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The sudden worldwide outbreak of Coronavirus Disease 2019 (COVID-19) has certainly provided new challenges in the management of acute ischaemic stroke, and the risk-benefit ratio of intravenous thrombolysis in COVID-19 positive patients is not well known. We describe four COVID-19 patients treated with intravenous thrombolysis for acute ischaemic stroke. Although rt-PA administration is the main therapeutic strategy, our patients experienced unpredictable complications and showed atypical features: the overall mortality was very high. In conclusion, in this article, we provide information about these cases and discuss the possible explanation behind this trend.

•Significant correlation between older age and location in basal ganglia.•Larger lacunar strokes are more severe.•Older age correlates with smaller and regular lesions. We evaluated a prospective cohort of 150 patients under observation in our centre for lacunar strokes. The purpose of this study was to investigate if lacunar stroke of varying size, shape and locations had different risk factors between them and possibly different mechanisms and causes. 150 patients with a lacunar stroke were included in the present study. Infarcts were classified by size, shape and location. We evaluated the correlation between several risk factors of stroke and the radiological characteristics of the infarcts. Older age was associated with the presence of a basal ganglia lesion (p < 0.001) and with the presence of a smaller lesion (trend to statistical significance, p = 0.07). Patients with infarcts >15 mm had higher NIHSS score at admission (p 0.01). The different subtypes of lacunar infarcts have distinct pathogenesis. Further studies, with a larger numbers of patients, are necessary to confirm our data.

Background We aim to assess the association between procedural time and outcomes in patients in unsuccessful mechanical thrombectomy (MT) for anterior circulation acute stroke. Methods We conducted a cohort study on prospectively collected data from patients with M1 and/or M2 segment of middle cerebral artery occlusion with a thrombolysis in cerebral infarction 0–1 at the end of procedure. Primary outcome was 90-day poor outcome. Secondary outcomes were early neurological deterioration (END), symptomatic intracranial hemorrhage (sICH) according to ECASS II and sICH according to SITS-MOST. Results Among 852 patients, after comparing characteristics of favourable and poor outcome groups, logistic regression analysis showed age (OR: 1.04; 95%CI: 1.02–1.05; p  < 0.001), previous TIA/stroke (OR: 0.23; 95%CI: 0.12–0.74; p  = 0.009), M1 occlusion (OR: 1.69; 95%CI: 1.13–2.50; p  = 0.01), baseline NIHSS (OR: 1.01; 95%CI: 1.06–1.13; p  < 0.001) and procedural time (OR:1.00; 95% CI: 1.00–1.01; p  = 0.003) as independent predictors poor outcome at 90 days. Concerning secondary outcomes, logistic regression analysis showed NIHSS (OR:0.96; 95%CI: 0.93–0.99; p  = 0.008), general anaesthesia (OR:2.59; 95%CI: 1.52–4.40; p  < 0.001), procedural time (OR: 1.00; 95% CI: 1.00–1.01; p  = 0.002) and intraprocedural complications (OR: 1.89; 95%CI: 1.02–3.52; p  = 0.04) as independent predictors of END. Bridging therapy (OR:2.93; 95%CI: 1.21–7.09; p  = 0.017) was associated with sICH per SITS-MOST criteria whereas M1 occlusion (OR: 0.35; 95%CI: 0.18–0.69; p  = 0.002), bridging therapy (OR: 2.02; 95%CI: 1.07–3.82; p  = 0.03) and intraprocedural complications (OR: 5.55; 95%CI: 2.72–11.31; p  < 0.001) were independently associated with sICH per ECASS II criteria. No significant association was found between the number of MT attempts and analyzed outcomes. Conclusions Regardless of the number of MT attempts and intraprocedural complications, procedural time was associated with poor outcome and END. We suggest a deeper consideration of procedural time when treating anterior circulation occlusions refractory to MT.

[...]the efficacy of these treatments is limited only to patients carefully selected with neuroimaging techniques. [...]EVT is now performed in witnessed, unwitnessed, or wake up strokes who have a mismatch between clinical deficit and infarct or between the ischemic core and penumbral regions. Intravenous alteplase was not administered because of the episode of coffee-ground vomitus and the history of frequent abnormal vaginal bleedings. [...]a mechanical thrombectomy using aspiration only was performed, resulting in a thrombolysis in cerebral infarction (TICI) IIb final angiographic recanalization. [...]the prevalence of AF in patients with primary myopathies is about 15%,8 and during hospitalization AF was detected and a proper anticoagulation was started. [...]in our opinion, clinical reports of challenging patients treated with EVT and hard to recruit in a trial, provide precious information, play an important role in improving health outcomes and can guide the clinicians in difficult choices during the routine clinical practice.

BackgroundMechanical thrombectomy (MT) was found to be beneficial in acute ischemic stroke patients with anterior tandem occlusion (a-TO). Instead, little is known about the effectiveness of MT in stroke patients with posterior tandem occlusion (p-TO). We aimed to compare MT within 24 h from last known well time in ischemic stroke patients with p-TO versus a-TO.MethodsWe conducted a cohort study on prospectively collected data of patients registered in the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) who were treated with MT within 24 h from last known well time for acute ischemic stroke with p-TO (n = 275) or a-TO (n = 1853).ResultsAfter adjustment for unbalanced pre-procedure variables (year 2015–2021, age, sex, NIHSS score, ASPECTS, and time strata for puncture groin) and pre-stroke mRS score as pre-defined predictor, p-TO was significantly associated with lower probability of mRS score 0–2 (OR 0.415, 95% CI 0.268–0.644) and with higher risk of death (OR 2.813, 95% CI 2.080–3.805) at 3 months. After adjustment for unbalanced procedural and post-procedure variables (IVT, general anesthesia, TICI 3, and 24-h HT) and pre-stroke mRS score as pre-defined predictor, association between p-TO and lower probability of mRS score 0–2 (OR 0.444, 95% CI 0.304–0.649) and association between p-TO and with higher risk of death (OR 2.971, 95% CI 1.993–4.429) remained significant.ConclusionsMT within 24 h from last known well time in ischemic stroke patients with p-TO versus a-TO was associated with worse outcomes at 3 months.