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There is a lack of consensus on indications for carotid stenting in the field of neurointervention, despite the widespread use of this intervention for a variety of reasons including inoperability. A number of publications have addressed the use of distal protection devices, and have concluded that these devices do not benefit the (imaging) outcome of patients. A potential explanation may be that the devices used are not adequately functioning or that the passage through the stenosed portion in itself carries risk. Furthermore, the use of proximal protection devices has to date resulted in highly complicated procedures and involves very expensive equipment. We describe two cases in which a proximal protection and aspiration with the Penumbra pump was utilized with only limited minimal modification to the usual procedure.

INTRODUCTION: Antiplatelet premedication policy for patients scheduled for endovascular treatment of stent-assisted coiling has become routine practice to avoid thrombotic complications. However, clopidogrel resistance remains a serious clinical challenge in predicting and preventing thrombotic complications. Measuring platelet activity is still an uncertain method for predicting clinical outcome and pharmacogenetic testing has not yet been proven as useful and cost-effective in clinical practice. We aimed to compare CYP2C19 polymorphism and MDR1 variances with point-of-care aggregometry test results in clopidogrel premedicated patients with non-ruptured intracranial aneurysms who were scheduled for stent-assisted endovascular treatment. METHODS: We designed a prospective study for our patient cohort with planned elective endovascular treatment. All patients were premedicated for the endovascular intervention with oral dual antiagregation therapy. In selected patients we analysed and compared demographic data, localisation of the aneurysm, endovascular material used, results of genetic analysis, results of the ADPtests for clopidogrel, dosing regimen for clopidogrel and incidence of angiographic and/or clinical complications. We compared and statistically analysed correlation between pharmacogenetic findings, aggregometry results and complication rates. RESULTS: We did not find a correlation between pharmacogenetic finding and aggregometry results. However, there was a statisticaly significant correlation between pharmacogenetic polymorphism of CYP2C19 and complication rate and a trend showing correlation between MDR1 variations and aggregometry results. CONCLUSION: CYP2C19 polymorphism as well as transport MDR1 activity are, according to our results, parameters which could be helpful in predicting possible complications and choosing another therapeutic approach in certain patient groups.

INTRODUCTION: Telestroke systems as known today used currently recommend imply transfer of patients with acute strokes to Community Hospitals (CommH) that cannot offer endovascular procedures (EVT). The primary benefit of this policy relies on the fact that intravenous ( tissue plasminogen activator (iv-tPA) one, may be offered earlier and two, unnecessary transfers to Comprehensive Stroke Centers (CSC) can be avoided. However, this strategy may generate time delays in potential EVT candidates. This study aimed to quantify the potential benefits and disadvantages of this strategy.

 METHODS: From March 2013 to March 2014, 533 teleconsults were centrally attended by stroke neurologists in the Catalan telestroke system that covers 105 CommH. We defined criteria to identify potential EVT candidates ion the f-field or in the CommH after teleconsultation (clinical and radiological).

 RESULTS: 
Eighty-four patients (15.7 %) could have been identified on-in the field before arrival to CommH as potential EVT candidates. Once at the CommH, of these 84 patients, 60 (71 %) were still potential EVT candidates after CT-scan and teleconsultation. Of these 84 patients, only 27 (32 %) received iv-TPA in the CommH; however 68 (80 %) were still emergently transferred to CSC, where only 13(19 %) finally received EVT. The median time from CommH-door to groin puncture was 216 min vVs CSC-door to groin 152 min for primary CSC admissions (p<0.01).
 CONCLUSIONS: 
Present telestroke systems offer safe and timely iv-tPA treatment to eligible patients but may induce a considerable time loss in EVT candidates. Only a third1/3 of the on-field potential EVT candidates benefit from admission in a CommH when being treated with iv-tPA, while more than three quarters 3/4 will still be transferred to the CSC.

We report a case of a 54-year-old man with an occluded straight sinus and dural AV-fistula. The patient was treated with PTA dilatation and stenting of the occluded straight sinus. A review of literature revealed no similar therapy has to date been described.

Early and complete recanalisation is the main goal to achieve in acute ischaemic stroke from arterial occlusion. Although intravenous (IV) thrombolysis is the standard therapy, its efficacy is limited in the setting of proximal arterial occlusion; however, systemic thrombolysis and endovascular therapy presents similar safety outcomes. Mechanical thrombectomy with the latest generation stent-retrievers allows a fast and a complete arterial recanalisation. We report a case of a patient with an acute basilar artery occlusion treated by a combined therapy (IV thrombolysis and mechanical thrombectomy). A complete recanalisation was rapidly obtained during the mechanical thrombectomy procedure, prior to termination of the IV thrombolysis. Early and complete recanalisation is the main goal to achieve in acute ischaemic stroke with arterial occlusion [1]. Intravenous (IV) thrombolysis is the standard therapy; however endovascular mechanical thrombectomy using stent-retrievers has been recently shown to provide fast, complete recanalisation [2]. We report here a case of a patient with an acute basilar artery occlusion, treated by a combined therapy (IV thrombolysis and mechanical thrombectomy). Complete recanalisation had been rapidly obtained during the mechanical thrombectomy procedure, prior to termination of the IV thrombolysis. A 56-year-old man developed an acute right hemiplegia and anarthria during a stenting procedure of a post-radiotherapy left extracranial internal carotid stenosis. Time of onset of symptoms was 16:15, and the patient was admitted to our stroke center at 18:20. NIH Stroke Scale (NIHSS) score on admission was 19 (right hemiplegia, anaesthesia, ophthalmoparesis and anarthria). An MRI was performed at 18:38 revealing a left latero-pontine infarct distal to an acute basilar artery occlusion. Due to the location of the occlusion, a combined therapy was initiated. First bolus dose of rt-PA (10 % dose, 5 mg) was administrated at 19:00 (165 min after the deficit onset). The femoral artery was punctured at 19:15 under local anaesthesia. Angiogram proved the persistence of a complete occlusion, 15 min after the first bolus of IV thrombolysis. The microcatheter was navigated and positioned in the right P1 posterior cerebral artery at 19:26. A Solitaire FR stent 4 x 20 mm was deployed at 19:40 and a complete recanalisation was observed at 19:46 (211 min after stroke onset, 31 min after femoral puncture and 46 min after initiation of rt-PA infusion). The IV thrombolysis ended at 20:00. The NIHSS score was 4 at 20:00 and 1 the next day.

INTRODUCTION: Similarities between chronic fatigue syndrome and idiopathic intracranial hypertension (IIH) invite speculation that they may be related. Cranial venous outflow obstruction plays a role in the development of IIH. Could it be a factor in chronic fatigue? This paper attempts to evaluate an investigative approach to chronic fatigue syndrome that allows for this possibility. METHODS: Since 2007, patients attending a specialist clinic at our institution diagnosed with chronic fatigue syndrome and with prominent headache have been offered CT venography, lumbar puncture and a trial of cerebrospinal fluid withdrawal looking for IIH. Also, if CT venography revealed focal narrowing of the jugular veins, patients were offered catheter cerebral venography and jugular venoplasty attempting to establish their clinical significance. RESULTS: In the 29 patients investigated to date, the mean cerebrospinal fluid (CSF) pressure was 19 cm H2O (range 12 – 41 cm H2O). Twenty-five patients responded positively to CSF withdrawal and in 5 the CSF pressures were high enough to allow an unequivocal diagnosis of IIH while in the remaining 20, symptoms improved with lumbar puncture even though CSF pressures were within the normal range. Twenty-one patients had focal narrowing of one or both internal jugular veins on CT venography. Fourteen of these have had jugular venoplasty, all of whom reported an improvement in symptoms afterwards lasting from a few minutes to more than 1 month. CONCLUSIONS: Chronic fatigue syndrome may represent an incomplete form of IIH. Cranial venous outflow obstruction deserves further investigation as a possible aetiological factor.

Stent-retriever devices achieve high rates of recanalisation in acute ischaemic stroke with proximal arterial occlusion. In the setting of distal occlusion such as M2 middle cerebral artery occlusion, stent-retrievers seem safe and recanalisation may double the chances of achieving a favourable outcome. In posterior circulation, technical feasibility, efficacy and safety of stent-retrievers are poorly documented. A 61-year-old man presented with an ischaemic stroke secondary to acute basilar artery occlusion. Mechanical thrombectomy with the Solitaire device was performed and complete recanalisation of basilar artery was achieved; however, a right P2 posterior cerebral artery occlusion was observed due to clot fragmentation. A complete distal artery recanalisation was achieved rapidly after a second passage of the stent-retriever. MR imaging on day 1 revealed a similar volume ischaemic lesion without haemorrhagic event. This case illustrates the feasibility, efficacy and safety of distal P2 posterior circulation occlusion recanalisation with a stent-retriever.

INTRODUCTION: Vertebro-vertebral arteriovenous fistulas (VVFs) are abnormal communications between the extracranial vertebral artery and one or multiple neighboring veins. We report an unusual case of a 72-year old woman with a single high-flow VVF between the left vertebral artery and the significantly dilated surrounding epidural venous plexus, located in the intervertebral foramina at the C2 level, after a craniocervical blunt injury, manifesting as progressive severe left arm paresis. METHODS: From a transarterial approach, the fistula venous site was selected with a microcatheter, and several Guglielmi detachable coils were deployed inside the venous part up to the fistula orifice until complete VVF occlusion was obtained maintaining the left vertebral arterial patency. RESULTS: Muscle strength of patient’s left arm improved completely. CONCLUSION: Endovascular selective occlusion of the VVFs is the treatment of choice and every effort should be made to preserve parent vessel patency according to fistula’s angioarchitecture and physician’s technical experience.

INTRODUCTION: Mechanical thrombectomy (MT) with stent-retrievers is increasingly used in acute ischemic stroke (AIS) treatment. Because patients undergoing such interventions typically do not cooperate, conscious sedation or general anesthesia is required. This study aims to analyse the technical feasibility and efficacy of MT under conscious sedation with a particular emphasis on procedural complications. METHODS: Consecutive patients with AIS who underwent MT with a stent-retriever from May 2010 to March 2014 at our center were prospectively included. Clinical and imaging data from presentation to 3-months were collected. Technical feasibility of MT, efficacy, safety and intra-procedural complications were reported. We also compared outcomes between agitated and calm patients. RESULTS: Among 103 patients intended to treat, 92 underwent MT under conscious sedation. MT was feasible in 83/92 patients (90.2 %). Successful (TICI≥2b) and partial or complete revascularisation (TICI≥2a) was achieved in 46/92 (50.0 %) and 56/92 (60.9 %) patients respectively. Procedural complications were: agitation in 17/92 (18.5 %), haemodynamic instability in 8/92 (8.7 %), respiratory failure in 2/92 (2.2 %), arterial dissection in 2/92 (2.2 %), and inhalation pneumonia in 3/92 (3.3 %). At 3 months, 44/92 patients (47.8 %) had a good neurological outcome (mRS≤2), mortality was 20.7 % (19/92) and symptomatic haemorrhage rate 7.6 % (7/92). Feasibility was lower in agitated than non-agitated patients (64.7 % vs 96.5 %, p=0.0005). CONCLUSION: MT under conscious sedation is feasible in most cases (90.2 %) with acceptable clinical and angiographic results. The frequency of procedure-related complications lies within acceptable limits for an emergency procedure. Technical feasibility decreases when the patient is agitated (64.7 %).