Comparison of the Clinical Outcome of Carotid Artery Stenting Between Institutions With a Treatment Strategy Based on Risk Factors and Those With First-Line Treatment.

PURPOSE: Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are recommended based on certain risk factors. The volume of an institution's treatment experience may be associated with good clinical outcomes. There is a dilemma between the treatment strategy based on risk factors and the experience volume. Therefore, we investigated the clinical outcomes of CAS performed at institutions that selected the treatment strategy based on risk factors and those that performed CAS at the first-line treatment. MATERIALS AND METHODS: Patients who underwent CAS at 5 institutions were included in this retrospective case-control study. We defined CEA/CAS institutions as those that selected the treatment option based on risk factors, and CAS-first institutions as those that performed CAS as the first-line treatment. We investigated cases of ischemic stroke, hemorrhagic stroke, myocardial infarction, and deaths within 30 days of the intervention between the CEA/CAS- and CAS-first institution groups. One-to-one propensity score matching was performed to compare rates of ischemic and hemorrhagic strokes within 30 days of the intervention. RESULTS: A total of 239 and 302 patients underwent CAS at the CEA/CAS institutions and CAS-first institutions, respectively; ischemic stroke occurred in 12 (5.0%) and 7 patients (2.3%), respectively (p=0.09). No differences in major ischemic strokes (0.8% vs 1.3%; p=0.59), hemorrhagic strokes (0.4% vs 0.3%; p=0.87), or deaths (0.0% vs 0.7%; p=0.21) were observed. Myocardial infarction did not occur in either group. Propensity score analysis showed that ischemic stroke (odds ratio: 1.845, 95% confidence interval: 0.601-5.668, p=0.28) and hemorrhagic stroke (odds ratio: 1.000, 95% confidence interval: 0.0061-16.418, p=1.00) were not significantly associated with either institution group. CONCLUSIONS: The CAS-specific treatment strategies for CAS can achieve the same level of outcomes as the treatment strategy based on risk factors. The CAS performed based on risk factors in CEA/CAS institutions and the treatment of more than 30 patients/year/institution in CAS-first institutions were associated with good clinical outcomes.

Development of cortical microvascularization in Moyamoya disease using the maximum intensity projection method from three-dimensional rotational angiography.

BACKGROUND: Neurosurgeons often experience increased cortical microvascularization in Moyamoya disease (MMD). However, there are no previous reports that radiologically evaluated preoperative cortical microvascularization. We investigated the development of cortical microvascularization and clinical characteristics of MMD using the maximum intensity projection (MIP) method. METHODS: We enrolled 64 patients at our institution, including patients with MMD (n = 26), intracranial atherosclerotic disease (ICAD; n = 18), and unruptured cerebral aneurysms (n = 20) as the control group. All patients underwent three-dimensional rotational angiography (3D-RA). The 3D-RA images were reconstructed using partial MIP images. Cortical microvascularization was defined as the vessels that branched off from the cerebral arteries and were classified as grade 0-2 depending on their development. RESULTS: Cortical microvascularization observed in patients with MMD was classified into grade 0 (n = 4, 8.9%), grade 1 (n = 17, 37.8%), and grade 2 (n = 24, 53.3%). The development of cortical microvascularization was more common in the MMD group than in the other groups. The inter-rater reliability measured using weighted kappa was 0.68 (95% confidence interval = 0.56-0.80). There were no significant differences in cortical microvascularization according to the onset type and hemispheres. Cortical microvascularization correlated with periventricular anastomosis. Most patients with Suzuki classifications 2-5 developed cortical microvascularization. CONCLUSION: Cortical microvascularization was characteristic of patients with MMD. These findings developed in the early stages of MMD and may act as a bridge to the development of periventricular anastomosis.

[Evidence and Patient Selection for Endovascular Reperfusion Therapy for Acute Ischemic Stroke:A Narrative Review].

Three former stroke trials failed to show the efficacy of endovascular stroke reperfusion therapy using intra-arterial thrombolysis or older-generation mechanical thrombectomy devices, compared with usual medical care in 2013. However, five pivotal trials in 2015(MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, and REVASCAT), using newer-generation devices(e.g., stent retrievers), have shown stroke thrombectomy to clearly improve the functional outcome of patients with occlusion of the internal carotid artery or the M1 portion of the middle cerebral artery(baseline National Institutes of Health Stroke Scale score ≥ 6; baseline Alberta Stroke Program Early Computed Tomography Score ≥ 6), and who could receive thrombectomy within 6 h of symptom onset . In 2018, the efficacy of stroke thrombectomy for late-presenting patients with up to 16-24 h of onset and those who had a mismatch between neurological severity and ischemic core volume was also established by the DAWN and DEFUSE 3 trials. In 2022, the efficacies of stroke thrombectomy for patients with a large ischemic core or basilar artery occlusion were identified. This article discusses the evidence and patient selection for endovascular reperfusion therapy for acute ischemic stroke.

Effect of Mechanical Thrombectomy Without vs With Intravenous Thrombolysis on Functional Outcome Among Patients With Acute Ischemic Stroke: The SKIP Randomized Clinical Trial.

IMPORTANCE: Whether intravenous thrombolysis is needed in combination with mechanical thrombectomy in patients with acute large vessel occlusion stroke is unclear. OBJECTIVE: To examine whether mechanical thrombectomy alone is noninferior to combined intravenous thrombolysis plus mechanical thrombectomy for favorable poststroke outcome. DESIGN, SETTING, AND PARTICIPANTS: Investigator-initiated, multicenter, randomized, open-label, noninferiority clinical trial in 204 patients with acute ischemic stroke due to large vessel occlusion enrolled at 23 hospital networks in Japan from January 1, 2017, to July 31, 2019, with final follow-up on October 31, 2019. INTERVENTIONS: Patients were randomly assigned to mechanical thrombectomy alone (n = 101) or combined intravenous thrombolysis (alteplase at a 0.6-mg/kg dose) plus mechanical thrombectomy (n = 103). MAIN OUTCOMES AND MEASURES: The primary efficacy end point was a favorable outcome defined as a modified Rankin Scale score (range, 0 [no symptoms] to 6 [death]) of 0 to 2 at 90 days, with a noninferiority margin odds ratio of 0.74, assessed using a 1-sided significance threshold of .025 (97.5% CI). There were 7 prespecified secondary efficacy end points, including mortality by day 90. There were 4 prespecified safety end points, including any intracerebral hemorrhage and symptomatic intracerebral hemorrhage within 36 hours. RESULTS: Among 204 patients (median age, 74 years; 62.7% men; median National Institutes of Health Stroke Scale score, 18), all patients completed the trial. Favorable outcome occurred in 60 patients (59.4%) in the mechanical thrombectomy alone group and 59 patients (57.3%) in the combined intravenous thrombolysis plus mechanical thrombectomy group, with no significant between-group difference (difference, 2.1% [1-sided 97.5% CI, -11.4% to ∞]; odds ratio, 1.09 [1-sided 97.5% CI, 0.63 to ∞]; P = .18 for noninferiority). Among the 7 secondary efficacy end points and 4 safety end points, 10 were not significantly different, including mortality at 90 days (8 [7.9%] vs 9 [8.7%]; difference, -0.8% [95% CI, -9.5% to 7.8%]; odds ratio, 0.90 [95% CI, 0.33 to 2.43]; P > .99). Any intracerebral hemorrhage was observed less frequently in the mechanical thrombectomy alone group than in the combined group (34 [33.7%] vs 52 [50.5%]; difference, -16.8% [95% CI, -32.1% to -1.6%]; odds ratio, 0.50 [95% CI, 0.28 to 0.88]; P = .02). Symptomatic intracerebral hemorrhage was not significantly different between groups (6 [5.9%] vs 8 [7.7%]; difference, -1.8% [95% CI, -9.7% to 6.1%]; odds ratio, 0.75 [95% CI, 0.25 to 2.24]; P = .78). CONCLUSIONS AND RELEVANCE: Among patients with acute large vessel occlusion stroke, mechanical thrombectomy alone, compared with combined intravenous thrombolysis plus mechanical thrombectomy, failed to demonstrate noninferiority regarding favorable functional outcome. However, the wide confidence intervals around the effect estimate also did not allow a conclusion of inferiority. TRIAL REGISTRATION: umin.ac.jp/ctr Identifier: UMIN000021488.

Significance of Nonfocal Symptoms in Patients With Transient Ischemic Attack.

Background and Purpose- Patients with transient ischemic attack (TIA) occasionally show nonfocal symptoms, such as unconsciousness, amnesia, and unsteadiness. The purpose of this study was to clarify the characteristics and prognosis of patients with TIA with nonfocal symptoms, using data from the PROMISE-TIA (Prospective Multicenter Registry to Identify Subsequent Cardiovascular Events After Transient Ischemic Attack). Methods- Patients with TIA within 7 days of onset were consecutively enrolled in the Japanese nationwide registry. Factors associated with nonfocal symptoms and 1-year risks of ischemic stroke and coronary artery diseases were assessed in multivariate-adjusted models. Results- We studied 1362 patients with TIA (879 men; mean age, 69±12 years), including 219 (16%) with nonfocal symptoms. Patients with TIA with nonfocal symptoms were more likely to show acute ischemic lesions in the posterior circulation on diffusion-weighted imaging (multivariate-adjusted odds ratio, 3.07; 95% confidence interval, 1.57-5.82) and arterial stenosis or occlusion in the posterior circulation on vascular examination (odds ratio, 1.94; 95% confidence interval, 1.19-3.09) than those without nonfocal symptoms. Although 1-year risk of ischemic stroke did not differ significantly between groups (adjusted hazard ratio, 0.79; 95% confidence interval, 0.42-1.37), risk of coronary artery disease was higher in patients with TIA with nonfocal symptoms (hazard ratio, 3.37; 95% confidence interval, 1.14-9.03). Conclusions- Both acute ischemic lesions and arterial stenosis and occlusion in the posterior circulation were more frequently observed in patients with TIA with nonfocal symptoms.

Embolic Stroke due to Carotidynia Potentially Associated with Moving Carotid Artery Caused by Swallowing.

A 63-year-old woman with end-stage renal disease on maintenance hemodialysis discontinued her medication for rheumatoid arthritis with prednisolone and azathioprine. One month later, she was admitted because of consciousness disturbance and right hemiparesis. Diffusion-weighted brain magnetic resonance imaging (MRI) revealed multiple hyperintensities in her left frontal and parietal lobes. She also developed high fever and left neck pain. Carotid ultrasonography showed calcified plaque with vessel wall swelling at the bifurcation of the left common carotid artery (LCCA) and surrounding hypoechoic soft tissue. The tissue was identified as an isodense lesion on noncontrast computed tomography (CT) and as a high-intensity lesion on fat-saturated T2-weighted MRI. From her symptoms and radiological findings, she was diagnosed with carotidynia. Cervical MRI also showed that the LCCA was transposed to a retropharyngeal location, suggesting a moving carotid artery. Carotid ultrasonography revealed that the LCCA moved to and from the retropharyngeal position with swallowing and was thus being compressed by the hyoid bone. After corticosteroid therapy was initiated with 30 mg of prednisolone, her symptoms and radiological findings improved. To our knowledge, this is the first report of a case of cerebral embolism due to carotidynia. The repetitive compressions by the hyoid bone during swallowing were presumed to have provoked shear stress and inflammation of the carotid vessel wall, which was aggravated by discontinuation of steroid therapy in our case. These mechanical and inflammatory stresses might cause dysfunction of endothelial cells, hypercoagulation, platelet hyperaggregation, and vulnerability and rupture of carotid plaques, and may subsequently result in embolic strokes.

Histopathologic Analysis of Retrieved Thrombi Associated With Successful Reperfusion After Acute Stroke Thrombectomy.

BACKGROUND AND PURPOSE: Histopathologic evaluation of occlusive thrombi retrieved from cerebral arteries using endovascular therapy is possible. We investigated the relationship between successful reperfusion after thrombectomy and histopathologic characteristics of retrieved thrombi. METHODS: Among consecutive patients with acute ischemic stroke treated with endovascular therapy at our institute from December 2010 to July 2015, we retrospectively reviewed those with acute major arterial occlusion from which retrieved thrombi were evaluated histopathologically. Obtained thrombi were assessed for the existence of atheromatous gruel, organization, and the ratios of erythrocyte and fibrin/platelet components. Successful reperfusion was defined as the modified Treatment in Cerebral Ischemia grade of 2b to 3. RESULTS: Of 83 patients studied, 58 (70%) underwent successful reperfusion. Atheromatous gruel was less frequently identified (3% versus 20%; P=0.024), and the proportion of erythrocyte components was higher (57±23% versus 47±24%; P=0.042) in thrombi retrieved from the reperfused than the unreperfused group. On multivariate logistic regression analysis, atheromatous gruel was inversely related (odds ratio, 0.062; 95% confidence interval, 0.002-0.864), and >64% erythrocyte components (cutoff obtained from receiver operating characteristic curve) were positively related (odds ratio, 4.352; 95% confidence interval, 1.185-19.363) to successful reperfusion. CONCLUSIONS: Successful reperfusion could be associated with the histopathology of occlusive thrombi, including the existence of atheromatous gruel and proportion of erythrocyte components. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02251665.

Acute reperfusion therapy and stroke care in Asia after successful endovascular trials.

The current status of and prospects for acute stroke care in Asia in the situation where both intravenous thrombolysis and endovascular therapies have been recognized as established strategies for acute stroke are reviewed. Of 15 million people annually having stroke worldwide, ≈9 million are Asians. The burdens of both ischemic and hemorrhagic strokes are severe in Asia. The unique features of stroke in Asia include susceptibility to intracranial atherosclerosis, high prevalence of intracerebral hemorrhage, effects of dietary and lifestyle habits, and several disorders with genetic causes. These features affect acute stroke care, such as the dosage of alteplase for thrombolysis and consideration of bleeding complications during antithrombotic therapy. Acute endovascular thrombectomy, as well as intravenous thrombolysis, is relatively prevalent in East Asia, but most of the other Asian countries need to develop their human resources and fundamental medical infrastructure for stroke care. A limitation of endovascular therapy in East Asia is the high prevalence of intracranial atherosclerosis that can cause recanalization failure and require additional angioplasty or permanent stent insertion although intracranial stenting is not an established strategy. Multinational collaboration on stroke research among Asian countries is infrequent. Asians should collaborate to perform their own thrombolytic and endovascular trials and seek the optimal strategy for stroke care specific to Asia.

[Construction of System for Support of Multifacility IVR Dose Analysis and Research].

Although measurement and management of angiographic entrance skin dose (ESD) are deemed extremely important, accurate determination of maximum ESD and its location is generally difficult because of the dependence on therapeutic technique and position. Following our development of body-mounted gear bearing radiophotoluminescence glass dosimeter (RPLD) arrays for direct measurement of ESD in cranial and cardiovascular angiography and interventional radiology (IVR), our focus next turned to the limited number of facilities equipped to read RPLD outputs and the need for methods to effectively provide feedback to clinical facilities. As described here, we first constructed an RPLD reading facility capable of sending and receiving RPLDs by post, offering the potential to enable utilization of the developed gear at all hospitals in Japan that perform angiography and IVR. We next developed specialized web-based system to generate dose maps from RPLD dose data, thereby enabling any facility to perform trial system analysis, evaluation, and implementation; and investigated the results and related problems.

[Estimation of Maximum Entrance Skin Dose during Cerebral Angiography].

Using radio-photoluminescence glass dosimeter, we measured the entrance skin dose (ESD) in 46 cases and analyzed the correlations between maximum ESD and angiographic parameters [total fluoroscopic time (TFT); number of digital subtraction angiography (DSA) frames, air kerma at the interventional reference point (AK), and dose-area product (DAP)] to estimate the maximum ESD in real time. Mean (± standard deviation) maximum ESD, dose of the right lens, and dose of the left lens were 431.2 ± 135.8 mGy, 33.6 ± 15.5 mGy, and 58.5 ± 35.0 mGy, respectively. Correlation coefficients (r) between maximum ESD and TFT, number of DSA frames, AK, and DAP were r=0.379 (P<0.01), r=0.702 (P<0.001), r=0.825 (P<0.001), and r=0.709 (P<0.001), respectively. AK was identified as the most useful parameter for real-time prediction of maximum ESD. This study should contribute to the development of new diagnostic reference levels in our country.

Emergence of the white-collar sign after coil embolization of cerebral aneurysms.

BACKGROUND: The white-collar sign (WCS) is represented by the formation of neointimal tissue at the level of the aneurysm neck as the successful outcome on follow-up angiography after coil embolization. WCS has been reported only in aneurysms treated with Matrix® coils. This is the first study to report WCS emergence in aneurysms treated with bare platinum coils, and potential factors associated with WCS emergence were evaluated. METHOD: Total 130 unruptured (female: male ratio, 100: 30; mean age, 60 years) cerebral aneurysms were treated with coil embolization. Embolization status was assessed immediately and 1 year after treatment, and emergence of WCS in follow-up angiography was assessed. We evaluated the association between WCS emergence and aneurysm location, dome diameter, neck diameter, dome-neck ratio, and type of coil used (bare platinum or bioactive). RESULTS: WCS appeared in nine aneurysms (6.9%), of which six were treated only with bare platinum coils. Neck diameter was significantly smaller in the WCS-positive group than in the WCS-negative group. The proportion of aneurysms treated with bioactive coils was not significantly different between the groups. Immediate embolization status in the WCS-positive group tended to be slightly better than that in the WCS-negative group. No aneurysmal morphological characteristics other than small neck diameter were associated with WCS emergence. CONCLUSIONS: WCS is not specific to bioactive coil usage. Small neck diameter was significantly associated with WCS emergence in our series. Further investigations to clarify the predictors of WCS will contribute to progress of aneurysmal embolization.

[Recent advances in therapeutic strategies of hyperacute and acute ischemic stroke in Japan].

Intravenous thrombolysis using tissue plasminogen activator (IV t-PA) and endovascular recanalization therapy are performed for neurological recovery in hyperacute ischemic stroke patients. Antithrombotic agents are given to prevent neurological worsening and recurrence in acute ischemic stroke patients. Therapeutic strategies for hyperacute and acute ischemic stroke have been in the process of change since the Merci retriever and Penumbra system as mechanical thrombectomy devices were approved in 2010 and 2011, and the therapeutic time window of IV t-PA was extended from 3 hours to 4.5 hours in 2012. The authors discussed on new evidences and future prospects of hyperacute recanalization therapy and acute antithrombotic therapy, bringing about a revolution to routine clinical practice in Japan.

Targeted Transarterial Embolization for Treatment of a Symptomatic Venous Varix in the Draining Vein of an Arteriovenous Malformation: Case Report and Literature Review.

BACKGROUND: Venous varices in the draining vein of arteriovenous malformations (AVMs) can result in compression symptoms. This condition is extremely rare, and its treatments and long-term outcomes are unresolved. Herein, we describe the treatment of a thrombosed venous varix in a draining vein and review the relevant literature. PATIENT: The patient presented with progressive right-sided hemiparalysis and aphasia. Magnetic resonance imaging revealed flow void accumulation from the corpus callosum to the left ventricle and a 30-mm mass in the left putamen. The patient underwent targeted transarterial embolization to reduce the blood flow to the venous varix and relieve the neurological symptoms. The patient had recovered completely from the right hemiparesis and aphasia 4 years after treatment, with a modified Rankin Scale score of 0. CONCLUSION: Targeted transarterial embolization for symptomatic venous varix is a palliative treatment that may improve long-term functional outcomes.

Transient Hemichorea-hemiballism Induced by a Combination of Postprandial Hypotension and Severe Stenosis of the Innominate Artery Concomitant with Left Carotid Occlusion.

Hemichorea-hemiballism (HCHB) due to transient ischemic attacks (TIAs) is rare. An 83-year-old woman had repeated episodes of right-sided HCHB for 3 months. Magnetic resonance (MR) angiography demonstrated occlusion of the left carotid and middle cerebral arteries and severe stenosis of the innominate artery, and 24-hour ambulatory blood pressure monitoring showed a blood pressure decrease of >20 mmHg after each meal. We speculated that HCHB developed as TIAs due to hemodynamic failure in the left cerebral hemisphere, caused by a combination of severe stenosis of the innominate artery concomitant with occlusion of the left carotid and middle cerebral arteries as well as postprandial hypotension.

Additional outlet occlusion as an important factor in avoiding retreatment after transvenous embolization for cavernous sinus dural arteriovenous fistulas.

BACKGROUND: Transvenous embolization (TVE), such as selective shunt occlusion, is the first line treatment for cavernous sinus dural arteriovenous fistula (CSDAVF). Despite the favorable outcomes of TVE, some cases necessitating retreatment due to recurrence or incomplete occlusion persist. Given the physical, psychological, and financial burden of multiple treatments, understanding the predictive factors for recurrence, spontaneous occlusion, or retreatment is important. However, few reports have addressed these factors, complicating decision making regarding the need for retreatment. This study analyzed predictive factors for retreatment and spontaneous occlusion to offer new insights into CSDAVF management. METHODS: This retrospective, observational study was conducted in two acute care hospitals. Patients aged 18-100 years undergoing endovascular treatment for CSDAVF from January 2011 to December 2022 were included. RESULTS: Of 65 patients treated with TVE, 29 experienced immediate complete occlusion. Meanwhile, 22 of 36 patients with incomplete occlusion had spontaneous occlusion, and retreatment was performed in 20% of patients. Additional outlet occlusion was negatively associated with retreatment (P=0.046), and it tended to promote spontaneous occlusion (P=0.056). Favorable functional outcomes were observed in all patients, and approximately 94% of patients showed complete occlusion at the latest follow-up. CONCLUSION: TVE is an effective treatment for CSDAVF. Outlet occlusion, when immediate complete occlusion is unattainable, is important to reduce retreatment and promote spontaneous occlusion. Substantially reducing shunt flow, carefully assessing dangerous drainage routes, and closely monitoring the residual shunt are crucial for preventing intracranial hemorrhage when outlet occlusion is performed.

Hidden Bow Hunter's Syndrome Diagnosed Using Dynamic Cerebral Angiography and Successfully Treated with Spinal Surgery: A Case Report and Review of the Literature.

Hidden bow hunter's syndrome (HBHS) is a rare disease in which the vertebral artery (VA) occludes in a neutral position but recanalizes in a particular neck position. We herein report an HBHS case and assess its characteristics through a literature review. A 69-year-old man had repeated posterior-circulation infarcts with right VA occlusion. Cerebral angiography showed that the right VA was recanalized only with neck tilt. Decompression of the VA successfully prevented stroke recurrence. HBHS should be considered in patients with posterior circulation infarction with an occluded VA at its lower vertebral level. Diagnosing this syndrome correctly is important for preventing stroke recurrence.

Short- versus long-term Dual AntiPlatelet Therapy for Stent-Assisted treatment of CErebral aneurysm (DAPTS ACE): a multicenter, open-label, randomized clinical trial.

BACKGROUND: The optimal duration of dual antiplatelet therapy (DAPT) after stent-assisted coil embolization (SACE) for cerebral aneurysm remains uncertain. This randomized trial of short- versus long-term Dual AntiPlatelet Therapy for Stent-Assisted treatment of CErebral aneurysm (DAPTS ACE) aimed to clarify whether long-term DAPT can reduce the occurrence of ischemic stroke in patients with cerebral aneurysms treated by SACE compared with short-term DAPT. METHODS: Patients treated for cerebral aneurysm with SACE were enrolled from 17 hospitals in Japan. Patients were enrolled within 30 days after SACE and assigned in a 1:1 ratio to receive long-term (12 months) or short-term (3 months) DAPT with aspirin and clopidogrel. Randomization was performed centrally through a web-based system. The primary outcome was the time to ischemic stroke event during 3 to 12 months after SACE. This trial was registered with the Japan Registry of Clinical Trials (jRCTs051180141). RESULTS: A total of 142 patients were recruited from November 4, 2016 to January 7, 2019. Among them, 65 and 68 patients assigned to the long- and short-term DAPT groups, respectively, were included in the full analysis set. Ischemic stroke occurred in no patients in the long-term DAPT group and in one patient in the short-term DAPT group. The incidence rate did not differ between the groups (0.0 vs 2.1/100 person-years; log rank test, P=0.33). CONCLUSIONS: In this multicenter randomized controlled trial, there was not a statistically significant difference in the rate of ischemic strokes between long- and short-term DAPT.

Efficacy and Safety of Lumbar Drainage before Endovascular Treatment for Ruptured Intracranial Aneurysms.

Objective: Intraoperative rebleeding during endovascular treatment for ruptured intracranial aneurysms is associated with poor prognosis. Lumbar drainage is performed preoperatively to control intracranial pressure; however, it is associated with a risk of brain herniation or rebleeding because intracranial pressure may change rapidly. Therefore, this study aimed to examine the efficacy and safety of preoperative lumbar drainage. Methods: This retrospective study enrolled 375 patients who underwent endovascular treatment of ruptured intracranial aneurysms at our institution between April 2013 and March 2018. The incidence of rebleeding and clinical outcomes were compared between patients who did and did not undergo preoperative lumbar drainage. Results: Among the 375 patients with ruptured intracranial aneurysms, 324 (86.0%) and 51 (14.0%) patients did and did not undergo lumbar drainage, respectively. The incidence of rebleeding was 11/324 (3.4%) and 2/51 (3.9%) in lumbar drainage and nonlumbar drainage groups, respectively, with no statistical differences (p = 0.98). Of the rebleeding cases, 9/11 (81%) and 2/2 (100%) in lumbar drainage and nonlumbar drainage groups, respectively, were due to intraoperative bleeding, and 2/11 (19%) in the lumbar drainage group, the causes of the rebleeding were undetermined. The incidence of symptomatic vasospasm did not differ significantly between the groups (13.2% vs. 11.8%, P = 0.776), while the incidence of hydrocephalus (24.6% vs. 11.8%, P = 0.043) and meningitis (15.2% vs. 5.9%, P = 0.075) were slightly higher in the lumbar drainage group. Favorable clinical outcomes (modified Rankin Scale score <2) at discharge were less frequent in the lumbar drainage group (55.3% vs. 70.0%, P = 0.051). No significant differences were observed in the propensity score-matched analysis. Conclusion: Lumbar drainage before endovascular treatment for ruptured intracranial aneurysms is a safe procedure that does not increase the incidence of rebleeding.

Optimal endovascular therapy technique for isolated intracranial atherothrombotic stroke-related large vessel occlusion in the acute to subacute stage.

BACKGROUND AND PURPOSE: Reocclusion after treatment is a concern in endovascular therapy (EVT) for isolated intracranial atherothrombotic stroke-related large vessel occlusion (AT-LVO). However, the optimal EVT technique for AT-LVO has not yet been investigated. This study evaluated the optimal EVT technique for AT-LVO in a real-world setting. MATERIALS AND METHODS: We conducted a historical multicenter registry study at 51 centers that enrolled patients with AT-LVO. We divided the patients into three groups based on the EVT technique: mechanical thrombectomy alone (MT-only), percutaneous transluminal angioplasty (PTA), and stent deployment (Stent). MT alone was classified into the MT-only group, PTA and MT-PTA into the PTA group, and MT-Stent, MT-PTA-Stent, PTA-Stent, and Stent-only into the Stent group. The primary outcome was the incidence of reocclusion of the treated vessels within 90 days of EVT completion. RESULTS: We enrolled 770 patients and analyzed 509 patients. The rates in the MT-only, PTA, and Stent groups were 40.7, 44.4, and 14.9%, respectively. The incidence rate of residual stenosis >70% of final angiography was significantly higher in the MT-only group than in the PTA and Stent groups (MT-only vs. PTA vs. Stent: 34.5% vs. 26.3% vs. 13.2%, p=0.002). The reocclusion rate was significantly lower in the PTA group than in the MT-only group (adjusted hazard ratio [95% confidence interval], 0.48 [0.29-0.80]). Of the patients, 83.5% experienced reocclusion within 10 days after EVT. Alarmingly, a substantial subset (approximately 62.0%) of patients underwent reocclusion within 2 days of EVT. The incidence of modified Rankin scale scores of 0-2 90 days after EVT was not significantly different among the three groups. The incidences of symptomatic intracranial hemorrhage (ICH), any other ICH, and death were not significantly different. CONCLUSIONS: The incidence rate of reocclusion was significantly lower in the PTA group than in the MT-only group. We found no significant difference in reocclusion rates between the Stent and MT-only groups. In Japan, GP IIb/IIIa inhibitors are not reimbursed. Therefore, PTA might be the preferred choice for AT-LVOs due to the higher reocclusion risk with MT-only. Reocclusion was likely to occur within 10 days, particularly within 2 days post-EVT. ABBREVIATIONS: EVT = endovascular treatment; LVO = large vessel occlusion; MT = mechanical thrombectomy; PTA = percutaneous transluminal angioplasty; ICH = intracranial hemorrhage; SD = standard deviation; IQR = interquartile range; HRs = hazard ratios; BMI = body mass index; LDL = low-density lipoprotein; HDL = high-density lipoprotein; DAPT = dual antiplatelet therapy; TAPT = triple antiplatelet therapy.