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1. Requena M, Olivé-Gadea M, Muchada M, et al. Direct to angiography suite without stopping for computed tomography imaging for patients with acute stroke: a randomized clinical trial. JAMA Neurol 2021;78:10 99–107

Direct transfer to angiography suite (DTAS)

Door-to-puncture [DTP]) time

Despite the efforts dedicated to reduce DTP times, published registries and clinical trials have shown the difficulties in decreasing DTP time below 60 minutes, a target that has been set by expert consensus. The HERMES meta-analysis reported DTP times ranging from 81 minutes for transferred patients to 116 minutes for patients directly admitted to an endovascular center. Research assessing optimized workflows has led to a newly proposed paradigm in the acute treatment of patients with severe stroke: direct transfer to angiography suite (DTAS). Protocols for DTAS were simultaneously designed in several centers mirroring the ST-segment elevation myocardial infarction strategy of bypassing the emergency department and conventional imaging. On arrival at the angiography suite, the use of flat-panel computed tomography (FPCT) enables the ruling out of either an intracranial hemorrhage (ICH) or a large established infarct. In addition, LVO can be diagnosed with a flat-panel angiography system immediately before arterial puncture or directly with initial diagnostic angiography. Regardless of the protocol details, DTAS has been consistently shown to be effective in decreasing DTP time to as low as 16 minutes without safety concerns. The effect of DTAS on long-term functional outcomes varies between published nonrandomized studies and is still unclear.

The study was an investigator-initiated, single-center, evaluator-blinded randomized clinical trial. Of 466 consecutive patients with acute stroke screened, 174 with suspected LVO acute stroke within 6 hours of symptom onset were included.

Patients were randomly assigned (1:1) to follow either DTAS (89 patients) or conventional workflow (85 patients received direct transfer to computed tomographic imaging, with usual imaging performed and EVT indication decided) to assess the indication of EVT.

Mean onset-to-door time was 228.0 minutes, and their median admission National Institutes of Health Stroke Scale score was 18. In the modified intention-to-treat population, EVT was performed for all 74 patients in the DTAS group and for 64 patients (87.7%) in the conventional workflow group. The DTAS protocol decreased the median door–to–arterial puncture time (18 minutes vs 42 minutes and door-to-reperfusion time (57 minutes vs 84 minutes). The DTAS protocol decreased the severity of disability across the range of the mRS (modified Rankin Scale).

DTAS protocol was safe and led to improved clinical outcomes compared with the DTCT protocol. The DTAS protocol decreased in-hospital delays, achieving shorter times from hospital admission to treatment onset and to reperfusion, which were associated with a significant shift toward better outcomes across the spectrum of disability.

2 figures, 3 tables

2. Manzano GS, McEntire CRS, Martinez-Lage M, et al. Acute disseminated encephalomyelitis and acute hemorrhagic leukoencephalitis following COVID-19. Neurol Neuroimmunol Neuroinflamm 2021;8:e1080

Patients with a history of COVID-19 infection were included if their reports provided adequate detail to confirm a diagnosis of ADEM or AHLE by virtue of clinical features, radiographic abnormalities, and histopathologic findings. Cases purported to be secondary to vaccination against COVID-19 or occurring in the context of a preexisting relapsing CNS demyelinating disease were excluded. Case reports and series were identified via PubMed on May 17, 2021, and 4 additional cases from the authors’ hospital files supplemented the systematic review of the literature.

Forty-six patients (28 men, median age 49.5 years, 1/3 >50 years old) were analyzed, derived from 26 case reports or series originating from 8 countries alongside 4 patient cases from the authors’ hospital files. COVID-19 infection was laboratory confirmed in 91% of cases, and infection severity necessitated intensive care in 67%. ADEM occurred in 31 cases, whereas AHLE occurred in 15, with a median presenting nadir modified Rankin Scale score of 5 (bedridden). Anti-MOG seropositivity was rare (1/15 patients tested). Noninflammatory CSF was present in 30%. Hemorrhage on brain MRI was identified in 42%. Seventy percent received immunomodulatory treatments, most commonly steroids, IV immunoglobulins, or plasmapheresis. The final mRS score was ≥4 in 64% of patients with adequate follow-up information, including 32% who died.

In contrast to ADEM cases from the prepandemic era, reported post–COVID-19 ADEM and AHLE cases were often advanced in age at onset, experienced severe antecedent infection, displayed an unusually high rate of hemorrhage on neuroimaging, morbidity with ADEM was high despite the use of standard ADEM treatments, and mortality was common even with relatively short follow-up.

3 figures, 4 tables including MR and histology

3. Bathla G, Abdel-Wahed L, Agarwal A, et al. Vascular involvement in neurosarcoidosis. Neurol Neuroimmunol Neuroinflamm 2021;8:e1063

A total of 13 consecutive patients with NS underwent VWI. Images were analyzed by 2 neuroradiologists in consensus. The assessment included segment-wise evaluation of larger and medium-sized vessels (internal carotid artery, M1-M3 middle cerebral artery; A1-A3 anterior cerebral artery; V4 segments of vertebral arteries; basilar artery; and P1-P3 posterior cerebral artery), lenticulostriate perforator vessels, and medullary and deep cerebral veins. Cortical veins were not assessed due to flow-related artifacts. Brain biopsy findings were available in 6 cases and were also reviewed.

Mean patient age was 54.9 years (33–71 years) with an M:F of 8:5. Mean duration between initial diagnosis and VWI study was 18 months. Overall, 9/13 (69%) patients had vascular abnormalities. Circumferential large vessel enhancement was seen in 3/13 (23%) patients, whereas perforator vessel involvement was seen in 6/13 (46%) patients. Medullary and deep vein involvement was also seen in 6/13 patients. In addition, 7/13 (54%) patients had microhemorrhages in susceptibility-weighted imaging, and 4/13 (31%) had chronic infarcts.

This study, although performed on a small patient cohort, provides insights into the spectrum of vascular involvement in patients with NS using dedicated VWI-MRI. The authors state that the findings support prior observations that cerebrovascular manifestations are likely more common than previously realized and involve both arterial and venous structures, similar to primary angiitis of the CNS. This is also supported by the review of brain histopathology slides, which were available in 6/13 patients with NS.

3 figures including MR, 2 tables

4. Metz I, Gavrilova RH, Weigand SD, et al. Magnetic resonance imaging correlates of multiple sclerosis immunopathological patterns. Ann Neurol 2021;90:44 0–54

Multiple sclerosis (MS) is an inflammatory demyelinating disease with unknown etiology and a considerable heterogeneity regarding clinical characteristics, therapeutic response, and MR features. Furthermore, histological analysis reveals substantial differences when comparing lesions from different patients. Although all lesions show the common characteristics of demyelination, inflammation, axonal damage, and astrocytic gliosis, major histological differences can be found, allowing their classification into 3 main immunopathological patterns of active demyelination (patterns I–III). Immunopatterns among early active MS lesions have been shown to be consistent within an individual over space and time. These patterns suggest different mechanisms of lesion development. Patterns I and II are typically sharply demarcated, and all myelin proteins are lost to an equal extent. However, only pattern II lesions are associated with immunoglobulins and complement deposited along myelin sheaths and present within macrophages, suggesting an antibody- and complement-mediated mechanism of demyelination. In contrast, pattern III lesions are characterized by an ill-defined lesion edge, the presence of apoptotic oligodendrocytes, and a preferential loss of myelin-associated glycoprotein (MAG) compared to other myelin proteins. MAG is located in distal oligodendrocyte processes, and its loss is considered to be a marker of metabolically stressed oligodendrocytes. Changes observed in pattern III lesions suggest oligodendrocyte damage preceding demyelination. Thus far, these immunopathological patterns can only be diagnosed by histology. The MRI correlates are unknown.

The authors evaluated in an international collaborative retrospective cohort study the MRI lesion characteristics of 789 conventional prebiopsy and follow-up MRIs in relation to their histopathologically classified immunopathological patterns (n = 161 subjects) and lesion edge features (n = 112).

A strong association of a ringlike enhancement and a hypointense T2-weighted (T2w) rim with patterns I and II, but not pattern III, was obs