No abstract available.
Aneurysm* ; Carotid Artery, Internal* ; Infarction, Middle Cerebral Artery* ; Middle Cerebral Artery* ; Thrombectomy*

No abstract available.
Leukoencephalopathy, Progressive Multifocal*

Endovascular therapy (EVT) is strongly indicated for acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) in the anterior and posterior circulation according to international recommendations, but the benefit is unclear for AIS patients with distal vessel occlusions (DVO) since these patients were systematically excluded from the vast majority of randomized controlled clinical trials (RCTs) establishing the safety and efficacy of EVT. Observational data from multiple registries appear promising but also highlight numerous challenges: identification of DVO is not straightforward and may necessitate advanced imaging, potential clinical benefits from the intervention are more limited than in LVOs since DVO patients present with milder deficits, recanalization of smaller caliber arteries is technically challenging and associated with greater risk for complications namely symptomatic intracranial hemorrhage and vessel perforation. There are multiple ongoing RCTs evaluating the safety and efficacy of EVT in AIS patients with DVOs in Europe, North America and Australasia. In view of the former considerations the current narrative review aims to present the different approaches to define DVO, summarize the epidemiology and natural history of DVO under best medical treatment, outline the diagnostic utility of different imaging modalities and critically address the observational data on the benefits and risks of EVT for DVO, with a special focus in M2 middle cerebral artery occlusions. Finally, we will also discuss the design and methodology of ongoing RCTs that will provide definitive data on the safety and efficacy of EVT for AIS patients with DVO.

Cardioembolic stroke is a major cause of morbidity, with a high risk of recurrence, and anticoagulation represents the mainstay of secondary stroke prevention in most patients. The implementation of endovascular treatment in routine clinical practice complicates the decision to initiate anticoagulation, especially in patients with early hemorrhagic transformation who are considered at higher risk of hematoma expansion. Late hemorrhagic transformation in the days and weeks following stroke remains a potentially serious complication for which we still do not have any established clinical or radiological prediction tools. The optimal time to initiate therapy is challenging to define since delaying effective secondary prevention treatment exposes patients to the risk of recurrent embolism. Consequently, there is clinical equipoise to define and individualize the optimal timepoint to initiate anticoagulation combining the lowest risk of hemorrhagic transformation and ischemic recurrence in cardioembolic stroke patients. In this narrative review, we will highlight and critically outline recent observational and randomized relevant evidence in different subtypes of cardioembolic stroke with a special focus on anticoagulation initiation following endovascular treatment. We will refer mainly to the commonest cause of cardioembolism, non-valvular atrial fibrillation, and examine the possible risk and benefit of anticoagulation before, during, and shortly after the acute phase of stroke. Other indications of anticoagulation after ischemic stroke will be briefly discussed. We provide a synthesis of available data to help clinicians individualize the timing of initiation of oral anticoagulation based on the presence and extent of hemorrhagic transformation as well as stroke severity.