Endovascular Treatment May Be Effective in Preventing Recurrence of Ischemic Stroke in Vertebral Artery Stump Syndrome: A Case Series.

Vertebral artery stump syndrome (VASS) is a rare condition that can cause posterior circulation ischemic stroke due to occlusion of the ipsilateral vertebral artery (VA) orifice, resulting in blood flow stagnation and embolus formation. Although there is no established treatment for this condition, we observed 3 cases of VASS out of 326 acute ischemic stroke cases at a single institution from April 2021 to October 2022. Despite the best possible antithrombotic treatment, all 3 patients had recurrent ischemic strokes. One patient underwent drug-eluting stenting of the VA orifice to relieve occlusive flow. The other 2 patients received coil embolization, which resulted in the disappearance of their culprit collateral flow. None of the patients had recurrent ischemic strokes after endovascular intervention. Based on our observations, stenting and coil embolization are effective methods for preventing future recurrences of VASS.

Incidence and Outcomes of Aneurysmal Subarachnoid Hemorrhage: A Multicenter Retrospective Registry-based Descriptive Trial in Kobe City.

The current study aims to evaluate the incidence and results of aneurysmal subarachnoid hemorrhage (aSAH) throughout Kobe City. Based on a multicenter retrospective registry-based descriptive trial involving all 13 primary stroke centers in Kobe City, patients with aSAH treated between October 2017 and September 2019 were studied. A total of 334 patients were included, with an estimated age-adjusted incidence of 11.12 per 100,000 person-years. Curative treatment was given to 94% of patients, with endovascular treatment (51%) preferred over surgical treatment (43%). Of the patients, 12% were treated by shunt surgery for sequential hydrocephalus with a worse outcome at 30 days or discharge (14% vs. 46%, odds ratio (OR): 0.19, 95% confidence interval (CI): 0.088-0.39, p-value <0.001). As for vasospasm and delayed cerebral ischemia, most patients were given intravenous fasudil infusion (73%), with endovascular treatment for vasospasm in 24 cases (7.2%). The fasudil group had more good outcomes (42% vs. 30%, OR: 1.64, 95% CI: 0.95-2.87, p-value = 0.075) and significantly less death (3.3% vs. 35%, OR: 0.064, 95% CI: 0.024-0.15, p-value <0.001) at 30 days or discharge. Mortality rose from 12% at 30 days or discharge to 17% at 1 year, but neurological function distribution improved over time (modified Rankin Scale 0-2 was 39% at 30 days or discharge, 53% at 60 days, and 63% at 1 year). Our retrospective registered trial presented various statistics on aSAH, summarizing the current treatment status and prognosis.

Clinical Trial Based Rationale for the Successful Use of DOAC in the Treatment of Cerebral Venous Sinus Thrombosis (CVST): A Case Report.

In cerebral venous sinus thrombosis (CVST), venous sinus occlusion increases venous pressure and disrupts venous return, resulting in progression to venous infarction and venous hemorrhage, with poor neurologic outcome. Therefore, early recanalization of the major venous sinus is critical. Anticoagulant therapy with continuous intravenous infusion of heparin and subsequent oral anticoagulant administration is the recommended first line of treatment for CVST. Some large clinical trials for venous thromboembolism (VTE) have shown that direct oral anticoagulant (DOAC) is non-inferior to the standard therapy with heparin or warfarin and causes less bleeding. In contrast, there are only a few reports on CVST treatment with DOAC such as Dabigatran, Rivaroxaban and Edoxaban describing good efficacy and safety. And there is one randomized clinical trial on DOAC treatment for CVST after acute phase. We report a successfully treated case of CVST in acute phase with progressive neurologic symptoms that achieved early recanalization of the obstructed sinus by an early switch from continuous intravenous infusion of heparin to oral Edoxaban.

Stroke Systems of Care During the COVID-19 Epidemic in Kobe City.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) outbreak raised concerns over healthcare systems' ability to provide suitable care to stroke patients. In the present study, we examined the provision of stroke care in Kobe City during the COVID-19 epidemic, where some major stroke centers ceased to provide emergency care. METHODS: This was a cross-sectional study. The Kobe Stroke Network surveyed the number of stroke patients admitted to all primary stroke centers (PSCs) in the city between March 1 and May 23, 2020, and between March 3 and May 25, 2019. In addition, online meetings between all PSC directors were held regularly to share information. The survey items included emergency response system characteristics, number of patients with stroke hospitalized within 7 days of onset, administered treatment types (IV rt-PA, mechanical thrombectomy, surgery, and endovascular therapy), and stroke patients with confirmed COVID-19. RESULTS: During the period of interest in 2020, the number of stroke patients hospitalized across 13 PSCs was 813, which was 15.5% lower than that during the same period of 2019 (p = 0.285). The number of patients admitted with cerebral infarction, intracerebral hemorrhage, and subarachnoid hemorrhage decreased by 15.4% (p = 0.245), 16.1% (p = 0.659), and 14.0% (p = 0.715), respectively. However, the rates of mechanical thrombectomy and surgery for intracerebral hemorrhage were slightly increased by 12.1% (p = 0.754) and 5.0% (p = 0.538), respectively. PSCs that ceased to provide emergency care reported a decrease in the number of stroke cases of 65.7% compared with the same period in 2019, while other PSCs reported an increase of 0.8%. No case of a patient with stroke and confirmed COVID-19 was reported during the study period. CONCLUSION: Kobe City was able to maintain operation of its stroke care systems thanks to close cooperation among all city PSCs and a temporal decrease in the total number of stroke cases.

Fatal Hemorrhage Immediately after Transvenous Embolization of Transverse-sigmoid Sinus Dural Arteriovenous Fistulas: A Case Report.

Objective: We report a case of intracerebral hemorrhage following emergency transvenous embolization for an acute symptomatic non-hemorrhagic dural arteriovenous fistula (dAVF). Case Presentation: An 83-year-old woman demonstrated gait disorder and disturbance of consciousness. A transverse-sigmoid dAVF with retrograde deep venous drainage was detected on DSA. The left sigmoid sinus-jugular vein and the sinus confluence were occluded and the dAVF drains via the straight sinus (SS), medial superior cerebral veins and deep veins to the superior sagittal sinus (SSS). The dAVF was emergently treated by sinus packing of the transverse-sigmoid sinus with coils with contralateral approach via the occluded sinus confluence. Although the dAVF was markedly regressed, massive cerebral hemorrhage developed in the left parietal lobe immediately after embolization. Conclusion: Although early treatment is required for dAVFs with aggressive symptoms, precious evaluation of their hemodynamics, particularly for drainage pattern, is mandatory to avoid a serious complication.

Total serum protein reference value as a clinical diagnostic index of equine proliferative enteropathy.

Equine proliferative enteropathy (EPE) caused by Lawsonia intracellularis is characterized by hypoproteinemia. There are currently no reliable reports that provide a reference value for the total serum protein (TP) concentration to clinically diagnose EPE. The objective of this study was to statistically determine the reference value. Feces and sera of 99 foals with EPE-like clinical signs and of 35 healthy foals were obtained. The samples were used for specific-gene detection of L. intracellularis, TP measurement, and specific-antibody detection against L. intracellularis. Based on these results, the optimal reference value for the TP concentration as a clinical diagnostic index of EPE was found to be ≤ 4.8 g/dl. This clinical diagnostic index will provide an effective approach for diagnosing EPE.

Successful Reperfusion with Endovascular Therapy Has Beneficial Effects on Long-Term Outcome Beyond 90 Days.

BACKGROUND AND PURPOSE: Recent studies have demonstrated that endovascular reperfusion therapy improves clinical outcomes at 90 days after ischemic stroke. However, the effects on long-term outcomes are not well known. We hypothesized that successful reperfusion might be associated with long-term improvement beyond 90 days after endovascular therapy. To assess the long-term effects beyond 90 days, we analyzed the association of successful reperfusion with a temporal change in modified Rankin Scale (mRS) score from 90 days to 1 year after endovascular therapy. METHODS: We retrospectively analyzed a database of consecutive patients with acute ischemic stroke who received endovascular therapy between April 2006 and March 2016 at 4 centers. We compared the incidences of improvement and deterioration in patients with successful reperfusion (i.e., modified thrombolysis in cerebral infarction score of 2b or 3) with those in patients with unsuccessful reperfusion. We defined improvement and deterioration as decrease and increase on the mRS score by 1 point or more from 90 days to 1 year after endovascular therapy respectively. RESULTS: A total of 268 patients were included in the current study. The rate of patients with improvement tended to be higher in patients with successful reperfusion than in patients with unsuccessful reperfusion (20% [34/167 patients] vs. 12% [12/101], p = 0.07). The rate of patients with deterioration was lower in patients with successful reperfusion than in patients with unsuccessful reperfusion (25% [42/167] vs. 42% [42/101], p < 0.01). After adjustment for confounders, successful reperfusion was associated with improvement (adjusted OR 2.65; 95% CI 1.23-5.73; p < 0.05) and deterioration (adjusted OR 0.33; 95% CI 0.18-0.62; p < 0.01), independent of the 90-day mRS score. CONCLUSIONS: Successful reperfusion has further beneficial legacy effects on long-term outcomes beyond 90 days after stroke.

Intentional Herniation Technique with the Neuroform EZ Stent System for Preservation of Aneurysmal Neck Branch: A Case Report.

Endovascular treatment of bifurcation aneurysms is difficult and complicated because arterial branches may arise from the aneurysmal neck. We treat these cases with complex techniques such as Y or T stenting. In this report, we deployed one Neuroform EZ stent using the intentional herniation technique for the preservation of arterial branches. A 78-year-old female presented with two unruptured aneurysms. One was an 8 mm aneurysm located at the bifurcation of the internal carotid artery and the posterior communicating artery (PcomA). The other was an 11 mm aneurysm located at the cavernous segment of the internal carotid artery. A 4.5x20 mm Neuroform EZ stent was placed across the aneurysm neck. The delivery wire and microcatheter were pushed during deployment, similar to braided stents. High resolution cone beam computed tomography (CT) after stenting revealed the stent strut to be vertically aligned near the aneurysmal sac, and the PcomA orifice was preserved. We performed coil embolization easily and achieved acceptable obliteration. Our intentional herniation technique may be useful in some cases. Open cell stents have some advantages depending on the method of deployment.

Therapeutic strategy for pineal parenchymal tumor of intermediate differentiation (PPTID): case report of PPTID with malignant transformation to pineocytoma with leptomeningeal dissemination 6 years after surgery.

Pineal parenchymal tumor of intermediate differentiation (PPTID) is rare. The WHO first classified PPTID in 2000 as a pineal parenchymal tumor (PPT) with an intermediate prognosis between pineocytoma (PC) and pineoblastoma (PB). It is considered an intermediate-grade tumor and divided into WHO grade II or III.The number of available reports about PPTID is presently limited, and the appropriate management for this tumor has not yet been determined.The authors report a rare case of PC in a 63-year-old woman who presented with lower-extremity weakness and gait disturbance. A pineal mass lesion was detected on MRI. A diagnosis of PC was established after microsurgical gross-total tumor resection, and the patient received no adjuvant therapy after surgery. Two years after surgery, a partial recurrence was recognized and Gamma Knife radiosurgery was performed. Fours years later, the patient developed diffuse leptomeningeal dissemination. She was successfully treated with craniospinal irradiation. Leptomeningeal dissemination may develop 6 years after the initial diagnosis of PC. A histopathological study of the recurrent tumor revealed a malignant change from PC to PPTID.The present case shows the importance of long-term follow-up of patients with PPTs following resection and the efficacy of craniospinal irradiation in the treatment of leptomeningeal dissemination.

Reevaluation of Pholiota squarrosa lectin-reactive haptoglobin as a pancreatic cancer biomarker using an improved ELISA system.

An increase in Lewis- and core-type fucosylation of haptoglobin has been reported in patients with pancreatic cancer (PC), suggesting that fucosylated haptoglobin is a candidate PC biomarker. Previously, we developed a Pholiota squarrosa lectin antibody enzyme-linked immunosorbent assay (PhoSL-ELISA) system for the detection of core-fucosylated haptoglobin. However, with this methodology, positive results were only obtained for some patients with PC, demonstrating the need for a more sensitive detection system. In the current study, we developed an improved PhoSL-ELISA system with higher sensitivity to detect core-fucosylated haptoglobin using high-concentration urea as a denaturing agent with lectin to facilitate detection. We then reevaluated the performance of PhoSL reactive-core-fucosylated haptoglobin (PhoSL-HP) as a PC biomarker using the improved PhoSL-ELISA system. PhoSL-HP levels in the sera of patients with PC were significantly higher than those in healthy volunteers, with an area under the curve (AUC) value of 0.753. Furthermore, the AUC value of CA19-9 improved from 0.793 to 0.907 when combined with PhoSL-HP. Additionally, several CA19-9-negative cases among the patients with PC were diagnosed as positive for PhoSL-HP. In conclusion, PhoSL-HP detection using our improved ELISA system might allow PhoSL-HP to serve as a potential biomarker for PC and thus might be useful to complement the detection of CA19-9 in PC diagnosis.

Utility of relative ADC ratio in patient selection for endovascular revascularization of large vessel occlusion.

PURPOSE: The relative apparent diffusion coefficient (ADC) ratio on magnetic resonance imaging (MRI) can be used to evaluate the degree of ischemia. Here, we assessed the predictability of ischemic reversibility and the risk of hemorrhagic transformation using the relative ADC ratio. METHODS: This single-center retrospective study analyzed 56 patients with acute occlusion of the internal carotid artery (ICA) or the middle cerebral artery (M1) with endovascular revascularization. Diffusion-weighted imaging (DWI) lesions were classified as reversible lesions, final infarct lesions, and hemorrhagic or non-hemorrhagic regions. The relative ADC ratio was calculated in each DWI lesion and was defined as the ratio of ADC pixel values within affected territory to ADC pixel values in contralateral normal brain regions. RESULTS: The average relative ADC ratio was 0.890±0.045 in reversible DWI lesion and 0.640±0.041 in final infarct DWI lesion (P<0.001). In 4 cases with hemorrhagic transformation, hemorrhagic transformation regions were 0.557±0.049 and non-hemorrhagic transformation regions were 0.762±0.042 (P<0.001). In addition, percentage DWI improvement was inversely correlated with DWI lesion volume at the time of hospitalization (r=-0.840) and onset-to-reperfusion time (r=-0.765), but no correlation was noted with patient age (r=-0.043) or the first NIHSS score (r=-0.277). CONCLUSIONS: The relative ADC ratio may be useful for predicting DWI reversibility and post-reperfusion hemorrhagic transformation, even in patients with an unknown time of onset.

Utility of MRI-based disproportionately enlarged subarachnoid space hydrocephalus scoring for predicting prognosis after surgery for idiopathic normal pressure hydrocephalus: clinical research.

OBJECTIVE The presence of disproportionately enlarged subarachnoid space hydrocephalus (DESH) on brain imaging is a recognized finding of idiopathic normal pressure hydrocephalus (iNPH), but the features of DESH can vary across patients. The aim of this study was to evaluate the utility of MRI-based DESH scoring for predicting prognosis after surgery. METHODS In this single-center, retrospective cohort study, the DESH score was determined by consensus between a group of neurosurgeons, neurologists, and a neuroradiologist based on the preoperative MRI findings of the patients with suspected iNPH. The DESH score was composed of the following 5 items, each scored from 0 to 2 (maximum score 10 points): ventriculomegaly, dilated sylvian fissures, tight high convexity, acute callosal angle, and focal sulcal dilation. The association between the DESH score and improvement of the scores on the modified Rankin Scale (mRS), iNPH Grading Scale (iNPHGS), Mini-Mental State Examination (MMSE), Trail Making Test-A (TMT-A), and Timed 3-Meter Up and Go Test (TUG-t) was examined. The primary end point was improvement in the mRS score at 1 year after surgery, and the secondary outcome measures were the iNPHGS, MMSE, TMT-A, and TUG-t scores at 1 year after surgery. Improvement was determined as improvement of 1 or more levels on mRS, ≥ 1 point on iNPHGS, ≥ 3 points on MMSE, a decrease of > 30% on TMT-A, and a decrease of > 10% on TUG-t. RESULTS The mean DESH score for the 50 patients (mean age 77.6 ± 5.9 years) reviewed in this study was 5.58 ± 2.01. The mean rate of change in the mRS score was -0.50 ± 0.93, indicating an inverse correlation between the DESH score and rate of change in the mRS score (r = -0.749). Patients who showed no improvement in mRS score tended to have a low DESH score as well as low preoperative MMSE and TMT-A scores. There were no differences in the areas of deep white matter hyperintensity and periventricular hyperintensity on the images between patients with and without an improved mRS score (15.6% vs 16.7%, respectively; p = 1.000). The DESH score did differ significantly between patients with and without improved scores on the iNPHGS (6.39 ± 1.76 vs 4.26 ± 1.69, respectively; p < 0.001), MMSE (6.63 ± 1.82 vs 5.09 ± 1.93; p = 0.010), TMT-A (6.32 ± 1.97 seconds vs 5.13 ± 1.93 seconds; p = 0.042), and TUG-t (6.48 ± 1.81 seconds vs 4.33 ± 1.59 seconds; p < 0.001). CONCLUSIONS MRI-based DESH scoring is useful for the prediction of neurological improvement and prognosis after surgery for iNPH.

YAMATO Study (Tissue-Type Plasminogen Activator and Edaravone Combination Therapy).

BACKGROUND AND PURPOSE: We investigated whether administration of edaravone, a free radical scavenger, before or during tissue-type plasminogen activator (tPA) can enhance early recanalization in a major arterial occlusion. METHODS: The YAMATO study (Tissue-Type Plasminogen Activator and Edaravone Combination Therapy) is an investigator-initiated, multicenter (17 hospitals in Japan), prospective, randomized, and open-label study. Patients with stroke secondary to occlusion of the M1 or M2 portion of the middle cerebral artery and within 4.5 hours of the onset were studied. The subjects were randomly allocated to the early group (intravenous edaravone [30 mg] was started before or during tPA) and the late group (edaravone was started after tPA and the assessment of early recanalization). RESULTS: One-hundred sixty-five patients (96 men; median age [interquartile range], of 78 [69-85] years) were randomized 1:1 to either the early group (82 patients) or the late group (83 patients). Primary outcome, defined as an early recanalization 1.5 hour after tPA, was observed in 53% of the early group and in 53% of the late group (P=1.000). About secondary outcomes, the rate of significant recanalization of ≥50% was not different between the 2 groups (28% versus 34%; P=0.393). The symptomatic intracerebral hemorrhage has occurred in 4 patients (5%) in the early group and in 2 patients (2%) in the late group (P=0.443). The favorable outcome (modified Rankin Scale score of 0-2) at 3 months was also similar between the groups (53% versus 57%; P=0.738). CONCLUSIONS: The timing of edaravone infusion does not affect the rate of early recanalization, symptomatic intracerebral hemorrhage, or favorable outcome after tPA therapy. CLINICAL TRIAL REGISTRATION: URL: http://www.umin.ac.jp/ctr/index-j.htm. Unique identifier: UMIN000006330.

Assay of hemoglobin A1c using lectin from Aleuria aurantia.

Hemoglobin A1c (HbA1c) has an N-terminal fructosyl valine on the ß-chain, and this modification is caused by the non-enzymatic glycosylation of hemoglobin (Hb). The relative concentration ratio of HbA1c to total Hb is an important biomarker for the diagnosis of diabetes. HbA1c-binding lectins were screened from 29 sources of lectin, and the lectin from Aleuria aurantia (AAL) was revealed to have higher affinity to HbA1c than to Hb. The concentration of HbA1c was determined by lectin-based enzyme-linked immunosorbent assay (ELISA) using the AAL lectin. Higher reproducibility of the assay was observed at 4 °C than at 25 and 37 °C. This observation is consistent with the known temperature-dependent behavior of lectins. Preincubation of HbA1c with an anti-HbA1c antibody inhibited the binding, suggesting that AAL binds to the N-terminal fructosyl valine epitope of HbA1c. Higher inhibitory effect was observed for 10 mM D-fructose than for the same concentrations of L-fucose, D-fucose, or D-glucose.

Segmental Arterial Mediolysis Involving Both Vertebral and Middle Colic Arteries Leading to Subarachnoid and Intraperitoneal Hemorrhage.

BACKGROUND: Segmental arterial mediolysis (SAM) is not yet well known in the neurosurgical field, even though it has become an increasingly recognized pathology in arterial dissection. CASE DESCRIPTION: A case of SAM presented as subarachnoid hemorrhage (SAH) due to a dissecting aneurysm of the left intracranial vertebral artery (VA), which extended from the proximal VA union to the distal portion of the left posterior inferior cerebellar artery. The lesion was successfully embolized by an endovascular technique. However, subsequent intraperitoneal hemorrhage due to rupture of a fusiform aneurysm of the middle colic artery prompted surgical treatments. The features of the extirpated visceral vascular lesion were compatible with the diagnosis of SAM based on histopathologic examinations. CONCLUSIONS: It is very important that SAM is recognized as a systemic disease that affects the central nervous system, visceral arteries, and coronary arteries. The possibility of SAM should always be considered, particularly in patients with ruptured VA dissection-which is nowadays treated by endovascular techniques-since concomitantly involved visceral arteries may cause unexpected hemorrhagic complications other than SAH.

Evaluation of the skin-prick test for predicting the outgrowth of cow's milk allergy.

BACKGROUND: Although considerable efforts have been made to develop diagnostic tools for predicting the outcome of oral food challenges, tests for predicting the outgrowth of food allergies are lacking. OBJECTIVE: The aim of this study was to assess the diagnostic value of the wheal size and skin index (SI) (the ratio of an allergen-induced wheal to a histamine-induced wheal diameter) of the skin-prick test based on the outcome of a controlled oral provocation test for cow's milk. Moreover, we assessed whether wheal size and/or SI were useful for predicting the outgrowth of cow's milk allergy (CMA). METHODS: This study included 135 children with suspected CMA. Eighty-one patients were definitely diagnosed by oral provocation tests for cow's milk, and their wheal diameters, SIs, and cow milk's-specific serum immunoglobulin E concentrations were determined. RESULTS: The wheal diameters were significantly larger and the SIs significantly higher in children with positive oral provocation test results than in those with negative test results. We found that 50% of the patients were expected to be able to drink cow's milk by age 5 years. In these patients, the wheal diameters were significantly smaller and the SIs significantly lower at the time of CMA outgrowth than at the time of diagnosis, whereas these values were apt to increase in patients who did not outgrow CMA, with no significant difference. CONCLUSIONS: The skin-prick test can be used to diagnose CMA and predict CMA outgrowth. A wheal diameter of 8 mm or/and an SI of 1.0 is informative, not only in diagnosing CMA but also in predicting a natural CMA outgrowth.

Ultrasonography and C-reactive protein can predict the outcomes of voiding cystography after the first urinary tract infection.

AIM: This study evaluated whether sex, clinical variables, laboratory variables or ultrasonography predicted the presence of vesicoureteric reflux during the first episode of urinary tract infection in paediatric patients. We also aimed to define the criteria that indicated the need for voiding cystography testing. METHODS: We used voiding cystography to investigate 200 patients who experienced their first urinary tract infection at our institution between 2004 and 2013 and retrospectively analysed the data by reviewing their medical records. RESULTS: Sex (p = 0.001), peak blood C-reactive protein levels (p < 0.001), the duration of fever after antibiotic administration (p = 0.007) and the ultrasonography findings grade (p < 0.001) were significantly different between patients with and without vesicoureteric reflux. Grade IV-V ultrasonography findings and C-reactive protein levels of ≥80 mg/L predicted vesicoureteric reflux with a sensitivity, specificity and odds ratio of 47.8%, 87.8% and 6.59 (95% confidence interval = 3.26-13.33), respectively (p < 0.001). CONCLUSION: Voiding cystography should be performed for patients with C-reactive protein levels of ≥80 mg/L and grade IV-V ultrasonography findings, but is not necessary in patients with C-reactive protein levels of <80 mg/L and grade I-III ultrasonography findings.

Correlation of middle cerebral artery tortuosity with successful recanalization using the Merci retrieval system with or without adjunctive treatments.

The Merci retrieval system is a useful modality for the recanalization of acute cerebral artery occlusion. However, it remains unclear whether the tortuosity of the middle cerebral artery (MCA) plays a role in successful recanalization. In this study, we investigated the association between the shape of the horizontal MCA segment (M1) and successful recanalization using the Merci retrieval system with or without adjunctive treatments. Twenty-three patients with M1 occlusion underwent thrombectomy using the Merci retrieval system with or without adjunctive treatments between July 2010 and July 2012. The anteroposterior view of final angiograms was used to measure the M1 curve angles. M1 with a curve angle measuring < 100° was defined as arch-type M1, whereas that with a curve angle measuring ≥ 100° was defined as straight-type M1. Angiographic findings were evaluated on the basis of the thrombolysis in cerebral infarction grade; grade 2B or 3 corresponds to successful recanalization. Eight patients had arch-type M1 and 15 patients had straight-type M1. Successful recanalization was achieved in 2 patients (25%) with arch-type M1 and 12 patients (80%) with straight-type M1 (p = 0.023). The mean M1 curve angle was significantly greater in the 14 patients in whom successful recanalization was achieved than in the 9 patients in whom it was not achieved (129 ± 21° vs. 93 ± 29°, p = 0.002). Arch-type M1 was an independent predictive factor of unsuccessful recanalization (odds ratio, 0.045; 95% confidence interval, 0.03-0.696). A tortuous M1 was associated with unsuccessful recanalization by the Merci retrieval system, even when adjunctive treatments were used.

"Loop-like formation" in the cortical venous reflux of dural arteriovenous fistula with intracranial hemorrhage.

BACKGROUND AND PURPOSE: Cortical venous reflux (CVR) in dural arteriovenous fistulas (AVFs) is a well-known risk factor for intracranial hemorrhage. However, the impact of the angiographic characteristics of CVR on the risk of intracranial hemorrhage remains unclear. This study retrospectively reviewed the angioarchitectural features of CVR to assess their influence on the risk of intracranial hemorrhage in dural AVFs. PATIENTS AND METHODS: We retrospectively evaluated 68 consecutive patients with dural AVFs treated at our hospital between September 2001 and February 2010. In all cases, the angioarchitectural features of CVR were analyzed using cerebral angiography with a special focus on the venous drainage pattern of dural AVFs. "Loop-like formation" was defined as at least one CVR forming a curvature and connection adjacent to the original arteriovenous shunt point. RESULTS: Ten dural AVF patients (14.7%) presented with intracranial hemorrhage. All ten dural AVFs with intracranial hemorrhage showed CVR with a "loop-like formation" on angiography. This association was found to be statistically significant (P<0.0001). CONCLUSION: "Loop-like formation" in CVR may be a risk factor for intracranial hemorrhage resulting from dural AVF. This angioarchitectural feature of venous drainage may be a useful prognostic indicator, and hence should be a point of focus during treatment decisions.