Lars Fjetland

Arteriovenous malformation as a consequence of a scar pregnancy

A scar pregnancy is an ectopic pregnancy implanted in a previous lower segment cesarean scar, and the incidence of this complication may be expected to rise along with increasing cesarean section rates. Arteriovenous malformation of the uterus may be congenital, associated with early pregnancy loss, trophoblastic disease, or surgical procedures. We describe a case of uterine arteriovenous malformation as a consequence of a scar pregnancy, complicated by recurrent, serious bleeding. The condition was diagnosed using three‐dimensional ultrasound with color Doppler and magnetic resonance imaging and appears not to have been described before. Selective embolization was performed, but eventually surgical intervention with resection of the affected uterine segment was necessary, and the patient recovered. The diagnosis was confirmed by pathologic‐anatomical diagnosis showing trophoblastic cells in the resected area. Because of collateral formation, non‐surgical options may be limited and not successful.

Evaluation of the recombinant tissue plasminogen activator pretreatment in acute stroke patients with large vessel occlusions treated with the direct bridging approach. Is it worth the effort

The direct bridging concept in acute stroke treatment combines intravenous thrombolysis (IVT) and endovascular treatment (EVT). The frequency and extent of reperfusion obtained already due to IVT were evaluated. Additionally undesired events and the clinical outcome were analysed.

Endovascular stroke treatment in a small-volume stroke center

Our purpose was to evaluate the safety and efficacy of endovascular treatment (EVT) of stroke caused by large vessel occlusions (LVO) performed by general interventional radiologists in cooperation with stroke neurologists and neuroradiologists at a center with a limited annual number of procedures. We aimed to compare our results with those previously reported from larger stroke centers.

Transcarotid Endovascular Thrombectomy for Acute Ischemic Stroke

Endovascular thrombectomy (EVT) via a transfemoral approach can be extremely time-consuming or even impossible. This brief review presents 7 transcarotid EVT procedures in which reperfusion graded as 2b or 3 on the Thrombolysis In Cerebral Infarction scale was achieved. Neck hematoma in need of treatment occurred in 1 patient. Two patients died. In the remaining patients, clinical outcome was graded as a modified Rankin scale score of 3 or less. The results suggest that transcarotid access may be a realistic option for EVT when transfemoral catheterization of the internal carotid artery is not feasible.

Encouraging and Positive Trend Towards Treatment of Acute Ischemic Stroke Performed by Vascular Interventional Radiologist

We read with great interest the paper from Fjetland et al. [1]. We agree with the authors that an interventional radiologist may perform endovascular stroke treatment, actually limited in most worldwide reality to the work of fellowship-trained interventional neuroradiologists. In our experience, between August 2009 and March 2013, 94 patients (64.1 ± 12.6 years old) underwent emergency cerebral angiography for acute ischemic stroke in our interventional radiology cathlab. Time from stroke onset-to-arterial puncture was 233.5 ± 68.0 min and from stroke onset to recanalization was 322.0 ± 85.2 min. A successful recanalization (TICI 2b/3) recanalization was obtained in 81 patients (86 %). Our technical success, as in previous experiences by other nonneurointerventional groups [1–4], are superior to that obtained with intra-arterial thrombolysis (successful recanalization rate ranging from 56 to 60 % [5, 6]) and comparable to that obtained with mechanical thrombectomy (successful recanalization rate ranging from 68 to 100 % [7–10] ) in previous studies performed by interventional neuroradiologists. At 3-month follow-up, 52 % of patients had an mRS B 2 and 23 % died, confirming good clinical results considering the baseline neurological symptoms. These clinical results are comparable with those of major clinical trials that reported a good symptoms recovery from 36 to 88 % of patients [7–10]. Despite treatment improvement developed in the past decade, stroke remains the fourth-leading cause of death [11] and the most important cause of disability in western countries [12]. Even if medical therapy is the only approved treatment described in stroke treatment guidelines [13], narrow time windows and the reduced efficacy in case of large artery occlusions limits the percentage of patients who could benefit of this approach [14]. Recently, some randomized trials [15–17], comparing the medical treatment with endovascular therapy, failed to show any outcomes improvement with endovascular approaches. This issue may be due to the prolonged time between stroke symptoms and endovascular treatment in these trials. The delay of endovascular therapy should be minimized in the future in order to improve these results. Involvement of peripherally trained interventional radiologist, as described by Fjetland et al. [1], may be a safe and effective approach to obtain a fast and efficacious stroke treatment, particularly in that area where there is a lack of dedicated neurointerventional center. Other divisions of interventional specialist started endovascular stroke treatment, driven by the need to ensure adequate treatment for stroke patients in areas without dedicated neuroradiology stroke team. DeVries et al. [4], a group of interventional cardiologists, described 26 patients undergoing endovascular stroke therapy. Successful artery recanalization was achieved in 23 (88 %) of the 26 patients. The authors have emphasized that the pool of physicians with carotid stent experience may reasonably augment the national shortage of neuroradiologists. For the authors, any operator with experience in carotid stenting is experienced in cerebral angiography, comfortable with R. Gandini C. Del Giudice (&) F. Chegai D. Konda E. Pampana M. Stefanini A. Spinelli S. Fabiano C. A. Reale G. Simonetti Department of Imaging Diagnostic, Molecular Imaging, Interventional Radiology and Radiation Therapy, IRCCS Policlinico Tor Vergata, Viale Oxford 81, 00133 Rome, Italy e-mail: costantino.delgiudice@gmail.com