<figure class="wp-block-audio"></figure>

1. Bonati LH, Jansen O, de Borst GJ, et al. Management of atherosclerotic extracranial carotid artery stenosis. Lancet Neurol 2022;21:27 3–83. Available from: http://dx.doi.org/10.1016/S1474-4422(21)00359-8

The benefit of carotid endarterectomy in patients with symptomatic carotid stenosis was established in the final two decades of the past century. In the NASCET trial, the 2-year risk of any ipsilateral stroke (including perioperative events) in patients with severe symptomatic carotid stenosis (≥70% narrowing of the lumen) was reduced from 26% to 9%. Modest benefit was also observed in patients with moderate stenosis (50–69%) by a reduction of stroke risk from 22.2% to 15.7% after 5 years. In the European Carotid Surgery Trial (ECST), endarterectomy prevented stroke only in patients with symptomatic carotid stenosis of 80% or greater, but measurement of the degree of stenosis on angiography differed between the trials. In a pooled analysis of NASCET, ECST, and the smaller Veterans Affairs trial, in which ECST angiograms were reanalyzed using the NASCET method, the absolute 5-year risk reduction from endarterectomy was 15.9% in patients with severe (≥70%) stenosis and 4.6% in patients with moderate (50–69%) stenosis. Thus, the number needed to treat would be six patients with severe symptomatic stenosis, or 22 patients with moderate symptomatic stenosis, had to be operated on to prevent one ipsilateral stroke after 5 years. Furthermore, extracranial-intracranial bypass surgery is not effective to prevent stroke in patients with carotid artery occlusion.

Among patients with symptomatic carotid stenosis, randomized controlled trials have consistently shown that the risk of periprocedural stroke or death is greater with stenting than with endarterectomy. However, this outcome was mainly caused by a higher risk of minor stroke occurring with stenting, and the extra events largely occurred in patients older than 70 years. Conversely, stenting reduces the risk of procedure-related myocardial infarction, cranial nerve palsy, and hematoma at the access site. Excluding periprocedural events, stenting and endarterectomy work equally well to prevent recurrent stroke or recurrence of stenosis. For patients in whom both stenting and endarterectomy are feasible (ie, symptomatic carotid stenosis), the choice of treatment should primarily be based on an assessment of procedural risks. Additionally, stenting might be considered in symptomatic patients at increased risk for complications with surgery, people in whom the stenosis occurred after previous surgery or after radiation therapy to the neck, and if the stenosis is not surgically accessible, provided these individuals are considered to benefit from revascularization. Stenting should not be routinely used to treat asymptomatic carotid stenosis but might be suggested in asymptomatic patients in whom revascularization is appropriate and who are less suitable for surgery.

4 panels and 2 figures with basic MR of embolic infarcts and CTA

2. Dobrocky T, Nicholson P, Häni L, et al. Spontaneous intracranial hypotension: searching for the CSF leak. Lancet Neurol 2022;21:36 9–80. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1474442221004233

Spontaneous intracranial hypotension is caused by loss of CSF at the level of the spine. The most frequent symptom of this disorder is orthostatic headache, with the headache worsening in the upright position and subsiding after lying down. Neuroimaging has a crucial role in diagnosing and monitoring spontaneous intracranial hypotension, because it provides objective (albeit often subtle) data despite the variable clinical syndromes and often normal lumbar puncture opening pressure associated with this disorder. Spine imaging aims to classify and localize the site of CSF leakage as either (1) a ventral dural leak, (2) a leaking spinal nerve root diverticulum, or (3) a direct CSF-venous fistula. Searching for a CSF leak can be very difficult; the entire spine must be scrutinized for a dural breach often the size of a pin. Precisely locating the site of CSF leakage is fundamental to successful treatment, which includes a targeted epidural patch and surgical closure or endovascular venous embolization when conservative measures do not provide long-term relief.  Conventional spine MRI has no localizing value, so a dynamic myelography technique with intrathecal contrast is generally required for leak localization. Intrathecal Gd-enhanced spine MRI is an off-label indication and should only be used for specific patients when alternative methods are not available. The spontaneous intracranial hypotension score (known as SIH score, aka Bern score, aka Dobrocky score) is a nine-point, brain MRI-based scale that denotes the likelihood of finding a spinal CSF leak in patients with clinically suspected spontaneous intracranial hypotension.

4 figures, 1 table

3. Pirson FAV, Boodt N, Brouwer J, et al. Endovascular treatment for posterior circulation stroke in routine clinical practice: results of the multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands Registry. Stroke 2022;53:75 8–68

The benefit of endovascular treatment (EVT) for posterior circulation stroke (PCS) remains uncertain, and little is known on treatment outcomes in clinical practice. This study evaluates outcomes of a large PCS cohort treated with EVT in clinical practice. Simultaneous to this observational study, several intervention centers participated in the BASICS trial (Basilar Artery International Cooperation Study), which tested the efficacy of EVT for basilar artery occlusion in a randomized setting. The authors additionally compared characteristics and outcomes of patients treated outside BASICS in trial centers to those from nontrial centers.

They included 264 patients of whom 135 (51%) had received intravenous thrombolysis. The basilar artery was most often involved (77%). Favorable outcome (modified Rankin Scale score 0–3) was observed in 115/252 (46%) patients, and 109/252 (43%) patients died. Successful reperfusion was achieved in 178/238 (75%), and symptomatic intracranial hemorrhage occurred in 9/264 (3%). The 154 nontrial patients receiving EVT in BASICS trial centers had similar characteristics and outcomes as the 110 patients treated in nontrial centers.

Regarding mortality within 90 days after EVT, they report a relatively high proportion (43%) compared with other PCS registries (28%–34%) but similar to several BAO registries (44%–47%). The authors think that the high mortality might be caused by the relatively high proportion of BAOs (77%) versus vertebral or posterior cerebral artery occlusions in their cohort. Furthermore, they found similar risk factors for worse outcome as in the anterior circulation stroke population treated with EVT.

3 tables, 2 figures, no imaging

4. Tsai H-H, Hsieh Y-C, Lin JS, et al. Functional investigation of meningeal lymphatic system in experimental intracerebral hemorrhage. Stroke 2022;53:98 7–98

ICH most commonly occurs due to rupture of the neurovascular unit that has been damaged by chronic hypertension or amyloid angiopathy. The subsequent release of blood components produces a dynamic, space-occupying intraparenchymal hematoma that is associated with mechanical brain architectural destruction, inflammatory responses, neurological complications, and poor clinical outcomes. Hematoma clearance through surgical removal or enhancement of endogenous hematoma resolution is a potential therapeutic target for treating ICH. Recently, the meningeal lymphatic system has been identified as a critical mediator of draining pathogenic substances including brain-derived antigens, immune cells, and amyloid-β out of the CNS.  However, whether the same system participates in modulation of intraparenchymal hematoma clearance and CNS pathologies after ICH remains unclear.

A total of 294 eight- to 12-week-old C57BL/6 (wild-type) male mice from the Jackson Laboratory were used in this study. Immunofluorescence of whole-mount meninges was used to measure complexity and coverage level of meningeal lymphatic vasculature following ICH induction. Fluorescent microbeads and PKH-26-labeled erythrocytes were used to evaluate drainage function of the meningeal lymphatic system. Visudyne treatment, deep cervical lymph node ligation, and VEGF (vascular endothelial growth factor)-C injection were performed to manipulate meningeal lymphatic function.

In the current study, the authors observed that meningeal lymphangiogenesis and increased lymphatic drainage occurred from days 10 to 14 and persisted until at least day 60 after ICH. Second, impairment of meningeal lymphatic function in ICH animals impeded intraparench