THE NIH REGISTRY ON USE OF THE WINGSPAN STENT FOR SYMPTOMATIC 70 – 99% INTRACRANIAL ARTERIAL STENOSIS To the Editor: We read with interest that a relatively high rate of in-stent restenosis (ISR) (25%) was revealed in the NIH Wingspan registry.1 This figure may not be an overestimate. In our cohort of 40 patients with self-expandable stenting for symptomatic intracranial stenosis, 19 had repeat digital subtraction angiography (DSA) in 12 months. ISR ( 50% stenosis) developed in 5 patients (26.3%), which was apparently independent of cardiovascular risk factor control. ISR may be more frequent in daily practice than the rate in the Wingspan phase I study.2 Although most patients with ISR remain asymptomatic, neo-intimal hyperplasia in intracranial vasculature may not be as benign as the authors suggested.1 In a coronary model, ISR may cause branch occlusion and symptom recurrence.3 In cerebral circulation, neo-intimal proliferation may similarly occlude perforators arising from middle cerebral artery (MCA) or basilar artery (BA) and cause infarction in the perforator territory where collateral is minimal. Furthermore, given the small luminal diameter of intracranial vessels, ISR predisposes to perfusion failure apart from thromboembolic risk. ISR could be an important factor governing the longterm outcome after intracranial stenting. A randomized trial is warranted to investigate the efficacy of stenting in symptomatic intracranial stenosis, and it is encouraging to know that one is currently planned in the United States.1 In a country where intracranial stenosis is particularly prevalent, we have been conducting a pilot, randomized study comparing optimal medical treatment vs early adjunctive self-expandable stenting in patients with high risk of recurrence (i.e., recent cerebral ischemic event attributed to a high-grade [ 70%] intracranial stenosis). Some issues encountered during the planning of our study may warrant discussion. First, we randomized patients based on DSA rather than CT angiography (CTA). CTA is invaluable for screening, but is insufficient to accurately quantify the severity of stenosis. In a few patients who had initially consented to the study, subtle vascular anomalies adjacent to the stenosis (like fenestrated MCA or BA) could only be revealed in threedimensional reconstruction of DSA but not in CTA. Catastrophic complications may have occurred if CTA alone was relied upon. Secondly, although double antiplatelet regimen has not been shown to be more effective than single antiplatelet treatment in symptomatic intracranial stenosis, combination therapy has been shown to decrease microembolic signal in symptomatic carotid stenosis.4 To avoid this potential confounder, patients in both stenting and medical groups are offered dual antiplatelets.

THE NIH REGISTRY ON USE OF THE WINGSPAN STENT FOR SYMPTOMATIC 70-99% INTRACRANIAL ARTERIAL STENOSIS. Authors' reply

Vaccine-induced immune thrombotic thrombocytopenia and cerebral venous sinus thrombosis post COVID-19 vaccination; a systematic review.

Abstract Safety and effectiveness of COVID-19 vaccines during pregnancy is a particular concern affecting vaccination uptake by this vulnerable group. Here we evaluated evidence from 23 studies including 117,552 COVID-19 vaccinated pregnant people, almost exclusively with mRNA vaccines. We show that the effectiveness of mRNA vaccination against RT-PCR confirmed SARS-CoV-2 infection 7 days after second dose was 89·5% (95% CI 69·0-96·4%, 18,828 vaccinated pregnant people, I 2 = 73·9%). The risk of stillbirth was significantly lower in the vaccinated cohort by 15% (pooled OR 0·85; 95% CI 0·73–0·99, 66,067 vaccinated vs. 424,624 unvaccinated, I 2 = 93·9%). There was no evidence of a higher risk of adverse outcomes including miscarriage, earlier gestation at birth, placental abruption, pulmonary embolism, postpartum haemorrhage, maternal death, intensive care unit admission, lower birthweight Z-score, or neonatal intensive care unit admission ( p &gt; 0.05 for all). COVID-19 mRNA vaccination in pregnancy appears to be safe and is associated with a reduction in stillbirth. 

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Systematic review and meta-analysis of the effectiveness and perinatal outcomes of COVID-19 vaccination in pregnancy

The COVID-19 pandemic has resulted in significant morbidity and mortality worldwide. To prevent severe infection, mass COVID-19 vaccination campaigns with several vaccine types are currently underway. We report pathological and immunological findings in 8 patients who developed vaccine-induced immune thrombotic thrombocytopenia (VITT) after administration of SARS-CoV-2 vaccine ChAdOx1 nCoV-19. We analyzed patient material using enzyme immune assays, flow cytometry and heparin-induced platelet aggregation assay and performed autopsies on two fatal cases. Eight patients (5 female, 3 male) with a median age of 41.5 years (range, 24 to 53) were referred to us with suspected thrombotic complications 6 to 20 days after ChAdOx1 nCoV-19 vaccination. All patients had thrombocytopenia at admission. Patients had a median platelet count of 46.5 x109/L (range, 8 to 92). Three had a fatal outcome and 5 were successfully treated. Autopsies showed arterial and venous thromboses in various organs and the occlusion of glomerular capillaries by hyaline thrombi. Sera from VITT patients contain high titer antibodies against platelet factor 4 (PF4) (OD 2.59±0.64). PF4 antibodies in VITT patients induced significant increase in procoagulant markers (P-selectin and phosphatidylserine externalization) compared to healthy volunteers and healthy vaccinated volunteers. The generation of procoagulant platelets was PF4 and heparin dependent. We demonstrate the contribution of antibody-mediated platelet activation in the pathogenesis of VITT.

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Antibody-mediated procoagulant platelets in SARS-CoV-2- vaccination associated immune thrombotic thrombocytopenia.

Vaccine-induced immune thrombotic thrombocytopenia: what we know and do not know.

Background: As of 8 April 2021, a total of 2.9 million people have died with or from the coronavirus infection causing COVID-19 (Corona Virus Disease 2019). On 29 January 2021, the European Medicines Agency (EMA) approved a COVID-19 vaccine developed by Oxford University and AstraZeneca (AZD1222, ChAdOx1 nCoV-19, COVID-19 vaccine AstraZeneca, Vaxzevria, Covishield). While the vaccine prevents severe course of and death from COVID-19, the observation of pulmonary, abdominal, and intracranial venous thromboembolic events has raised concerns. Objective: To describe the clinical manifestations and the concerning management of patients with cranial venous sinus thrombosis following first exposure to the “COVID-19 vaccine AstraZeneca”. Methods: Patient files, laboratory findings, and diagnostic imaging results, and endovascular interventions of three concerning patients were evaluated in retrospect. Results: Three women with intracranial venous sinus thrombosis after their first vaccination with “COVID-19 vaccine AstraZeneca” were encountered. Patient #1 was 22 years old and developed headaches four days after the vaccination. On day 7, she experienced a generalized epileptic seizure. Patient #2 was 46 years old. She presented with severe headaches, hemianopia to the right, and mild aphasia 13 days after the vaccination. MRI showed a left occipital intracerebral hemorrhage. Patient #3 was 36 years old and presented 17 days after the vaccination with acute somnolence and right-hand hemiparesis. The three patients were diagnosed with extensive venous sinus thrombosis. They were managed by heparinization and endovascular recanalization of their venous sinuses. They shared similar findings: elevated levels of D-dimers, platelet factor 4 antiplatelet antibodies, corona spike protein antibodies, combined with thrombocytopenia. Under treatment with low-molecular-weight heparin, platelet counts normalized within several days. Conclusion: Early observations insinuate that the exposure to the “COVID-19 vaccine AstraZeneca” might trigger the expression of antiplatelet antibodies, resulting in a condition with thrombocytopenia and venous thrombotic events (e.g., intracranial venous sinus thrombosis). These patients’ treatment should address the thrombo-embolic manifestations, the coagulation disorder, and the underlying immunological phenomena.

Thrombocytopenia and Intracranial Venous Sinus Thrombosis after “COVID-19 Vaccine AstraZeneca” Exposure

Background Balloon dilatation and deployment of a self-expanding stent is a safe treatment for intracranial atherosclerotic stenoses. The significant recurrence rate might be related to the high radial force of the Wingspan stent. Objective To evaluate the procedural safety and stenosis recurrence rate by the use of a stent with reduced radial force (Enterprise). Methods Two hundred nine atherosclerotic stenoses (189 patients) were treated (median age, 68 years; 132 male) in a single center. Lesion locations included internal carotid artery (n = 27), middle cerebral artery (n = 62), vertebral artery (n = 64), basilar artery (n = 55), and posterior cerebral artery (n = 1). Pre- and postmedication included acetylsalicylic acid and Clopidogrel for at least 12 months. Preprocedural and follow-up examinations included magnetic resonance imaging (MRI), neurological assessment, and digital subtraction angiography (6, 12, 26, and 52 weeks). Data registry included age, sex, normal vessel diameter, degree of stenosis, residual stenosis after stent, minimal in-stent diameter, and occurrence of ischemic symptoms during follow-up. Results Median pre- and postprocedural stenosis rate was 65.4 ± 1% vs 25.1 ± 1%. Technical success rate was 100%. Major procedural complications occurred in 16 patients (8.1%). Combined neurological morbidity and mortality rate at 30 days was 2 patients (0.9%). In 174 stenoses (83%) angiographic follow-up was obtained (mean, 10.2 months). A restenosis (>50%) was observed in 43 (24.7%) cases after 4.2 months (mean) with 4 (9.3%) symptomatic lesions. Incidence of recurrent ischemia related to the stented artery was 2.2% during 10.2 months of mean follow-up. Conclusion Undersized balloon angioplasty and deployment of an Enterprise stent is safe and effective for intracranial stenoses. Follow-up results were equal to or better than those reported for bare-metal balloon-expandable or self-expanding stents and yielded excellent protection from recurrent ischemia.

The modified Bose method for the endovascular treatment of intracranial atherosclerotic arterial stenoses using the Enterprise stent.

Background: There is uncertainty about the role of endovascular recanalization procedures for the treatment of acute ischemic stroke in patients aged ≥ 80 years. Therefore, careful patient selection is mandatory. Our aim was to find valid predictors of clinical outcome after mechanical thrombectomy (mTE) based on the sparse information available in the emergency setting. Methods: We included consecutive patients aged ≥ 80 years treated by mTE for anterior circulation thromboembolic vessel occlusion in our department between January 2008 and January 2013. Successful recanalization was defined as a thrombolysis in cerebral infarction (TICI) score of 2b or 3. The rates of parenchymal hemorrhage types I (PHI) and II (PHII) according to the ECASS definition and the rate of focal and diffuse subarachnoid hemorrhage (SAH) were reported. A modified Ranking scale (mRS) score of 0–2 at 90 days was defined as a favorable outcome. We evaluated the influence of gender, smoking habits, atrial fibrillation, diabetes, hypertension, hyperlipidemia, coronary artery and peripheral artery disease, National Institutes of Health Stroke Scale (NIHSS) score, Totaled Health Risks in Vascular Events (THRIVE) score, Alberta Stroke Program Early CT Score (ASPECTS), and duration of symptoms on favorable outcome. Significant pre

Predictors of Outcome after Mechanical Thrombectomy for Anterior Circulation Large Vessel Occlusion in Patients Aged ≥ 80 Years

BACKGROUND

In order to identify risk periods with an increased demand in technical and human resources, we tried to determine patterns and associations in the incidence of acute ischemic stroke due to embolic large vessel occlusions (eLVO) requiring mechanical thrombectomy (MT).

METHODS

We conducted a time series analysis over a 9-year period (2010-2018) based on observational data in order to detect seasonal patterns in the incidence of MT due to eLVO (n = 2628 patients). In a series of sequential negative binominal regression models, we aimed to detect further associations (e.g., temperature, atmospheric pressure, air pollution).

RESULTS

There was a 6-month seasonal pattern in the incidence of MT due to eLVO (p = 0.024) peaking in March and September. Colder overall temperature was associated with an increase in MT due to eLVO (average marginal effect [AME], [95% CI]: -0.15 [-0.30-0.0001]; p = 0.05; per °C). A current increase in the average monthly temperature was associated with a higher incidence of MT due to eLVO (0.34 [0.11-0.56]; p = 0.003). Atmospheric pressure was positively correlated with MT due to eLVO (0.38 [0.13-0.64]; p = 0.003; per hectopascal [hPa]). We could detect no causal correlation between air pollutants and MT due to eLVO.

CONCLUSIONS

Our data suggest a 6-month seasonal pattern in the incidence of MT due to eLVO peaking in spring and early autumn. This might be attributed to two different factors: (1) a current temperature rise (comparing the average monthly temperature in consecutive months) and (2) colder overall temperature. These results could help to identify risk periods requiring an adaptation in local infrastructure.

Seasonal patterns and associations in the incidence of acute ischemic stroke requiring mechanical thrombectomy.

https://link-springer-com-443.webvpn.jmu.edu.cn/content/pdf/10.1007%2F978-3-319-77827-3_63.pdf

Superior Cerebellar Artery Aneurysm: Spontaneous SAH, Occlusion of a Mid-sized, Wide-Necked Superior Cerebellar Artery Aneurysm with a Medina Device and Coils; Subsequent Coil Compaction, Treated with Flow Diversion Using a p64

Ludwig Niehaus

Papers

Thrombocytopenia and Intracranial Venous Sinus Thrombosis after “COVID-19 Vaccine AstraZeneca” Exposure

The modified Bose method for the endovascular treatment of intracranial atherosclerotic arterial stenoses using the Enterprise stent.

Predictors of Outcome after Mechanical Thrombectomy for Anterior Circulation Large Vessel Occlusion in Patients Aged ≥ 80 Years

Seasonal patterns and associations in the incidence of acute ischemic stroke requiring mechanical thrombectomy.

Superior Cerebellar Artery Aneurysm: Spontaneous SAH, Occlusion of a Mid-sized, Wide-Necked Superior Cerebellar Artery Aneurysm with a Medina Device and Coils; Subsequent Coil Compaction, Treated with Flow Diversion Using a p64