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Angioplasty and stenting are emerging alternative treatments to endarterectomy for carotid stenosis. The increasing number of procedures performed carries an increased diagnosis rate of associated asymptomatic intracranial aneurysms, resulting in a clinical and therapeutic dilemma, not fully solved in the literature. When an incidental lesion is found, the first question is whether it is necessary to treat it or not? If treatment is decided, the next question is which should be treated first, the intra or the extracranial lesion? We review our experience and the literature and discuss our preferred approach of single-procedure carotid stenting and aneurysm coiling, which we believe is feasible, safe and effective constituting an option when confronted with this difficult therapeutic dilemma.

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We report the results of transcranial ultrasound monitoring in three patients with intracranial arterial stenosis of the middle cerebral artery treated with the only drug-eluting balloon certificated for intracranial use in highly symptomatic intracranial arterial stenosis, ELUTAX “3” (AR Baltic Medical). We performed transcranial Doppler ultrasounds 24 h, 72 h, 10 days, 15 days and 30 days after the angioplasty, thereby measuring mean flow velocity (MFV) in the maximum stenosis area in patients with symptomatic steno-occlusive disease of the middle cerebral artery treated with ELUTAX “3”. Two patients were treated during mechanical thrombectomy (MT) due to acute ischemic stroke and one patient was treated on elective basis due to symptomatic pre-occlusive stenosis, with recurrent transient ischemic attacks (TIAs) refractory to medical therapy. In Case 1, the first transcranial Doppler ultrasounds evidenced MFV of 348 cm/s, with progressive MFV reduction until 15 days post-treatment, with MFV of 177 cm/s. In Case 2, 24 h after angioplasty had an MFV of 258 cm/s, decreasing to 103 cm/s at 30 days. Case 3 had an MFV of 436 cm/s before angioplasty that immediately decreased after the procedure to 364 cm/s, with a final MFV of 260 cm/s at 30 days. We have recorded a progressive MFV reduction in intracranial arterial stenosis, with better outcomes in patients treated during MT. In our experience, the use of ELUTAX “3” for the treatment of symptomatic intracranial arterial stenosis achieves a progressive improvement of stenosis, evident in the first weeks, to a higher extent in cases of occlusive thrombosis. More studies are needed to provide more information about this device.

The aim of this study was to analyse the normalization rate of compression ultrasonography after a first episode of proximal deep venous thrombosis (DVT). Patients underwent compressive ultrasound (C-US) examinations during the 3-6 months following the first proximal DVT episode. Normalization rate of compressive ultrasound (C-US) during the follow-up period was 26.4% [95% confidence interval, 16.3-37.3]. Allelic variation in factor XIII gene (Val34Leu) significantly affected the improvement of popliteal residual thrombi (P = 0.019). We also observed a significant negative correlation between D-dimer levels at 3 months and improvement of popliteal residual thrombi (P = 0.016). There was a significant positive correlation between baseline lumen diameter of the femoral thrombi and IL-8 cytokine (P = 0.015). A significant difference was also found between 1 month-tumor necrosis factor (TNF)-α levels and improvement of residual thrombi (P = 0.047). Our results show that normalization after a standard period of anticoagulation is not frequent and procoagulant and inflammatory biomarkers and also some genetic variations might be related to the resolution of thrombosis.