and local findings, such as Horner syndrome, are generally present from the beginning, while stroke may arise only after a latency of hours to days. If the diagnosis is made early with MRI, CT, or ultrasound, and anticoagulation or antiplatelet drugs can help prevent a stroke, yet none of these methods can detect all cases. Recurrent dissection is rare, except in patients with connective tissue diseases such as Ehlers-Danlos syndrome or fibromuscular dysplasia. Spontaneous dissection of the great vessels of the neck must be differentiated from aortic dissection spreading to the supra-aortic vessels and from traumatic dissection due to blunt or penetrating vascular trauma. Conclusion: Dissection of the cervical brain-supplying vessels is not always revealed by the imaging methods that are used to detect it. Stroke prevention thus depends on the physician's being aware of the symptoms and signs of this disease entity, so that early diagnosis can be followed by appropriate treatment.

We report the first case of de novo formation of a small 4- × 3-mm symptomatic aneurysm with subsequent subarachnoid haemorrhage (SAH) within 15 days. A pre-existing aneurysm was excluded by magnetic resonance angiography, as well as conventional angiography. In this case, there was no history of SAH, which is in contrast to other reported cases of de novo aneurysms that developed after previous aneurysm rupture.

Objective The objective of this study was to characterize patients with extracranial giant cell arteritis with intracranial involvement. Methods In a multicenter retrospective study, we included 31 patients with systemic giant cell arteritis (GCA) with intracranial involvement. Clinical characteristics, pattern of arterial involvement, and cytokine profiles were assessed. Patients with GCA without intracranial involvement (n = 17), and with intracranial atherosclerosis (n = 25) served as controls. Results Erythrocyte sedimentation rate (ESR) was elevated in 18 patients (69.2%) with and in 16 patients (100%) without intracranial involvement ( p = 0.02). Headache was complained by 15 patients (50.0%) with and 13 patients (76.5%) without intracranial involvement ( p = 0.03). Posterior circulation arteries were affected in 26 patients (83.9%), anterior circulation arteries in 17 patients (54.8%), and both territories in 12 patients (38.7%). Patients with GCA had vertebral artery stenosis proximal and, in contrast, patients with atherosclerosis distal to the origin of posterior inferior cerebellar artery (PICA). Among patients with GCA with intracranial involvement, 11 patients (37.9%) had a rapid progressive disease course characterized by short‐term recurrent ischemic events. The median modified Rankin Scale (mRS) at follow‐up in these patients was 4 (interquartile range [IQR] = 2.0–6.0) and 4 patients (36.4%) died. Vessel wall expression of IL‐6 and IL‐17 was significantly increased in patients with rapid progressive course. Interpretation Typical characteristics of GCA, headache, and an elevated ESR, are frequently absent in patients with intracranial involvement. However, differentiation of intracranial GCA from atherosclerosis can be facilitated by the typical pattern of vertebral artery stenosis. About one‐third of patients with intracranial GCA had a rapid progressive course with poor outcome. IL‐17 and IL‐6 may represent potential future treatment targets. ANN NEUROL 2021;90:118–129

BACKGROUND:Normal pressure hydrocephalus is a disease in elderly patients and one of the most common causes of treatable dementia. It occurs frequently with microangiopathy and Alzheimer's disease, so that differential diagnosis plays an important role. This is crucially determined by imaging findings. Therapy consists of cerebrospinal fluid drainage through a shunt, which should be performed as early as possible to improve the chances of success. METHOD:This report is based on a summary of the relevant literature that has been reviewed in PubMed with reference to epidemiology, symptoms, pathophysiology, diagnostics, and therapy. The results were supplemented by the joint guidelines of the German Society of Neurology and the German Society of Neurosurgery. RESULTS AND CONCLUSION:The understanding of the pathophysiologic changes leading to normal pressure hydrocephalus has expanded significantly in recent years to include concepts explaining relevant comorbidities. Diagnosis is based on radiological and clinical indicators, although accurate differentiation with respect to comorbidities is not always possible. A high response rate to treatment can be achieved by good patient selection. Positive prognostic markers for therapeutic success include Disproportionately Enlarged Subarachnoid Space Hydrocephalus (DESH), short disease duration, predominant gait disturbance, and few comorbidities. KEY POINTS:· Normal pressure hydrocephalus mainly affects patients older than 65 years of age with high comorbidity rate for microangiopathy and Alzheimer's disease. · Radiologic findings play an important role in the diagnosis and follow-up after shunting. · The earlier a shunt is placed, the better the outcome. CITATION FORMAT:· Illies T, Eckert B, Kehler U. What Radiologists Should Know About Normal Pressure Hydrocephalus. Fortschr Röntgenstr 2021; 193: 1197 - 1206.

OBJECTIVE:In this retrospective observational study and referring to a historical case presented in 2009, we searched for typical clinical and imaging features of brainstem encephalitis in neuroborreliosis.METHODS:In addition to the historical case we describe five affected patients.RESULTS:All patients had a very similar prolonged clinical course with unspecific symptoms such as wasting, fatigue and headache. Brainstem signs were irregularly observed. MRI showed symmetrical brainstem alterations in all patients. In coronary FLAIR imaging these changes formed a figure resembling a Philippine tarsier.CONCLUSIONS:A subset of patients with neuroborreliosis develops a brainstem encephalitis with a typical clinical course and distinct MRI findings.

Background and Purpose-Using a novel study design with virtual comparators based on predictive modeling, we investigated whether next-generation mechanical thrombectomy devices improve outcomes in patients with ischemic stroke. We hypothesized that this new study design shows that a next-generation mechanical thrombectomy system is superior to intravenous tPA (tissue-type plasminogen activator) therapy (IVT) alone. Methods-ERASER (Eric Acute Stroke Recanalization) was an investigator-initiated, prospective, multicenter, single-arm (virtual 2-arm) study that evaluated the effectiveness of a new recanalization device together with a specific intermediate catheter (Embolus Retriever with Interlinked Cages/SOFIA, Microvention) in stroke patients with internal carotid artery or middle cerebral artery occlusions. The primary end point was the volume of saved tissue. Volume of saved tissue was defined as the difference of actual infarct volume and brain volume predicted to develop infarction using a machine learning model based on data from intravenous tPA therapy patients. Results-Eighty-one patients were enrolled. The median patient age was 71 years (interquartile range, 61-77). National Institutes of Health Stroke Scale score was 14 (interquartile range, 12-18). The actual infarct volume was smaller than predicted by the intravenous tPA therapy model, with a median volume of saved tissue of 50 mL (interquartile range, 19-103; P<0.0001). Good clinical outcome (modified Rankin Scale, 0-2 at 90 days) was observed in 48 out of 69 (70%). The recanalization rate (Thrombolysis in Cerebral Infarction 2b/3) was 95%. Conclusions-ERASER is the first mechanical thrombectomy study with a primary end point based on predictive analytics enabling intraindividual virtual comparisons. The next-generation mechanical thrombectomy method resulted in smaller infarcts than predicted after intravenous tPA therapy alone and showed a high rate of good clinical outcome. The novel study design with virtual comparisons is promising for further application and testing in the neurovascular arena.

Posterior reversible encephalopathy syndrome (PRES) is a multipathological entity with a common ending point-dysfunction of the blood-brain barrier and formation of vasogenic edema, defined by a unique brain magnetic resonance (MR) imaging pattern with white matter abnormalities. Among atypical underlying causes, intracranial hypotension has been reported in few cases. We present what we believe to be another case of PRES possibly associated with intracranial hypotension, in absence of other known contributing factors. A 68-year-old woman with a dural tear was treated with lumbar liquor drainage and judged to have been cured. Three weeks later she suddenly presented with somnolence, agitation and disorientation. Brain MR showed hyperdense cortico-subcortical FLAIR lesions predominately in both occipital lobes. None of the typical predisposing factors were present. During the following 4 weeks the symptoms regressed significantly without any treatment, with follow up MRI also showing a clear remission of the hyperintense lesions in the temporal and occipital lobes. Data from individual cases suggest that intracranial hypotension may lead to PRES-like radiological patterns. Further observations are necessary to confirm this hypothesis and establish a pathological theory that would bind the two entities. The working theory could be based on compensatory vein dilatation and stagnation of venous flow leading to cytotoxic edema.