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We aimed to assess the potential role of Asymmetric dimethylarginine (ADMA) in conditioning respiratory function and pulmonary vasoregulation during Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) infection. Within 72 h from admission, samples from 90 COVID-19 patients were assessed for ADMA, SDMA, L-arginine concentrations. In addition to classical statistics, patients were also clustered by a machine learning approach according to similar features. Multivariable analysis showed that C-reactive protein (OR 1.012), serum ADMA (OR 4.652), white blood cells (OR = 1.118) and SOFA (OR = 1.495) were significantly associated with negative outcomes. Machine learning-based clustering showed three distinct clusters: (1) patients with low severity not requiring invasive mechanical ventilation (IMV), (2) patients with moderate severity and respiratory failure whilst not requiring IMV, and (3) patients with highest severity requiring IMV. Serum ADMA concentration was significantly associated with disease severity and need for IMV although less pulmonary vasodilation was observed by CT scan. High serum levels of ADMA are indicative of high disease severity and requirement of mechanical ventilation. Serum ADMA at the time of hospital admission may therefore help to identify COVID-19 patients at high risk of deterioration and negative outcome.

Intrasaccular flow diverters such as the Contour Neurovascular System represent a significant advancement in the endovascular management of intracranial aneurysms, particularly those with complex bifurcation morphology. However, complications such as incomplete occlusion or recurrence post-implantation remain prevalent challenges in clinical practice. Depending on the specific failure mode and anatomy, various bailout strategies may involve parent vessel reconstruction with flow diverters or surgical clipping.1–4 This technical video (video 1) shows a novel bailout strategy that integrates adjunctive coil embolization through a pre-existing Contour device to address aneurysm recurrence. Key procedural elements are demonstrated, including microcatheter navigation into the residual aneurysm sac adjacent to the Contour, precise coil deployment into the interstice between the device and the aneurysm wall, and achieving complete angiographic occlusion while preventing any displacement or compromise of functionality of the existing intrasaccular device. This technique exemplifies a viable endovascular rescue approach for selected instances of aneurysm recurrence following Contour treatment, enhancing the therapeutic armamentarium available to clinicians. Video 1  Endovascular coil embolization through a previously implanted Contour intrasaccular device for recurrent posterior communicating artery aneurysm.

Non-contrast computer tomography detects the presence of hyperdense middle cerebral artery sign (HMCAS). Studies on the prognostic value of HMCAS among patients undergoing mechanical thrombectomy (MT) are conflicting. A retrospective analysis of consecutive patients with acute ischemic stroke due to middle cerebral artery occlusion, presenting with or without HMCAS, who underwent MT, was performed. We enrolled 191 patients (HMCAS +, n = 140; HMCAS –, n = 51). Prevalence of successful recanalization was significantly higher in patients with HMCAS than in those without HMCAS (92.1% versus 74.5%, p = 0.001). Patients with HMCAS had a better clinical outcome than those HMCAS – (54.3% versus 37.3%, p = 0.037, for three-month favorable outcome; 62.9% versus 39.3%, p = 0.004, for major neurological improvement at discharge; 8.6% versus 19.6%, p = 0.035, for in-hospital mortality; 14.3% versus 27.5%, p = 0.035, for intracranial hemorrhage; 2.9% versus 17.6%, p = 0.001, for symptomatic intracranial hemorrhage). Multivariate analyses confirmed that HMCAS represents an independent predictor of three-month favorable outcome (OR 2.48, 95% CI 1.10–5.58, p = 0.028), major neurological improvement at discharge (OR 2.40, 95% CI 1.09–5.20, p = 0.030), in-hospital mortality (OR 0.29, 95% CI 0.010–0.81, p = 0.018), presence of ICH (OR 0.49, 95% CI 0.25–0.97, p = 0.042) and presence of SICH (OR 0.16, 95% CI 0.04–0.63, p = 0.009). HMCAS presence predicts favorable outcome in patients undergoing MT. This result may indicate that hyperdense clots are more likely to respond to MT than isodense ones. This effect is mediated by reduction in hemorrhagic transformation.HighlightsHyperdense middle cerebral artery sign on native non-contrast computer tomography predicts severe brain ischemia and poor functionally outcome in patients with acute ischemic stroke not treated with recanalization therapies and in those receiving intravenous thrombolysis.Prevalence of successful recanalization after mechanical thrombectomy was significantly higher in patients with than in those without hyperdense middle cerebral artery sign.Patients with hyperdense middle cerebral artery sign had a significantly better clinical outcome than those without hyperdense middle cerebral artery sign.These very promising results might affect clinical practice of neurologists and interventional radiologists/neuroradiologists.

Background Although mechanical thrombectomy (MT) represents the standard of care for ischemic stroke due to large‐vessel occlusion (LVO), the impact of sex on outcomes in tandem occlusions remains unclear. We investigated sex‐based differences in outcomes after MT for tandem occlusions. Methods This multicenter observational study included consecutive patients with tandem occlusion treated with MT across three stroke centers (2021–2023). Propensity score matching was performed. Primary outcomes were the 90‐day favorable functional outcome (mRS 0–2) and mRS score shift. Secondary outcomes included favorable recanalization, 24‐h early neurological improvement, and NIHSS median score. Safety outcomes were post‐MT intracerebral hemorrhage and 90‐day mortality. Results Of 635 patients (46.8% women), 289 women were matched to 289 men. There were no significant differences in primary, secondary, or safety outcomes between sexes. Subgroup analysis showed a lower rate of favorable 90‐day mRS scores in women with diabetes compared to men. Women not receiving emergent carotid treatment had higher rates of favourable outcomes. No significant sex differences were found in other subgroups. Conclusions Women with anterior circulation tandem occlusions treated with MT have similar outcomes to men. However, women with diabetes and those treated with intracranial MT alone exhibited sex‐specific differences. Further studies are needed to explore underlying mechanisms.

Pulmonary sequestrations are rare congenital malformations. They are often located in the lower lobes, and they are supplied by an aberrant systemic vessel arising from the thoracic aorta or abdominal arteries. These pulmonary malformations are divided into intra- and extralobar sequestrations, depending on the respective lack or presence of an independent pleural covering. Pulmonary sequestration can be asymptomatic or lead to recurrent pulmonary infections. The goal of this study was to analyse the feasibility and safety of a hybrid sequential approach. We report a small series of intralobar pulmonary sequestrations, from November 2017 to December 2018, successfully treated with a hybrid minimally invasive approach consisting of endovascular embolization of the aberrant arterial branch followed by video-assisted thoracoscopic lobectomy the day after. Thoracic pain following endovascular embolization was noted in all cases. Patients were discharged early in the absence of major postoperative complications. Prolonged air leak was observed in only 1 case. Despite the presence of sequestration-related pulmonary inflammation, in our experience, hybrid treatment for intralobar pulmonary sequestration is a safe and reproducible approach in terms of postoperative complications and hospital stay.

Background There is a lack of data regarding patients aged 90 years or older undergoing mechanical thrombectomy and their predictors of futile recanalization. Aims We sought to evaluate the predictors of futile recanalization in patients ≥ 90 years with large vessel occlusion undergoing mechanical thrombectomy. Methods This multi-center observational retrospective study included patients ≥ 90 years consecutively treated with mechanical thrombectomy in four thrombectomy capable centers between January 1st, 2016 and 30th March 2023. Futile recanalization was defined as large vessel occlusion patients experiencing a 90-day poor outcome (mRS 3–6) despite successful recanalization (mTICI ≥ 2b) after mechanical thrombectomy. Results Our cohort included 139 patients ≥ 90 years with acute ischemic stroke due to anterior circulation large vessel occlusion treated with mechanical thrombectomy. One hundred seventeen of one hundred thirty-nine patients ≥ 90 years who achieved successful recanalization were included in the analysis (seventy-six female (64.9%)), of whom thirty-one (26.49%) experienced effective recanalization and eighty-six (73.51%) experienced futile recanalization. Patients with futile recanalization had higher NIHSS on admission ( p  < 0.001); they were less frequently treated with intravenous thrombolysis ( p  = 0.048), had more often general anesthesia ( p  = 0.011), and longer door to groin puncture delay ( p  = 0.002). Univariable regression analysis showed that use of intravenous thrombolysis (0.29, 95% CI 0.02–0.79, p  = 0.034) and site of occlusion distal vs proximal (0.34, 95% CI 0.11–0.97, p  = 0.044) were associated with reduced probability of futile recanalization while NIHSS on admission (1.29, 95% CI 1.16–1.45, p  < 0.001), NIHSS at 24 h (1.15, 95% CI 1.07–1.25, p  = 0.002), type of anesthesia used (4.18, 95% CI 1.57–11.08, p  = 0.004), and door to groin puncture time (1.02, 95% CI 1.00–1.05, p  = 0.005) were associated with increased probability of futile recanalization. Multivariable regression analysis showed that use of intravenous thrombolysis (0.44, 95% CI 0.09–0.88, p  = 0.039) was associated with reduced probability of futile recanalization. Conclusion Our study seems to suggest that mechanical thrombectomy with intravenous thrombolysis is associated with reduced probability of futile recanalization in a multi-center cohort of patients aged 90 years or older.

Purpose The aim of this registry was to assess technical success, procedural safety and mid- to long-term follow-up results of the Silk Vista “Mama” (SVM) flow diverter (BALT, Montmorency, France) for the treatment of proximal intracranial aneurysms. Methods Between August 2020 and March 2022, data from nine Italian neurovascular centres were collected. Data included patients’ clinical presentation, aneurysms’ size, location and status, technical details, overall complications and mid- to long-term angiographic follow-up. Results Forty-eight aneurysms in 48 patients were treated using the SVM. Most aneurysms were small (≤ 10 mm: no. 29, 60%) and unruptured (no. 31, 65%); 13 aneurysms were recurrent after coiling or clipping. 37/48 aneurysms involved the internal carotid artery (77%). Optimal opening and complete wall apposition of the device were achieved in 46 out of 48 cases (96%). Four intra- or periprocedural complications occurred (two thrombotic complications successfully resolved, one cerebellar ischemia, one perirenal hematoma), without new neurological deficit. No significant intra-stent stenosis or stent displacement was observed during follow-up. No FD-related morbidity nor mortality was reported. At midterm (6–12 months) to long-term (> 12 months) follow-up, complete aneurysm occlusion (OKM D) was achieved in 76% of cases. Eighty-eight percent of patients had complete aneurysm occlusion or entry remnant (OKM D + C). Conclusions Our experience suggests that the new generation of low-profile SVM flow diverter for the treatment of proximal intracranial aneurysms is safe and effective, with low rates of intraprocedural complications and acceptable mid- to long-term occlusion rate.

Recent clinical trials demonstrated that mechanical thrombectomy (MT) using second-generation endovascular devices has beneficial effects in acute ischemic stroke (AIS) due to large vessel occlusion (LVO). However, it remains controversial if intravenous thrombolysis (IVT) prior to MT is superior compared to direct mechanical thrombectomy (DMT). The aims of this study were to compare short and long-term outcomes between IVT + MT and DMT patients. We prospectively recruited AIS patients with LVO in the anterior or posterior circulation eligible for MT with and without prior IVT. Modified Rankin Scale (mRS) and mortality were assessed at baseline, at discharge, 90-days and 1-year after stroke. Favorable outcome was defined as a mRS score ≤2. Of the 66 patients included, 33 (50%) were in IVT + MT group and 33 (50%) were in DMT group. Except for a higher prevalence of patients using anticoagulants at admission in DMT group, baseline characteristics did not differ in the two groups. Procedural characteristics were similar in IVT + MT and DMT group. Rate of favorable outcome was significantly higher in IVT + MT patients than DMT ones both 90-days (51.5 vs. 18.2%; p = 0.004) and 1-year (51.5 vs. 15.2%; p = 0.002) after stroke. DMT patients were six times more likely to die during the 1-year follow-up compared to IVT + MT patients. This study suggests that bridging therapy may improve short and long-term outcomes in patients eligible for endovascular treatment. Further studies with larger patient numbers and randomized design are needed to confirm our findings.

Background: Admission hyperglycemia impairs outcome in acute ischemic stroke (AIS) patients undergoing mechanical thrombectomy (MT). Since hyperglycemia in AIS represents a dynamic condition, we tested whether the dynamic patterns of hyperglycemia, defined as blood glucose levels > 140 mg/dl, affect outcomes in these patients. Methods: We retrospectively analyzed data of 200 consecutive patients with prospective follow-up. Based on blood glucose level, patients were distinguished into 4 groups: (1) persistent normoglycemia; (2) hyperglycemia at baseline only; (3) hyperglycemia at 24-h only; and (4) persistent (at baseline plus at 24-h following MT) hyperglycemia. Results: AIS patients with persistent hyperglycemia have a significantly increased risk of poor functional outcome (OR 6.89, 95% CI 1.98–23.94, p = 0.002, for three-month poor outcome; OR 11.15, 95% CI 2.99–41.52, p = 0.001, for no major neurological improvement), mortality (OR 5.37, 95% CI 1.61–17.96, p = 0.006, for in-hospital mortality; OR 4.43, 95% CI 1.40–13.97, p = 0.01, for three-month mortality), and hemorrhagic transformation (OR 6.89, 95% CI 2.35–20.21, p = 0.001, for intracranial hemorrhage; OR 5.42, 95% CI 1.54–19.15, p = 0.009, for symptomatic intracranial hemorrhage) after endovascular treatment. These detrimental effects were partially confirmed after also excluding diabetic patients. The AUC-ROC showed a very good performance for predicting three-month poor outcome (0.76) in-hospital mortality (0.79) and three-month mortality (0.79). Conclusions: Our study suggests that it is useful to perform the prolonged monitoring of glucose levels lasting 24-h after MT.