Key PointsQuestionDoes the use of adjunct intra-arterial thrombolysis following an angiographically successful thrombectomy improve functional outcomes in patients with large vessel occlusion acute ischemic stroke?FindingsIn this randomized clinical trial that included 121 adults, treatment with intra-arterial alteplase compared with placebo resulted in a modified Rankin Scale score of 0 or 1 in 59.0% vs 40.4% of patients at 90 days. This difference was statistically significant.MeaningAmong patients with large vessel occlusion acute ischemic stroke and successful reperfusion following thrombectomy, the use of adjunct intra-arterial alteplase compared with placebo resulted in a greater likelihood of excellent neurological outcome at 90 days; however, the findings should be considered preliminary until replicated.

Neurotoxicity from contrast media used in angiography is a rare complication from these procedures. The infrequency with which it is encountered makes it a diagnostic challenge. We present the case of a 51-year-old male who, 30 min after successful angiography for treatment of a right carotid-ophthalmic fusiform aneurysm with a stent, developed psychomotor agitation, disorientation, and progressive left faciobrachial hemiparesis (4/5). An emergency nonenhanced CT showed marked cortical enhancement and edema in the right cerebral hemisphere. Cortical enhancement is thought to be secondary to contrast extravasation due to disruption of the blood-brain barrier. Angiography was performed immediately, without any pathologic findings. After this procedure there was an increase in the left faciobrachial hemiparesis (3/5), right gaze deviation, Gerstmann syndrome, and left anosognosia and left homonymous hemianopsia. Endovenous dexamethasone and mannitol were initiated. Twenty-four hours later an MRI showed no signs of acute infarct, just gyriform signal increase in the right cerebral hemisphere on FLAIR and a decrease in the edema observed before. The patient had progressive improvement of his neurological deficit. A control MRI done 5 days later was normal. The patient recovered completely and was discharged. This rare entity should be kept in mind but diagnosed only when all other causes have been ruled out, because more important and frequent causes, such as acute infarct, must be excluded promptly.

Background and Purpose-We sought to quantitatively and qualitatively evaluate the release of atheromatous plaque debris induced by carotid stenting procedures. Methods-Eight patients with severe carotid atheromatous stenoses were treated by stent implantation under distal balloon protection. Blood samplings were obtained after stent deployment in the blood pooled below the inflated protection balloon. The samples were centrifuged and evaluated for plaque debris with the use of light microscopy. The debris release was quantitatively estimated by dividing the total volume of debris obtained by the mean debris size. Five patients without endovascular procedure were used as a control group. Results-The 2 main debris types found were nonrefringent cholesterol crystals (4 to 389 m; 115 to 8697 in number) and lipoid masses (7 to 600 m; 341 to 34 000 in number). There was a statistically significant difference compared with the samples obtained in the control group (Pϭ0.017). Conclusions-Blood

Five recent randomized controlled trials provided clear evidence that endovascular thrombectomy (EVT) improves outcomes after acute ischemic stroke caused by large vessel occlusions (LVOs), [1][2][3][4][5] and current guidelines recommend EVT in addition to intravenous thrombolysis (IVT) within 4.5 hours among patients with anterior circulation strokes and LVO. 6,7 Patients eligible for IVT should receive it without delay even if EVT is being considered, but the particular benefit of IVT is not yet well established. Moreover, in the real world, a significant proportion of acute ischemic stroke patients receive IVT at local stroke centers where EVT is not available. Such centers apply a drip and ship protocol when an EVT candidate is identified, with the necessary subsequent transfer causing a delayed puncture. In this context, building up evidence of the specific role of IVT when added to EVT among LVO patients is necessary to reorganize stroke systems of care accordingly. We compared direct EVT (dEVT) against combined IVT+EVT in patients with anterior circulation strokes caused by LVO. MethodsWe used data included in the SONIIA registry (Sistema Online d'Informació de l'Ictus Agut), a government-mandated, populationbased, externally audited, prospective database that includes all acute ischemic stroke patients treated with reperfusion therapies in the region Background and Purpose-Whether intravenous thrombolysis adds a further benefit when given before endovascular thrombectomy (EVT) is unknown. Furthermore, intravenous thrombolysis delays time to groin puncture, mainly among drip and ship patients. Methods-Using region-wide registry data, we selected cases that received direct EVT or combined intravenous thrombolysis+EVT for anterior circulation strokes between January 2011 and October 2015. Treatment effect was estimated by stratification on a propensity score. The average odds ratios for the association of treatment with good outcome and death at 3 months and symptomatic bleedings at 24 hours were calculated with the Mantel-Haenszel test statistic. Results-We included 599 direct EVT patients and 567 patients with combined treatment. Stratification through propensity score achieved balance of baseline characteristics across treatment groups. There was no association between treatment modality and good outcome (odds ratio, 0.97; 95% confidence interval, 0.74-1.27), death (odds ratio, 1.07; 95% confidence interval, 0.74-1.54), or symptomatic bleedings (odds ratio, 0.56; 95% confidence interval, 0.25-1.27). of Catalonia from January 2011. Further details of this registry have been published elsewhere. 8 Briefly, the database includes relevant baseline information (prestroke medical history, medications and functional status, time of stroke onset and hospital arrival, severity, time of neuro/ vascular imaging, IVT and groin puncture time, and complications) and the neurological situation at 24 to 36 hours post-treatment, including symptomatic bleedings. Outcome variables at 3 months are good outcome (modif...