Impact of Endovascular Therapy in Patients With Large Ischemic Core: Subanalysis of Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2

Background and Purpose: Endovascular therapy (EVT) is strongly recommended for acute cerebral large vessel occlusion with the Alberta Stroke Program Early CT Score (ASPECTS) ≥6 due to occlusion of the internal carotid artery or M1 segment of the middle cerebral artery. However, the effect of EVT for patients who have ischemic core with ASPECTS ≤5 (0­5) was not established. The purpose of this study was to elucidate the outcomes of EVT for patients with large ischemic core. Methods: Based on the data of The Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2, patients with internal carotid artery or M1 segment of the middle cerebral artery occlusion and pretreatment ASPECTS 0 to 5 on noncontrast CT or diffusion-weighted image were extracted, and the outcomes by EVT were analyzed. Primary end point was defined as a good functional outcome (modified Rankin Scale score of ≤2) after 90 days. Result: Among 2420 registered patients, 504 patients were with internal carotid artery or M1 segment of the middle cerebral artery occlusion and ASPECTS 0 to 5. Among these 504 patients, 172 (34.1 %) were treated with EVT (EVT group) and 332 (65.9 %) without (no-EVT group). In the no-EVT group, elderly patients, females, poor prestroke modified Rankin Scale, high National Institutes of Health Stroke Scale, low ASPECTS, and late admission were significantly more observed. Good functional outcomes were significantly more observed in the EVT group than in the no-EVT group (19.8 % versus 4.2 %; P<0.0001; adjusted odds ratio, 2.33; 95% CI, 1.10­4.94). The incidences of symptomatic intracranial hemorrhage within 72 hours did not significantly different between the EVT group and the no-EVT group (3.7 % versus 4.9%; P=0.55; adjusted odds ratio, 0.50; 95% CI, 0.14­1.73). Conclusions: Although outcomes in this group of patients were usually poor, the data suggested EVT may increase the likelihood of a good functional outcome.

The randomized study of enteral nutrition with rapid versus conventional administration in acute stroke patients; the protocol of rapid EN trial.

Rationale: Enteral nutrition is beneficial for stroke patients with oral intake difficulties. However, it is time consuming and may interfere with routine medical care. Therefore, there is a clinical benefit if enteral nutrition can be safely administered in a short time. Although our retrospective study showed the safety of rapid administration, it remains unclear whether rapid administration of enteral nutrition is as safe as conventional administration. Aim: The randomized study of Enteral Nutrition with Rapid versus conventional administration in acute stroke patients (Rapid EN trial) aims to clarify the safety of rapid feeding of enteral nutrition compared with conventional feeding. Methods and design: This is an investigator-initiated, multicenter, prospective, randomized, open-label, blinded end-point clinical trial. Eligible criteria include acute stroke patients who have difficulty with oral intake defined as severe altered consciousness (Japan Coma Scale 10-300) or modified water swallowing test <4. The target enrollment is 700 patients, with 350 patients receiving rapid enteral nutrition at a rate of 100 mL in 5 min (Rapid EN group) and 350 patients receiving conventional enteral nutrition at a rate of 100 mL in 30 min (Conventional EN group). Study outcome: The primary outcome is the incidence of one or more complications of vomiting or diarrhea or pneumonia within 7 days would be non-inferior in the rapid EN group compared to the conventional EN group. Secondary outcomes were total time spent on enteral nutrition within 7 days from enteral nutrition, the incidence of vomiting, diarrhea and pneumonia within 3 or 7 days, and the rate of favorable clinical outcome. Discussion: Since no previous reports have focused on the speed of administration, we felt it was necessary to prove the safety of rapid administration. If this study shows positive results, it will not only benefit patients, but also reduce the burden of medical care. We believe this study is novel and will be useful in clinical practice. Clinical trial registration: https://rctportal.niph.go.jp/s/detail/um?trial_id=UMIN000046610 Identifier UMIN000046610.

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 for isolated intracranial atherothrombotic stroke-related large-vessel occlusion (AT-LVO). However, the optimal endovascular therapy technique for AT-LVO has not yet been investigated. This study evaluated the optimal endovascular therapy 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 3 groups based on the endovascular therapy technique: mechanical thrombectomy alone, percutaneous transluminal angioplasty (PTA), and stent deployment. Mechanical thrombectomy alone was classified into the mechanical thrombectomy-only group; PTA and mechanical thrombectomy-PTA, into the PTA group; and mechanical thrombectomy-stent deployment, mechanical thrombectomy-PTA-stent deployment, PTA-stent deployment, and stent deployment-only into the stent group. The primary outcome was incidence of reocclusion of the treated vessels within 90 days of endovascular therapy completion. RESULTS: We enrolled 770 patients and analyzed 509 patients. The rates in the mechanical thrombectomy-only, PTA, and stent deployment groups were 40.7%, 44.4%, and 14.9%, respectively. Incidence rate of residual stenosis >70% of final angiography was significantly higher in the mechanical thrombectomy-only group than in the PTA and stent deployment groups (mechanical thrombectomy-only versus PTA versus stent deployment: 34.5% versus 26.3% versus 13.2%, P = .002). Reocclusion rate was significantly lower in the PTA group than in the mechanical thrombectomy-only group (adjusted hazard ratio, 0.48; 95% CI, 0.29-0.80). Of the patients, 83.5% experienced reocclusion within 10 days after endovascular therapy. Alarmingly, a substantial subset (approximately 62.0%) of patients experienced reocclusion within 2 days of endovascular therapy. Incidence of mRS scores of 0-2 ninety days after endovascular therapy was not significantly different among the 3 groups. Incidences of symptomatic intracranial hemorrhage, any other intracranial hemorrhage, and death were not significantly different. CONCLUSIONS: Incidence rate of reocclusion was significantly lower in the PTA group than in the mechanical thrombectomy-only group. We found no meaningful difference in reocclusion rates between the stent deployment and mechanical thrombectomy-only groups. In Japan, glycoprotein IIb/IIIa inhibitors are not reimbursed. Therefore, PTA might be the preferred choice for AT-LVOs due to the higher reocclusion risk with mechanical thrombectomy-only. Reocclusion was likely to occur within 10 days, particularly within 2 days post-endovascular therapy.

Differences in mechanical thrombectomy for acute ischemic stroke on weekdays versus nights/ weekends in a Japanese primary stroke core center.

OBJECTIVE: The term "weekend effect" refers to an increase in the mortality rate for hospitalizations occurring on weekends versus weekdays. In this study, we investigated whether such an effect exists in patients undergoing mechanical thrombectomy for acute ischemic stroke with large vessel occlusion (currently the standard treatment for this condition) at a single center in Japan. METHODS: We surveyed 151 patients who underwent mechanical thrombectomy for acute ischemic stroke with large vessel occlusion (75 and 76 patients were treated during daytime and nighttime, respectively) from January 2019 to June 2021. The items evaluated in this analysis were the rate of modified Rankin Scale ≤2 or prestroke scale, mortality, and procedural treatment time. RESULTS: The rates of modified Rankin Scale ≤2 or prestroke scale and mortality at 90 days after treatment did not differ significantly between daytime and nighttime (41.3% vs. 29.0%, p=0.11; 14.7% vs. 11.8%, p=0.61, respectively). The door-to-groin time tended to be shorter during daytime versus nighttime (57 [IQR: 42.5-70] min vs. 70 [IQR: 55-82]) min, p=0.0507). CONCLUSIONS: This study did not reveal differences in treatment outcome between daytime and nighttime in patients undergoing mechanical thrombectomy for acute ischemic stroke with large vessel occlusion. Therefore, the "weekend effect" was not observed in our institution.

Endovascular therapy for acute intracranial large vessel occlusion due to atherothrombosis: Multicenter historical registry.

BACKGROUND: Atherothrombotic stroke-related large vessel occlusion (AT-LVO) is caused by two etiologies, the intracranial artery occlusion due to in situ occlusion (intracranial group) or due to embolism from cervical carotid occlusion or stenosis (tandem group). The prognosis and reocclusion rate of each etiology after endovascular therapy (EVT) is unclear. METHODS: We conducted a historical multicenter registry study at 51 Japanese centers to compare the prognoses of AT-LVO between two etiologies. The primary outcome was the incidence of recurrent ischemic stroke or reocclusion of the treated vessels within 90 days after EVT. Each of the primary outcome means the incidence of recurrent ischemic stroke and reocclusion of the treated vessels within 90 days after EVT. RESULTS: We analyzed 582 patients (338 in the intracranial group and 244 in the tandem group). Patients in the intracranial group were younger (mean 71.9 vs 74.5, p=0.003), more of them were female and fewer of them were current smokers than those in the tandem group. In the tandem group, the patients' National Institutes of Health Stroke Scale score on admission was higher (13 vs 15, p=0.006), onset to puncture time was shorter (299 [145-631] vs 232 [144-459] minutes, p=0.03) and Alberta Stroke Program Early CT Score (ASPECTS) was lower (8 [7-9] vs 8 [6-9], p=0.0002). The primary outcome was higher in the intracranial group (22.5% vs 8.2%, p<0.0001). However, any ICH and death were not significantly different in the two groups. CONCLUSIONS: The incidence of recurrent ischemic stroke or reocclusion after EVT for AT-LVO was higher in the intracranial group.

Endovascular Therapy for an Aneurysm of a Distal Posterior Inferior Cerebellar Artery via the Ipsilateral Persistent Primitive Proatlantal Artery: A Case Report.

Objective: We describe the rare case of a patient who was treated for a ruptured distal posterior inferior cerebellar artery (PICA) aneurysm via an ipsilateral persistent primitive proatlantal artery (PPPA). Case Presentation: An 86-year-old female with a medical history of hypertension presented with headache and nausea. CT showed subarachnoid hemorrhage in the posterior cranial fossa, and CTA revealed an aneurysm at the left-side distal PICA. In the left-sided common carotid angiography, the artery with a branch of the occipital artery from the external carotid artery was described. This artery continued as the V3 segment and entered the dura via the foramen magnum. The artery perfused the territory of the left vertebral artery and PICA. We concluded that the artery, which entered the dura, was a PPPA. We decided to perform endovascular therapy that passed through the PPPA. The aneurysm was located in the cortical segments, beyond the cranial loop. We decided that parent artery occlusion (PAO) would be more effective than selective coil embolization to achieve safe and adequate hemostasis. The patient had a good outcome with PAO not assessing collateral circulation. Conclusion: The emergency endovascular treatment with rare vascular variations requires accurate anatomical knowledge for treatment.

Usefulness of three-dimensional fast imaging employing steady-state acquisition MRI of large vessel occlusion for detecting occluded middle cerebral artery and internal carotid artery before acute mechanical thrombectomy.

OBJECTIVE: Acute mechanical thrombectomy (AMT) in patients with acute ischemic stroke from large vessel occlusion (LVO) is performed without directly identifying the occluded vessels. In this study, we evaluated whether 1.5 T magnetic resonance imaging (MRI) with 3D-fast imaging employing steady-state acquisition (FIESTA) could visualize the occluded intracranial middle cerebral artery (MCA) and internal carotid artery (ICA) before AMT. METHODS: This retrospective study included 21 consecutive patients who underwent time-of-flight magnetic resonance angiography (TOF MRA) and 3D-FIESTA MRI immediately before AMT. The patients also underwent TOF MRA after AMT and achieved TICI 2b or 3 by AMT at our hospital between February 2018 and April 2019. When LVO in the anterior circulation was detected by TOF MRA, 3D-FIESTA MRI was additionally performed. Then, the occluded intracranial MCA and ICA, including their branches, were constructed on the workstation with volume rendering. The obtained images were fused with the TOF MRA images to create combined 3D images. RESULTS: The length and top-to-bottom distance of the affected M1 segment (calculated by the ipsilateral-to-contralateral ratio) were 1.29 and 1.17, respectively, on 3D-FIESTA MRI before AMT and 1.34 and 1.24, respectively, on TOF MRA after AMT. We assessed the number of M2 segments branching from the affected M1/M2 junction and visualized the affected anterior temporal artery. The 3D-FIESTA MRI before AMT and TOF MRA after AMT were consistent in all patients, except for two who moved vigorously during imaging. CONCLUSIONS: Images acquired by 1.5T 3D-FIESTA MRI can visualize to predict the existing path of the occluded MCA and ICA before AMT in patients with LVO of the anterior circulation.

Clinical Results of Mechanical Thrombectomy in Nonagenarians with Acute Ischemic Stroke.

Objective: Multiple randomized trials have demonstrated the efficacy of mechanical thrombectomy (MT), but very elderly patients aged ≥90 years were excluded. It remains uncertain whether endovascular therapy is effective for nonagenarians. The objective of this study was to investigate the effectiveness and safety of MT in nonagenarians. Methods: Between January 2016 and March 2019, acute ischemic stroke patients aged ≥80 years who underwent MT at our hospital were retrospectively reviewed. Patients with a baseline pre-stroke modified Rankin Scale (mRS) score ≥3 were excluded from the analysis. They were divided into octogenarians (80-89 years old) and nonagenarians (90-99 years old). Results: Forty-five patients met the inclusion criteria, including 34 octogenarians and 11 nonagenarians. Nonagenarians were more likely to be female (47.0% vs 90.9%; p <0.05). There was a significantly lower rate of a pre-stroke mRS score of 0-1 among the nonagenarians (91.1% vs 63.6%; p <0.05). Revascularization was successful in 71.0% and 81.8% (p = 0.46) of octogenarians and nonagenarians, respectively. Functional independence (mRS ≤2) at discharge was observed in 26.4% vs 27.2% (p = 0.95) of octogenarians and nonagenarians, respectively. Conclusion: MT in nonagenarians can be considered safe without increasing hemorrhagic complications in comparison with that in octogenarians. One in four patients may have a good outcome and obtain effects equivalent to those in octogenarians if they have a good pre-stroke functional status.

Clinical Outcomes of Mechanical Thrombectomy for Acute Ischemic Stroke in Transfer Cases.

Objective: There are regional disparities in endovascular thrombectomy, and problems with emergency transport systems and hospital collaboration when transferring need to be addressed. In this study, the clinical outcomes of endovascular thrombectomy for transferred patients were analyzed. Methods: Acute ischemic stroke patients who underwent endovascular thrombectomy between January 2016 and March 2019 were enrolled. They were retrospectively reviewed and divided into the direct group and transfer group, and we compared treatment results and clinical outcomes between them. Results: In all, 122 patients met the inclusion criteria, comprising 93 patients in the direct group and 29 patients in the transfer group. The time from onset to door of our hospital was longer in the transfer group than in the direct group (73 minutes vs. 158 minutes, P = 0.80), but the time from arrival to reperfusion was significantly shorter in the transfer group (139 minutes vs. 106 minutes, P = 0.001). As the time from onset to reperfusion did not differ significantly between the two groups (220 minutes vs. 256 minutes, P = 0.60), there was no significant difference in good outcome at discharge (38.7 vs. 41.3%, P = 0.79). Conclusion: Clinical outcomes of transferred patients for endovascular thrombectomy may be equivalent to those of directly transported patients. Promoting close hospital cooperation may improve clinical outcomes and resolve regional disparities.

Parent Artery Occlusion for Treatment of a Traumatic Pericallosal Artery Aneurysm: Case Report and Review of the Literature.

BACKGROUND: Traumatic intracranial aneurysms are rare complications after head trauma. This report describes the case of a patient with a traumatic pericallosal aneurysm. CASE DESCRIPTION: A 73-year-old man developed headache and lower limb paresis, and emergency computed tomography scan revealed a hematoma in the corpus callosum. We performed coil embolization for a pericallosal aneurysm, but follow-up angiography showed recurrence of the aneurysm 6 days after the surgery. We diagnosed this as a traumatic aneurysm and subsequently performed parent artery occlusion without any complications. CONCLUSIONS: We performed parent artery occlusion for a traumatic aneurysm of the pericallosal artery without complications. Pericallosal aneurysms are rare, but we must consider them when encountering a delayed hematoma around the corpus callosum.

Mechanical Thrombectomy for Large Vessel Occlusion via the Transbrachial Approach: Case Series.

Mechanical thrombectomy has become a standard treatment for acute ischemic stroke with large vessel occlusion. In aged patients, it is difficult to guide the catheter via the transfemoral approach due to vessel tortuosity and aortic elongation. We report our preliminary clinical experience using the transbrachial approach. Among the 119 patients who underwent thrombectomy from April 2018 to December 2019, a total of 5 patients were treated via the transbrachial approach. Clinical outcomes were retrospectively analyzed. Successful reperfusion was achieved in 4 out of 5 cases. There was 1 death due to symptomatic intracranial hemorrhage. One patient had a good outcome at discharge. There were no access-site complications associated with any of these cases. Transbrachial access for mechanical thrombectomy is feasible and can provide an alternative to the transfemoral approach.