Time Window for Induced Hypertension in Acute Small Vessel Occlusive Stroke With Early Neurological Deterioration.

BACKGROUND: Therapeutic-induced hypertension treatment (iHTN) is helpful for alleviating early neurological deterioration (END) in acute small vessel occlusive stroke. We examined the time parameters related to iHTN effectiveness in these patients. METHODS: We retrospectively reviewed patients with acute small vessel occlusive stroke who underwent iHTN for END, defined as an increase of ≥2 points in total National Institutes of Health Stroke Scale (NIHSS) score or ≥1 point in motor items of NIHSS. The primary outcome was an early neurological improvement (ENI; a decrease of ≥2 points in total NIHSS score or ≥1 point in motor items of NIHSS), and the secondary outcome was any neurological improvement (a decrease of ≥1 point in the total NIHSS score). We conducted a multivariable logistic regression analysis, adjusting for demographics, risk factors, baseline clinical status, and intervention-related variables. We also generated a restricted cubic spline curve for the END-to-iHTN time cutoff. RESULTS: Among the 1062 patients with small vessel occlusive stroke screened between 2017 and 2021, 136 patients who received iHTN within 24 hours from END were included. The mean age was 65.1 (±12.0) years, and 61.0% were male. Sixty-five (47.8%) patients showed ENI and 77 (56.6%) patients showed any neurological improvement. END-to-iHTN time was significantly shorter in patients with ENI (150 [49-322] versus 290 [97-545] minutes; P=0.018) or any neurological improvement (150 [50-315] versus 300 [130-573] minutes; P=0.002). A 10-minute increase in the time between END and iHTN decreased the odds of achieving ENI (odds ratio, 0.984 [95% CI, 0.970-0.997]; P=0.019) or any neurological improvement (odds ratio, 0.978 [95% CI, 0.964-0.992]; P=0.002). The restricted cubic spline curve showed that the odds ratio of ENI reached its minimum at ≈3 hours. CONCLUSIONS: Among patients with small vessel occlusive stroke with END, a shorter interval between END and the initiation of iHTN was associated with increased odds of achieving neurological improvement. The efficacy of iHTN may be limited to induction within the first 3 hours of END.

Variations in Risk Factors across Different Periods of Stroke and Transient Ischemic Attack Recurrence.

INTRODUCTION: Accurately discerning periods of heightened risk of stroke or transient ischemic attack (TIA) recurrence and managing modifiable risk factors are essential for minimizing overall recurrence risk. This study identified differences in the timing of stroke or TIA recurrence based on risk factors and patient characteristics to develop strategies for reducing recurrence in clinical practice. METHODS: We retrospectively selected patients with ischemic stroke or TIA at the Korea University Ansan Hospital Stroke Center between March 2014 and December 2021 using the prospective institutional database of the Korea University Stroke Registry. We collected demographic, clinical data and categorized participants by recurrence timing (early within or late after 3 months). Using multinomial logistic regression analysis, we examined variables associated with early and late recurrent stroke or TIAs. RESULTS: Among 3,646 patients, 255 experienced a recurrent stroke or TIA and 3,391 experienced their first stroke or TIA. Multinomial logistic regression analysis revealed significant associations between early recurrent stroke or TIA and diabetes mellitus (odds ratio [OR] 1.98, 95% confidence interval [CI] 1.25-3.15), other determined etiologies in the Trial of Org 10172 in the Acute Stroke Treatment classification (OR 3.00, 95% CI 1.37-6.61), and white matter changes (OR 1.97, 95% CI 1.17-3.33). Late recurrence showed a significant correlation with TIA (OR 2.95, 95% CI 1.52-5.71) and cerebral microbleeds (OR 2.22, 95% CI 1.32-3.75). CONCLUSION: Substantial differences in factors contribute to stroke or TIA recurrence based on timing. Managing the risk of recurrence in clinical practice necessitates accurate identification of heightened risk periods and rigorous control of modifiable risk factors.

Early Response to Endovascular Thrombectomy after Stroke: Early, Late, and Very Late Time Windows.

BACKGROUND AND PURPOSE: Endovascular thrombectomy (EVT) has benefits in selected patients 6-24 h after stroke onset. However, the response to EVT >24 h after stroke onset is still unclear. We compared the early response to EVT in patients with different time windows. METHODS: Patients who underwent EVT in an emergency setting were enrolled and categorized according to when EVT was performed: within 6 (early), 6-24 (late), and >24 h (very late) after stroke onset. Early neurological improvement (ENI) and deterioration (END) were defined as improvement and worsening, respectively, of National Institutes of Health Stroke Scale (NIHSS) score by ≥4 points after EVT. The three groups' clinical characteristics and response to EVT were compared. We also investigated factors associated with ENI and END. RESULTS: During study period, 274 patients underwent EVT (109 early, 104 late, and 61 very late). Patients who underwent EVT very late were younger (p = 0.007), had smaller ischemic cores, and had lower initial NIHSS scores (8 ± 5) than those who underwent EVT early (14 ± 6) and late (13 ± 7; p < 0.001). Stroke mechanisms also differed according to the time window (p < 0.001): cardioembolism was more common after early EVT, whereas large-artery atherosclerosis was more prevalent among patients who underwent EVT very late. ENI was significantly more common after early (60.6%) and late EVT (51.0%) than after very late EVT (29.5%; p = 0.001); however, rates of END did not differ (11.0%, 13.5%, and 4.9%, respectively). ENI was independently associated with male, higher NIHSS score, and early and late EVT. END was associated with failure of recanalization. CONCLUSIONS: ENI was more observed and associated with early and late EVT. Highly selected patients receiving very late EVT may not benefit from ENI but may still have a chance to prevent END. The occurrence of END was associated not with time window but with failure of recanalization.

In-stent restenosis and stented-territory infarction after carotid and vertebrobasilar artery stenting.

BACKGROUND: Prognosis after vertebrobasilar stenting (VBS) may differ from that after carotid artery stenting (CAS). Here, we directly compared the incidence and predictors of in-stent restenosis and stented-territory infarction after VBS and compared them with those of CAS. METHODS: We enrolled patients who underwent VBS or CAS. Clinical variables and procedure-related factors were obtained. During the 3 years of follow-up, in-stent restenosis and infarction were investigated in each group. In-stent restenosis was defined as reduction in the lumen diameter > 50% compared with that after stenting. Factors associated with the occurrence of in-stent restenosis and stented-territory infarction in VBS and CAS were compared. RESULTS: Among 417 stent insertions (93 VBS and 324 CAS), there was no statistical difference in in-stent restenosis between VBS and CAS (12.9% vs. 6.8%, P = 0.092). However, stented-territory infarction was more frequently observed in VBS than in CAS (22.6% vs. 10.8%; P = 0.006), especially a month after stent insertion. HbA1c level, clopidogrel resistance, and multiple stents in VBS and young age in CAS increased the risk of in-stent restenosis. Diabetes (3.82 [1.24-11.7]) and multiple stents (22.4 [2.4-206.4]) were associated with stented-territory infarction in VBS. However, in-stent restenosis (odds ratio: 15.1, 95% confidence interval: 3.17-72.2) was associated with stented-territory infarction in CAS. CONCLUSIONS: Stented-territory infarction occurred more frequently in VBS, especially after the periprocedural period. In-stent restenosis was associated with stented-territory infarction after CAS, but not in VBS. The mechanism of stented-territory infarction after VBS may be different from that after CAS.

Long-Term Changes in Poststroke Depressive Symptoms: Effects of Functional Disability and Social Support.

OBJECTIVE: Long-term changes in specific depressive symptoms have rarely been studied in stroke patients. Such changes and the effects of social support and functional disability on specific symptoms after a long-term follow-up period (LTP) were investigated. METHODS: The Montgomery-Åsberg Depression Rating Scale (MADRS), ENRICHD Social Support Instrument, and modified Rankin Scale (mRS) for functional disability were administered at baseline, a 6-month follow-up, and an LTP (35-83 months). Effects of social support and poor functional outcome (mRS score of 3 to 6) on the 10 single items included on the MADRS were identified. RESULTS: Among 222 patients, mRS score, total MADRS score, and all single-item scores except "concentration difficulties," "inability to feel," and "suicidal thoughts" improved at the 6-month follow-up. From the 6-month follow-up to the LTP, the total MADRS score and half of the single-item scores worsened, although the functional outcome measure continued to improve. In multivariable linear regression tests, low social support was associated with "reduced sleep" (standardized ß=0.20; 95% CI=0.06 to 0.34, p=0.005) and "pessimistic thoughts" (standardized ß=0.16, 95% CI=0.03 to 0.30, p=0.019), and poor functional outcome was associated with all specific symptoms (standardized ß values=0.18-0.43, all p<0.02) except "reduced sleep." CONCLUSIONS: Although total MADRS and single-item scores improved in parallel with improvements in functional outcome at the 6-month follow-up, these scores worsened afterward. The lack of social support and presence of functional disability were both associated with total MADRS scores. However, specific symptoms were differentially affected, suggesting that tailored strategies should be applied to manage depression in stroke patients.

Basilar Artery Tortuosity May Be Associated with Early Neurological Deterioration in Patients with Pontine Infarction.

BACKGROUND: Early neurological deterioration (END) occurs in patients with pontine infarction that is adversely associated with a long-term functional outcome. As basilar artery (BA) tortuosity may alter hemodynamics, we investigated whether factors including BA tortuosity are associated with END and poor outcome at 3 months. METHODS: We reviewed patients with acute (<7 days from stroke onset) unilateral pontine infarction mainly involving the pontine base and/or tegmental regions from January 2017 through April 2021. END was defined as increase of ≥2 in total National Institutes of Health Stroke Scale (NIHSS) score or ≥1 in motor NIHSS score within first 72 h. A poor clinical outcome was defined as modified Rankin Scale (mRS) 3-6 at 3 months. The BA tortuosity index (TI) was measured: ([actual/straight length -1] x 100). To assess interobserver agreement, TI measurements were obtained by 2 independent raters. RESULTS: The study included 245 patients; END occurred in 72 (29.3%) and 35 (14.2%) showed poor outcome at 3 months. Old age (odds ratio [OR] = 1.03, 95% confidence interval [CI] 1.004-1.062; p = 0.027), previous stroke history (OR = 2.36, 95% CI: 1.176-4.717; p = 0.016), lower initial NIHSS (OR = 0.72, 95% CI: 0.628-0.827; p < 0.001), and high BA TI (OR = 1.17, 95% CI: 1.062-1.295; p = 0.002) were associated with END. On the other hand, old age (OR = 1.04, 95% CI: 1.002-1.073; p = 0.037) and END (OR = 3.03, 95% CI: 1.429-6.403; p = 0.004) were associated with poor outcome at 3 months. CONCLUSIONS: High BA tortuosity may be a factor associated with END in patients with pontine infarction. As END was related to unfavorable clinical outcome, this risk may have to be carefully considered in patients with high BA tortuosity.

High serum total cholesterol associated with good outcome in endovascular thrombectomy for acute large artery occlusion.

BACKGROUND: The effect of cholesterol on the functional outcome after endovascular thrombectomy (EVT) is still controversial. This study aimed to investigate whether the lipid profile is associated with the EVT prognosis. METHODS: We retrospectively analyzed patients with emergent large vessel occlusion who underwent EVT. The blood lipid levels were measured in the fasting state, 1 day after admission. We divided patients into terciles of serum total cholesterol (TC) levels and compared the clinical characteristics among the groups. The factors associated with a good outcome at 3 months (modified Rankin scale 0-2) were investigated, considering the stroke mechanism and recanalization status. RESULTS: Among 274 patients, good outcomes were observed in 108 (39.4%) patients. Low initial severity (odds ratio (OR), 0.91, 95% confidence interval (CI), 0.858-0.954; p < 0.001) and high TC level (1.35, 1.034-1.758; p = 0.041) were associated with good outcomes. In patients with cardioembolism, young age (0.95, 0.915-0.991; p = 0.021), low initial severity (0.92, 0.857-0.988; p = 0.024), and high TC level (1.60, 1.019-2.499; p = 0.036) were associated with good outcomes. The lipid profile was not associated with a functional outcome in those with large artery atherosclerosis. In patients with complete recanalization, young age (0.97, 0.941-0.994; p = 0.016), low initial severity (0.91, 0.864-0.961; p = 0.001), absence of diabetes (0.45, 0.218-0.947; p = 0.035) or any hemorrhage (0.33, 0.142-0.760; p = 0.009), and high TC level (1.40, 1.031-1.879; p = 0.031) were associated with good outcomes. CONCLUSIONS: A high TC level was associated with favorable outcomes after EVT, especially in patients with cardioembolism and complete recanalization.

Mechanisms of Stroke in Patients with Fetal Posterior Cerebral Artery.

OBJECTIVES: The fetal-type posterior cerebral artery (FTP) is a normal variation of the posterior cerebral artery (PCA), occurring in 3-36% of general population. The effects of the FTP in stroke mechanisms remain debatable. We aimed to investigate the differences in stroke mechanisms and lesion locations between patients with and without FTP. METHODS: A total of 394 patients with PCA territory stroke were divided into those with PCA ischemic stroke associated with ipsilateral FTP and those without. The baseline characteristics, vascular risk factors, infarct pattern, stroke location, stroke etiology, and the diameter of P1 in patients without FTP or posterior communicating artery (PcoA) in patients with FTP were investigated. RESULTS: Among the 394 patients, 52 (13.2%) PCA stroke patients with ipsilateral FTP were enrolled. Patients with FTP, in comparison with those without, had a higher frequency of deep infarct pattern (69.2% vs. 47.1%, P=0.012), small vessel occlusion (51.9% vs. 28.9%, P=0.009), ventrolateral thalamic involvement (65.4% vs. 49.1%, P=0.042), and a lower frequency of cardiac embolism (9.6% vs. 24.0%, P=0.009). The diameter of P1 in patients without FTP was larger than that of PcoA in patients with FTP (2.1 ± 0.3 mm vs. 1.6 ± 0.2 mm, P <0.001). CONCLUSIONS: The stroke mechanisms, infarct pattern, and the location of the stroke were different between patients with and without FTP. PCA stroke patients with FTP more often had small vessel occlusion and ventrolateral thalamic involvement. These results are probably associated with difference in the hemodynamic status according to the presence of FTP.

A Far-Red-Emitting Fluorescence Probe for Sensitive and Selective Detection of Peroxynitrite in Live Cells and Tissues.

In this study, the far-red-emitting fluorescence probe 1, containing a rhodamine derivative and a hydrazide reactive group, was developed for peroxynitrite detection and imaging. This probe, which is cell permeable and shows high sensitivity and selectivity in fluorometric detection of peroxynitrite over other ROS/RNS, was successfully utilized to detect exogenous and endogenous peroxynitrite in HeLa and RAW 264.7 cells, respectively. More importantly, 1 can also be used to detect endogenous peroxynitrite generated in Pseudomonas aeruginosa (PAO1)-infected mouse bone marrow-derived neutrophils. We anticipate that the new probe will serve as a powerful molecular imaging tool in investigations of the role(s) played by peroxynitrite in a variety of physiological and pathological contexts.

Distinct TLR-mediated pathways regulate house dust mite-induced allergic disease in the upper and lower airways.

BACKGROUND: Allergic rhinitis (AR) and asthma are 2 entities of allergic airway diseases that frequently occur together, which is referred to as united airways. In contrast to this general concept, we hypothesized that innate immunity of the upper and lower airways is respectively distinctive, because the immunologic conditions of the nasal and lung mucosa as well as the functions of the immune cells within their epithelia are different. OBJECTIVE: We wanted to identify distinctive mechanisms of innate immunity in the nose and lung mucosa, which are responsible for house dust mite (HDM)-induced AR and allergic asthma (AA), respectively. METHODS: We constructed a mouse model of AR or AA induced by sensitization and consequent provocation with HDM extracts. RESULTS: HDM-derived ß-glucans, rather than LPS, were proven to be essential to activating innate immunity in the nasal mucosa and triggering AR, which depended on Toll-like receptor 2 (TLR2), but not on TLR4; however, the LPS/TLR4 signaling axis, rather than ß-glucans/TLR2, was critical to HDM-induced AA. These differences were attributed to the specific role of ß-glucans and LPS in inducing the surface expression of TLR2 and TLR4 and their translocation to lipid rafts in nasal and bronchial epithelial cells, respectively. We also showed that dual oxidase 2-generated reactive oxygen species mediate both ß-glucan-induced TLR2 activation and LPS-induced TLR4 activation. CONCLUSIONS: We describe a novel finding of distinctive innate immunity of the nose and lungs, respectively, which trigger AR and AA, by showing the critical role of HDM-induced TLR activation via dual oxidase 2-mediated reactive oxygen species.

Contrast enhancement patterns associated with acute stroke in moyamoya disease using MR vessel wall imaging.

BACKGROUND AND PURPOSE: High-resolution magnetic resonance imaging (HR-MRI) can provide valuable insights into the histopathological characteristics of moyamoya disease (MMD). However, the patterns of vessel wall contrast enhancement have not been well established. We aimed to identify the contrast enhancement patterns of the vessel walls associated with acute cerebral infarction using HR-MRI in MMD. METHODS: In this retrospective study, we conducted genetic tests for Ring Finger Protein 213 (RNF 213) and performed HR-MRI on patients suspected of having MMD. We analyzed wall enhancement patterns including concentric, eccentric, or mixed enhancement types, and the occurrence of acute cerebral infarction in patients who simultaneously tested positive for RNF 213 and exhibited definite features of MMD on HR-MRI. RESULTS: Among 306 patients who underwent RNF 213 tests for the evaluation of MMD, 56 showed positive RNF 213, and HR-MRI was performed on 32 of them. Among the patients with acute cerebral infarction, the incidence rate was significantly higher in the group with concentric wall enhancement compared to patients without acute cerebral infarction (73.3% vs. 17.0%, p < .002). Furthermore, the incidence was notably elevated, even in patients with pure concentric wall enhancement (40.0% vs. 5.9%, p = .033). The area under the curve (AUC) for the group with any concentric wall enhancement showed a significant result of .78 (95% confidence interval [CI]: .61-.95, p = .007), whereas the predictive ability for pure concentric wall enhancement did not reach significance (AUC = .67, 95% CI: .48-.86, p = .100). CONCLUSIONS: Concentric wall enhancement was a significant predictor of acute cerebral infarction in patients with MMD.

Effect of Intravenous Thrombolysis Prior to Mechanical Thrombectomy According to the Location of M1 Occlusion.

BACKGROUND AND PURPOSE: The additive effects of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) remain unclear. We aimed to investigate the efficacy and safety of IVT prior to MT depending on the location of M1 occlusion. METHODS: We reviewed the cases of patients who underwent MT for emergent large-vessel occlusion of the M1 segment. Baseline characteristics as well as clinical and periprocedural variables were compared according to the location of M1 occlusion (i.e., proximal and distal M1 occlusion). The main outcome was the achievement of functional independence (modified Rankin Scale score, 0-2) at 3 months after stroke. The main outcomes were compared between the proximal and distal groups based on the use of IVT before MT. RESULTS: Among 271 patients (proximal occlusion, 44.6%; distal occlusion, 55.4%), 33.9% (41/121) with proximal occlusion and 24.7% (37/150) with distal occlusion underwent IVT prior to MT. Largeartery atherosclerosis was more common in patients with proximal M1 occlusion; cardioembolism was more common in those with distal M1 occlusion. In patients with proximal M1 occlusion, there was no association between IVT before MT and functional independence. In contrast, there was a significant association between the use of IVT prior to MT (odds ratio=5.30, 95% confidence interval=1.56-18.05, P=0.007) and functional independence in patients with distal M1 occlusion. CONCLUSION: IVT before MT was associated with improved functional outcomes in patients with M1 occlusion, especially in those with distal M1 occlusion but not in those with proximal M1 occlusion.

Distal normal vessel diameter might be associated with silent brain infarcts after stenting for symptomatic carotid stenosis.

BACKGROUND: Carotid artery stenting (CAS) has been the standard treatment for carotid stenosis because it is less invasive; however, the risk of periprocedural thromboembolism is high. We investigated the predictors for silent brain infarcts (SBIs), focusing on embolic protection in CAS. METHODS: This study was single-center retrospective study, and we obtained baseline demographics and clinical, laboratory, and periprocedural variables of patients who underwent CAS. Also, methods used for embolic protection (no EPD, distal EPD, or proximal balloon guiding catheter) during CAS were obtained. Distal normal vessel diameter was defined as the diameter of cervical internal carotid artery where the artery wall becomes parallel. Diffusion-weighted imaging was performed before and after procedure to detect SBIs. The primary outcome was stented territory SBIs, and the secondary outcomes were any territories SBIs and stented territory SBIs in cases with EPD. RESULTS: A total of 196 CAS procedures with mean age 69.1 ± 9.9 years were included. After CAS, stented territory SBIs occurred in 53 (27.0 %) cases and any territories SBIs in 60 (30.6 %) cases. Univariable analyses revealed that distal normal vessel diameter (odds ratio = 1.71, 95 % confidence interval = 1.20-2.43, P = 0.003) was associated with the occurrence of stented territory SBIs after CAS. After adjusting for potential variables, larger distal normal vessel diameter (1.61 [1.10-2.36], P = 0.014) increased the occurrence of SBIs after CAS. Consistent results were obtained when the outcome was any territories SBIs or stented territory SBIs in cases with EPD. CONCLUSIONS: Distal normal vessel diameter was a predictor for the occurrence of SBI after CAS. The passable pore size of EPDs may vary depending on vessel diameter, and may impact the occurrence of SBIs.

Low-Density Lipoprotein Cholesterol Levels Are Associated With Subsequent Stented-Territory Ischemic Stroke After Carotid Artery Stenting: A Single Center Retrospective Study.

Objective: The role of low-density lipoprotein cholesterol (LDL-C) after carotid artery stenting (CAS) is not well known with respect to stented-territory infarction (STI) and in-stent restenosis (ISR). We hypothesized that LDL-C levels after CAS might be independently associated with STI and ISR. Methods: We conducted a retrospective study for patients with significant extracranial carotid stenosis who were subjected to CAS between September 2013 and May 2021. LDL-C levels were measured after 6 and 12 months following CAS. The association between STI and ISR, and LDL-C was explored using Cox proportional-hazard model. Results: Of 244 patients enrolled, STI and ISR were observed in 11 (4.5%) and 10 (4.1%) patients, respectively. In multivariable analysis, higher white blood cell count (hazard ratio [HR], 1.408 per 103/mm3; 95% confidence interval [CI], 1.085-1.828; p=0.010), higher LDL-C levels after 12 months (HR, 1.037 per 1 mg/dL; 95% CI, 1.011-1.063; p=0.005), and ISR (HR, 13.526; 95% CI, 3.405-53.725; p<0.001) were independent predictors of STI. Diabetes (HR, 4.746; 95% CI, 1.026-21.948; p=0.046), smaller stent diameter (HR, 0.725 per 1 mm; 95% CI, 0.537-0.980; p=0.036), and higher LDL-C levels after 12 months (HR, 1.031 per 1 mg/dL; 95% CI, 1.007-1.055; p=0.011) were independent predictors of ISR. Conclusion: We showed that LDL-C levels after 12 months independently predict STI and ISR after CAS. It is necessary to investigate the optimal target LDL-C level for STI prevention through well designed research in the future.

Silent brain infarcts after carotid or vertebrobasilar artery stenting.

BACKGROUND AND PURPOSE: Stenting is an important treatment for preventing stroke. However, the effect of vertebrobasilar stenting (VBS) might be limited because of relatively high periprocedural risks. Silent brain infarcts (SBIs) are known as a predictor for future stroke. Because of anatomical differences, factors for SBIs might be different between carotid artery stenting (CAS) and VBS. We compared the characteristics of SBIs between VBS and CAS. METHODS: We included patients who underwent elective VBS or CAS. Diffusion-weighted imaging was performed pre- and post-procedure to detect new SBIs. Clinical variables, occurrence of SBIs, and procedure-related factors were compared between CAS and VBS. Moreover, we investigated predictors of SBIs in each group separately. RESULTS: Ninety-two (34.2%) out of 269 patients had SBIs. SBIs were more frequently observed in VBS (29 [56.6%] vs. 63 [28.9%], p<.001). The risk of SBIs outside the stent-inserted vascular territory was higher in VBS compared to CAS (14 [48.3%] vs. 8 [12.7%], p<.001). Larger-diameter stents (odds ratio: 1.28, 95% confidence interval: 1.06-1.54, p = .012) and prolonged procedure time (1.01, [1.00-1.03], p = .026) increased the risk of SBIs in CAS, whereas only age increased the risk of SBIs in VBS (1.08 [1.01-1.16], p = .036). CONCLUSIONS: Compared to CAS, VBS was associated with longer procedure time, more residual stenosis, and more SBIs, especially outside the stent-inserted vascular territory. The risk of SBIs after CAS was associated with stent size and procedural difficulty. Only age was associated with SBIs in VBS. The pathomechanism of SBIs after VBS and CAS may be different.

Reduction of Radiation Dose to Eye Lens in Cerebral 3D Rotational Angiography Using Head Off-Centering by Table Height Adjustment: A Prospective Study.

OBJECTIVE: Three-dimensional rotational angiography (3D-RA) is increasingly used for the evaluation of intracranial aneurysms (IAs); however, radiation exposure to the lens is a concern. We investigated the effect of head off-centering by adjusting table height on the lens dose during 3D-RA and its feasibility in patient examination. MATERIALS AND METHODS: The effect of head off-centering during 3D-RA on the lens radiation dose at various table heights was investigated using a RANDO head phantom (Alderson Research Labs). We prospectively enrolled 20 patients (58.0 ± 9.4 years) with IAs who were scheduled to undergo bilateral 3D-RA. In all patients' 3D-RA, the lens dose-reduction protocol involving elevation of the examination table was applied to one internal carotid artery, and the conventional protocol was applied to the other. The lens dose was measured using photoluminescent glass dosimeters (GD-352M, AGC Techno Glass Co., LTD), and radiation dose metrics were compared between the two protocols. Image quality was quantitatively analyzed using source images for image noise, signal-to-noise ratio, and contrast-to-noise ratio. Additionally, three reviewers qualitatively assessed the image quality using a five-point Likert scale. RESULTS: The phantom study showed that the lens dose was reduced by an average of 38% per 1 cm increase in table height. In the patient study, the dose-reduction protocol (elevating the table height by an average of 2.3 cm) led to an 83% reduction in the median dose from 4.65 mGy to 0.79 mGy (P < 0.001). There were no significant differences between dose-reduction and conventional protocols in the kerma area product (7.34 vs. 7.40 Gy·cm², P = 0.892), air kerma (75.7 vs. 75.1 mGy, P = 0.872), and image quality. CONCLUSION: The lens radiation dose was significantly affected by table height adjustment during 3D-RA. Intentional head off-centering by elevation of the table is a simple and effective way to reduce the lens dose in clinical practice.

Hypercoagulability on Thromboelastography Can Predict the Functional Outcomes in Patients with Acute Ischemic Stroke.

BACKGROUND: We investigated the association between the reaction time (R), a thromboelastography (TEG) parameter for hypercoagulability, and functional outcomes based on the occurrence of hemorrhagic transformation (HT) and early neurological deterioration (END). METHODS: We enrolled ischemic stroke patients and performed TEG immediately after the patients' arrival. The baseline characteristics, occurrence of HT and END, stroke severity, and etiology were compared according to the R. END was defined as an increase of ≥1 point in motor or ≥2 points in the total National Institute of Health Stroke Scale within 3 days after admission. The outcome was the achievement of functional independence (modified Rankin scale [mRS]: 0-2) at 3 months after stroke. Logistic regression analyses were performed to verify the association between R and outcome. RESULTS: HT and END were frequently observed in patients with an R of <5 minutes compared with the group with an R of ≥5 minutes (15 [8.1%] vs. 56 [21.0%], p < 0.001; 16 [8.6%] vs. 65 [24.3%], p = 0.001, respectively). In multivariable analysis, an R of <5 minutes was associated with decreased odds of achieving functional independence (0.58 [0.34-0.97], p = 0.038). This association was maintained when the outcome was changed to disability free (mRS 0-1) and when mRS was analyzed as an ordinal variable. CONCLUSION: Hypercoagulability on TEG (R <5 minutes) may be a negative predictor for functional outcome of stroke after 3 months, with more frequent HT, END, and different stroke etiologies. This study highlights the potential of TEG parameters as biomarkers for predicting functional outcomes in ischemic stroke patients.

Delayed low cerebellar perfusion status is associated with poor outcomes in top-of-basilar occlusion treated with thrombectomy.

Background and purpose: Top-of-basilar artery occlusion (TOB) is one of the most devastating strokes despite successful mechanical thrombectomy (MT). We aimed to investigate the impact of initial low cerebellum perfusion delay on the outcomes of TOB treated with MT. Methods: We included patients who underwent MT for TOB. Clinical and peri-procedural variables were obtained. Perfusion delay in the low cerebellum was defined as (1) time-to-maximum (Tmax) >10 s lesions or (2) relative time-to-peak (rTTP) map >9.5 s with a diameter of ≥6 mm in the low cerebellum. The good functional outcome was defined as the achievement of a modified Rankin Scale score of 0-3 at 3 months after stroke. Results: Among the 42 included patients, 24 (57.1%) patients showed perfusion delay in the low cerebellum. The admission National Institutes of Health Stroke Scale (NIHSS) score was significantly higher in those with perfusion delay [17 (12-24) vs. 8 (6-15), P = 0.002]. Accordingly, the proportion of good functional outcomes was lower in those with perfusion delay than in those without [5 (20.8%) vs. 13 (72.2%), P = 0.003]. From the multivariable analysis, the admission NIHSS score [odds ratio (OR) = 0.86, 95% confidence intervals (CIs) = 0.75-0.98, P = 0.021] and low cerebellum perfusion delay (OR = 0.18, 95% Cis = 0.04-0.86, P = 0.031) were independently associated with the 3-month functional outcomes. Conclusion: We found that initial perfusion delay proximal to TOB in the low cerebellum might be a predictor for poor functional outcomes in TOB treated with MT.

Association between lipid profile changes and risk of in-stent restenosis in ischemic stroke patients with intracranial stenosis: A retrospective cohort study.

OBJECTIVE: The risk of ischemic stroke with intracranial stenosis is associated with various serum lipid levels. However, the effects of changes in the lipid profile on the risk of in-stent restenosis have not been verified. Therefore, we investigated the association between the occurrence of in-stent restenosis at 12-month follow-up and changes in various lipid profiles. METHODS: In this retrospective cohort study, we included ischemic stroke patients who had undergone intracranial stenting for symptomatic intracranial stenosis between February 2010 and May 2020. We collected data about serum low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), total cholesterol (TC), and triglyceride (TG) levels, and calculated the TC/HDL-C and LDL-C/HDL-C ratios at baseline and after 12 months. We conducted multivariable logistic regression analyses to verify the association between various lipid profile changes and in-stent restenosis at 12 months. RESULTS: Among the 100 patients included in the study (mean age, 60.8 ± 10.0 years; male: 80 [80.0%]), in-stent restenosis was found in 13 (13.0%) patients. The risk of in-stent restenosis of more than 50% was significantly decreased when TC/HDL-C ratio (odds ratio [OR] 0.22, [95% confidence interval (CI) 0.05-0.87]) and LDL-C/HDL-C ratio (OR 0.23, [95% CI 0.06-0.93]) decreased or when HDL-C levels (OR 0.10, [95% CI 0.02-0.63]) were increased at 12 months compared with baseline measurements. CONCLUSIONS: Improvement of HDL-C levels, TC/HDL-C ratio, and LDL-C/HDL-C ratio were associated with decreased risk of in-stent restenosis at 12-month follow-up. Management and careful monitoring of various lipid profiles including HDL-C levels, TC/HDL-C ratio, and LDL-C/HDL-C ratio may be important to prevent in-stent restenosis in patients with intracranial stenting.

Impact of a selective lens dose reduction protocol in 3D rotational angiography on radiation exposure to the eye lens during cerebral angiography: a randomized controlled trial.

BACKGROUND: We aimed to investigate the radiation dose to the eye lens (lens dose) during cerebral angiography and to evaluate the effectiveness of the lens dose reduction protocol for 3-dimensional rotational angiography (3D-RA) in reducing overall lens dose exposure. METHODS: We conducted a randomized, controlled clinical trial at a tertiary hospital with patients undergoing cerebral angiography. The lens dose reduction protocol in 3D-RA involved raising the table to position the patient's eye lens away from the rotation axis. The lens dose was estimated by measuring the entrance surface air kerma using a photoluminescent glass dosimeter. The lens doses of 3D-RA, overall examination, and image quality were analyzed and compared between the two groups. RESULTS: A total of 20 participants (mean age, 58±9.4 years; including 12 men [60%]) were enrolled and randomly assigned to either the conventional group or the dose reduction group. The median lens dose in 3D-RA was significantly lower in the dose reduction group compared with the conventional group (1.1 mGy vs 4.5 mGy, p<0.001). The total dose was significantly lower in the dose reduction group (median of 7.5 mGy vs 10.2 mGy, p=0.003). In the conventional group, 3D-RA accounted for 46% of the total lens dose, while in the dose reduction group, its proportion decreased to 16%. No significant differences were observed in the image quality between the groups. CONCLUSION: The lens dose reduction protocol resulted in a significant reduction in the lens dose of the 3D-RA as well as entire cerebral angiography, while maintaining the image quality.