Recurrent Transient Ischemic Attacks Revealing Cerebral Amyloid Angiopathy: A Comprehensive Case

This case report investigates the manifestation of cerebral amyloid angiopathy (CAA) through recurrent Transient Ischemic Attacks (TIAs) in an 82-year-old patient. Despite initial diagnostic complexities, cerebral angiography-MRI revealed features indicative of CAA. Symptomatic treatment resulted in improvement, but the patient later developed a fatal hematoma. The discussion navigates the intricate therapeutic landscape of repetitive TIAs in the elderly with cardiovascular risk factors, emphasizing the pivotal role of cerebral MRI and meticulous bleeding risk management. The conclusion stresses the importance of incorporating SWI sequences, specifically when suspecting a cardioembolic TIA, as a diagnostic measure to explore and exclude CAA in the differential diagnosis. This case report provides valuable insights into these challenges, highlighting the need to consider CAA in relevant cases.

Incidence and predictors of futile recanalisation after endovascular therapy in acute vertebrobasilar artery occlusion patients:insight from the ANGEL-ACT registry

Objectives To identify the occurrence rate and predictors of futile recanalisation after endovascular therapy(EVT)for acute vertebrobasilar artery occlusion(VBAO).Methods Participants of the Endovascular Treatment Key Technique and Emergency Workflow Improvement of Acute Ischaemic Stroke(ANGEL-ACT)registry were selected for the analysis.Futile recanalisation was defined as patients did not achieve a 90-day good outcome(modified Rankin Scale≤3)despite successful recanalisation(modified Treatment in Cerebral Ischaemia Scale≥2b)after the procedure.Multivariable logistic regression analysis was conducted to find independent predictors of futile recanalisation in VBAO patients undergoing EVT.Results Three hundred and fifteen patients with VBAO who achieved successful recanalisation after EVT were included in current analysis,of whom,155(49.2%)suffered futile recanalisation,and 160 achieved effective recanalisation.After the multivariable analysis,we found admission National Institutes of Health Stroke Scale(NIHSS)≥19(OR 4.81,95%CI 2.76 to 8.39,p<0.001),platelet-lymphocyte ratio(PLR)≥162.2(OR 1.93,95%CI 1.14 to 3.27,p=0.001),onset-to-puncture time(OTP)≥334min(OR 2.15,95%CI 1.25 to 3.68,p=0.005)and use of general anesthesia(GA)(OR 1.87,95%CI 1.09 to 3.22,p=0.024)were associated with futile recanalisation.Conclusions Futile recanalisation after EVT occurred 49.2%of VBAO patients in the ANGEL-ACT registry.NIHSS≥19,PLR≥162.2,OTP≥334min and use of GA were independent predictors of futile recanalisation.

When treating acute ischaemic stroke of LVO type,time window prevails over tissue window

Time is brain.How fast an occluded cerebral artery can be reopened is directly related to how many brain cells can be saved.The iden-tification of a tissue window as indicated by the presence of a penumbra on multimodality imaging study has opened the time window of treatment to 24 hours after the onset.1 From 2019 to 2022,the issue of direct intra-arterial(IA)mechanical thrombectomy(MT)is non-inferior to bridging therapy or not has been settled.2 Bridging therapy may have slight advantage in re-opening the occluded arteries than direct IA MT.3 Recently published data on IA MT to treat acute ischaemic stroke(AIS)from a large vessel occlusion but with a low Alberta Stroke Programme Early CT(ASPECT)score indicated that in these patients,performing a multimodality imaging study may not be necessary.Multimodality imaging study including MRI of head,MRA of head and neck and magnetic resonance perfusion(MRP)of head or CT of head,CTA of head and neck and CT perfusion(CTP)of head are must-to do tests when evaluating patients with AIS with an onset time between 6 and 24 hours in current clinical practice.

Randomised study of bailout intracranial angioplasty following thrombectomy for acute large vessel occlusion(ANGEL-REBOOT):protocol of a multicentre randomised controlled trial

Rationale Unsuccessful thrombectomy of acute large vessel occlusions(LVOs)has been associated with unfavourable outcomes.Multiple randomised controlled trials(RCTs)have reported a failure rate of 12%–41%for thrombectomy procedures.Various factors contribute to failed thrombectomy,including technical difficulties in accessing the occlusion,unsuccessful thrombus retrieval,thrombotic reocclusion and pre-existing intracranial atherosclerotic stenosis.Although some studies have explored balloon dilation or permanent stenting as rescue intracranial angioplasty for failed thrombectomy in individual cases,there is currently no evidence from RCTs on this specific topic.Aim To evaluate the potential superiority of bailout angioplasty over standard treatment in cases of unsuccessful recanalisation(eTICI 0 to 2a)or residual severe stenosis(>70%)after thrombectomy in acute LVO patients within 24 hours of stroke onset.Design This study is a multicentre,prospective,randomised,controlled clinical trial designed by investigators.It compares bailout angioplasty with standard therapy and follows an open-label treatment approach while maintaining a blinded outcome assessment(PROBE design).Our objective is to allocate 348 patients in a 1:1 ratio to either receive bailout angioplasty as an intervention or standard therapy as a control,following unsuccessful thrombectomy.Outcome The main measure of interest is the modified Rankin Scale(mRS)Score,which will be assessed in a blinded manner at 90(±14)days following randomisation.The primary effect size will be determined using ordered logistic regression to calculate the common OR,representing the shift on the six-category mRS Scale at the 90-day mark.Additionally,the safety outcomes will be evaluated,including symptomatic intracranial haemorrhage within 18–36hours,severe procedure-related complications and mortality within 90(±14)days,among others.Discussion The ANGEL-REBOOT study aims to generate substantial evidence regarding the efficacy and safety of bailout intracranial angioplasty as a treatment option for patients with LVO who have experienced unsuccessful thrombectomy.Trial registration number NCT05122286.

Role of endovascular embolisation for curative treatment of intracranial non- Galenic pial arteriovenous fistula

Background and purpose The safety and effectiveness of endovascular treatment for non-Galenic pial arteriovenous fistula(NGPAVF)is inadequately known.The aim of this study is to explore the role of endovascular embolisation for curative treatment of NGPAVF.Materials and methods Patients with NGPAVF underwent endovascular treatment from January 2011 to November 2019 in our institution were retrospectively reviewed.Demographics,clinical information,treatment details and clinical outcomes were collected.Factors associated with clinical outcomes were statistically analysed.Results Twenty patients were included,with a total of 22(2 patients have 2 fistulas)lesions.A total of 25 procedures were performed and 5 patients underwent 2 procedures.Follow-up ranged from 3 to 84 months(mean=34.5 months).Thirteen(59.1%)lesions in 12(60.0%)patients acquired immediate occlusion after initial treatment(immediately occluded group)and follow-up confirmed the complete obliteration.A total of 17(77.3%)lesions in 15(75.0%)patients were cured at last follow-up.The maximal diameter of feeding arteries(p=0.04)and the maximal diameter of the varix(p=0.01)in immediately occluded group was smaller than non-immediately occluded group.The number of feeding artery(p=0.004)and the maximal diameter of the varix(p<0.001)were much smaller in curative group than non-curative group.Seven patients suffered procedure-related complications.No patients had an increased Modified Rankin Scale(mRS)and all patients had favourable clinical outcome(mRS≥2)at last follow-up.Conclusions Endovascular therapy plays an important role in curative treatment of NGPAVF.Patients with less feeding arteries and small varix may be easier to be cured by endovascular embolisation.

Chinese Stroke Association guidelines for clinical management of ischaemic cerebrovascular diseases:executive summary and 2023 update

Background China is one of the countries with the highest burden of stroke.Implementing multidimensional management guidelines will help clinicians practise evidence-based care,improve patient outcomes and alleviate societal burdens.This update of the 2019 edition will provide the latest comprehensive recommendations for the diagnosis and treatment of ischaemic cerebrovascular diseases.Methods We conducted a comprehensive search on MEDLINE(via PubMed)up to 31 August 2023.The writing team established the recommendations through multiple rounds of online and offline discussions.Each recommendation was graded using the evidence grading algorithm developed by the Chinese Stroke Association(CSA).The draft was reviewed and finalised by the CSA Stroke Guidelines Writing Committee.Results This update included revisions of 15 existing recommendations and 136 new recommendations in the following areas of stroke care:emergency assessment and diagnosis of ischaemic cerebrovascular disease,acute-phase reperfusion therapy,evaluation of underlying mechanisms,antithrombotic therapy,prevention and treatment of complications,and risk factor management.Conclusions This guideline updated the recommendations for the clinical management of ischaemic cerebrovascular disease from 2019.