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1. Boulenoir N, Turc G, ter Schiphorst A, et al. Should Patients With Acute Minor Ischemic Stroke With Isolated Internal Carotid Artery Occlusion Be Thrombolysed? Stroke. 2022;(November):3304-3312. doi:10.1161/strokeaha.122.039228

Isolated cervical or intracranial internal carotid artery occlusion (iICAo), without associated occlusion of the circle of Willis (ie, without T-shaped, L-shaped, or tandem occlusions), is observed in ≈5% of acute stroke patients admitted in an early time window, with atherosclerosis as the leading cause followed by dissection and cardioembolism. Clinical severity is highly variable, in part as a function of collateral circulation, and patients with iICAo frequently present with minor neurological deficits. Given the lack of evidence derived from randomized controlled trials, the management of acute iICAo remains unclear. The early clinical course of acute iICAo treated or not with reperfusion therapies has been reported in few observational studies, all with small samples, and remains little known. In the 4.5-hour window, international guidelines recommend intravenous thrombolysis (IVT) in the context of disabling ischemic minor stroke in general, whereas an expert consensus from the European Stroke Organization suggests using IVT in nondisabling minor stroke with large vessel occlusion. Regarding iICAo, the authors recently reported a worrying 30% rate of early neurological deterioration (END) occurring within 24 hours following IVT in a multicentric cohort of patients with minor stroke iICAo, which occurred mostly within the first 2 hours from IVT start and was ascribed to artery-to-artery embolism in 3/4^th of the cases. These observations led the authors to propose that IVT may foster carotid thrombus fragmentation and subsequent distal embolism and could therefore be deleterious in this situation. However, this study lacked a control group (ie, nonthrombolysed acute minor stroke with iICAo), which limited interpretation. In this paper, the authors tested the above hypothesis by comparing the incidence and mechanisms of early neurological deterioration within 24 hours (END24h), END within 7 days, and 3-month outcome of patients with acute minor stroke iICAo treated with IVT or antithrombotics only.

189 patients were included (IVT=95; antithrombotics=94 [antiplatelets, n=58, anticoagulants, n=36]) from 34 centers.

Four key findings emerged: (1) END was a frequent event in this population— occurring in 1 of 3 patients within the first week, predominantly in case of nonatheromatous cause—and was strongly associated with poor 3-month outcome; (2) END was of thromboembolic origin in two-thirds of the cases; (3) the rate of END within the first 24 hours was 2-fold higher following IVT, driven by higher odds of thromboembolic END; and (4) however, the rate of END occurring within 7 days did not significantly differ between the 2 treatment groups, and 3-month outcome was similar.

The higher END24h incidence following IVT, together with the lack of better 3-month functional outcome as found here, may suggest that the benefit/risk ratio may not favor IVT at least in case of nondisabling symptoms, a situation where the benefit of IVT is unproven. Apart from IVT alone, 3 other therapeutic options may be considered in this population. First, adding early post-IVT antiplatelet administration may be an attractive approach to prevent thromboembolic ENDs. A post hoc analysis of ARTIS, a randomized trial comparing early (within 90 minutes of IVT start) addition of aspirin after IVT versus IVT alone in an unselected acute stroke population, found that aspirin increased the risk of END24h due to intracranial hemorrhage, and had no effect on incidence of nonhemorrhagic END24h. However, this approach could still be of interest in populations at high risk of post-IVT thromboembolic END and low risk of intracranial hemorrhage, such as nonatheromatous iICAo with minor symptoms, and should be further tested, perhaps with later antiplatelet agent administration. Second, in patients with non-IVT–treated iICAo, more intensive antithrombotic strategies than aspirin alone may be of interest. An observational study focusing on patients with non-IVT–treated iICAo admitted within 24 hours from symptom onset suggested that, as compared to standard antiplatelet therapy, anticoagulation was associated with lower END7d rate. More intensive antiplatelet therapies such as dual antiplatelet therapy plus argatroban may reduce END risk, as reported in branch atherosclerosis disease. Last, direct—as opposed to rescue—endovascular therapy may be considered to prevent END. Two case series in acute iICAo suggested that immediate endovascular therapy including angioplasty and stenting may afford high rates of successful recanalization, although appeared to be associated with a substantial rate of intracranial embolism.

4 tables, 2 figures, no imaging

2. Siegler JE, Shu L, Yaghi S, et al. Endovascular Therapy for Cerebral Vein Thrombosis: A Propensity-Matched Analysis of Anticoagulation in the Treatment of Cerebral Venous Thrombosis. Neurosurgery. 2022;91(5):749-755. doi:10.1227/neu.0000000000002098

Definitive treatment of CVT includes recanalization of occluded cerebral vein or dural sinus with anticoagulation for 3 to 6 months. Endovascular treatment (EVT) in the form of thrombectomy is considered in patients for whom anticoagulation may be contraindicated, or symptoms progress despite anticoagulation, and is recommended with a low level of evidence by the American Heart Association (Class IIb, Level of Evidence C). Systematic review and meta-analyses indicate that EVT is reasonable and safe as a salvage treatment for CVT, with similar patient outcomes compared with medically managed patients. However, these data are limited by small patient populations, with the largest cohort comprising 63 patients. Furthermore, the adjunctive benefit of endovascular treatment in CVT was not proven in the TO-ACT multicenter randomized clinical trial. In Thrombolysis or Anticoagulation for Cerebral Venous Thrombosis (TO-ACT), the likelihood of achieving a good functional outcome (modified Rankin Scale [mRS] 0-1) was no different between the endovascular and medically managed arms.

Of the 1025 patients from the original ACTION-CVT cohort, 987 (96%) had complete demographic and treatment data for this analysis and were included.

This analysis of the ACTION-CVT multicenter cohort study represents the largest observational cohort study of patients with CVT who underwent medical or EVT management.

The authors found no difference in excellent functional outcome (mRS 0-1) at 90 days and no difference in secondary clinical or radiographic outcomes with EVT over medical treatment of CVT. In a sensitivity analysis limiting inclusion of patients based on eligibility for the TO-ACT randomized clinical trial, there was no significant difference in the prespecified primary outcome based on treatment. Altogether, their findings provide real-world data supporting the TO-ACT trial results. It is possible that only a subgroup (or subgroups) of patients with CVT may benefit from EVT (eg, refractory intracranial hypertension, progressive venous infarction, or hemorrhage expansion), and this needs to be determined by future randomized clinical trials. Furthermore, among the few patients who underwent successful recanalization with EVT and had available recanalization and long-term follow-up data (n = 11), there was a suggestion of improved outcomes when compared with patients treated using medical management.

2 figures, 2 tables, no imaging

3. Jack MM, Smith BW, Capek S, et al. The spectrum of brachial plexopathy from perineural spread of breast cancer. J Neurosurg. 2022;137(November):1-10. doi:10.3171/2021.12.JNS211882

The differential diagnosis for breast cancer–related upper- extremity neurological issues is vast. The nerves can be damaged directly during surgery (especially with axillary lymph node dissections), compressed by local disease progression/recurrence, chemically damaged in a length dependent fashion from chemotherapy regimens, or injured – typically in a delayed fashion—as a complication of radiation treatments. One less common and thus less often recognized insult to the brachial plexus in patients with breast cancer is perineural spread.

The aim of this study was to describe the clinical, pathological, and radiological findings in the largest series of patients with pathologically verified perineural spread of breast cancer to the brachial plexus. A total of 19 female patients who all presented with evidence of brachial plexopathy, who had pathological evidence of perineural spread of breast cancer on fascicular nerve biopsy, and who were treated at the authors institution between