Endovascular Therapy for Acute Stroke with a Large Ischemic Region.

BACKGROUND: Endovascular therapy for acute ischemic stroke is generally avoided when the infarction is large, but the effect of endovascular therapy with medical care as compared with medical care alone for large strokes has not been well studied. METHODS: We conducted a multicenter, open-label, randomized clinical trial in Japan involving patients with occlusion of large cerebral vessels and sizable strokes on imaging, as indicated by an Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) value of 3 to 5 (on a scale from 0 to 10, with lower values indicating larger infarction). Patients were randomly assigned in a 1:1 ratio to receive endovascular therapy with medical care or medical care alone within 6 hours after they were last known to be well or within 24 hours if there was no early change on fluid-attenuated inversion recovery images. Alteplase (0.6 mg per kilogram of body weight) was used when appropriate in both groups. The primary outcome was a modified Rankin scale score of 0 to 3 (on a scale from 0 to 6, with higher scores indicating greater disability) at 90 days. Secondary outcomes included a shift across the range of modified Rankin scale scores toward a better outcome at 90 days and an improvement of at least 8 points in the National Institutes of Health Stroke Scale (NIHSS) score (range, 0 to 42, with higher scores indicating greater deficit) at 48 hours. RESULTS: A total of 203 patients underwent randomization; 101 patients were assigned to the endovascular-therapy group and 102 to the medical-care group. Approximately 27% of patients in each group received alteplase. The percentage of patients with a modified Rankin scale score of 0 to 3 at 90 days was 31.0% in the endovascular-therapy group and 12.7% in the medical-care group (relative risk, 2.43; 95% confidence interval [CI], 1.35 to 4.37; P = 0.002). The ordinal shift across the range of modified Rankin scale scores generally favored endovascular therapy. An improvement of at least 8 points on the NIHSS score at 48 hours was observed in 31.0% of the patients in the endovascular-therapy group and 8.8% of those in the medical-care group (relative risk, 3.51; 95% CI, 1.76 to 7.00), and any intracranial hemorrhage occurred in 58.0% and 31.4%, respectively (P<0.001). CONCLUSIONS: In a trial conducted in Japan, patients with large cerebral infarctions had better functional outcomes with endovascular therapy than with medical care alone but had more intracranial hemorrhages. (Funded by Mihara Cerebrovascular Disorder Research Promotion Fund and the Japanese Society for Neuroendovascular Therapy; RESCUE-Japan LIMIT ClinicalTrials.gov number, NCT03702413.).

Thrombolysis for Acute Wake-Up and Unclear-Onset Strokes with Alteplase at 0.6 mg/kg in Clinical Practice: THAWS2 Study.

INTRODUCTION: The aim of this study was to determine the safety and efficacy of intravenous (IV) alteplase at 0.6 mg/kg for patients with acute wake-up or unclear-onset strokes in clinical practice. METHODS: This multicenter observational study enrolled acute ischemic stroke patients with last-known-well time >4.5 h who had mismatch between DWI and FLAIR and were treated with IV alteplase. The safety outcomes were symptomatic intracranial hemorrhage (sICH) after thrombolysis, all-cause deaths, and all adverse events. The efficacy outcomes were favorable outcome defined as an mRS score of 0-1 or recovery to the same mRS score as the premorbid score, complete independence defined as an mRS score of 0-1 at 90 days, and change in NIHSS at 24 h from baseline. RESULTS: Sixty-six patients (35 females; mean age, 74 ± 11 years; premorbid complete independence, 54 [82%]; median NIHSS on admission, 11) were enrolled at 15 hospitals. Two patients (3%) had sICH. Median NIHSS changed from 11 (IQR, 6.75-16.25) at baseline to 5 (3-12.25) at 24 h after alteplase initiation (change, -4.8 ± 8.1). At discharge, 31 patients (47%) had favorable outcome and 29 (44%) had complete independence. None died within 90 days. Twenty-three (35%) also underwent mechanical thrombectomy (no sICH, NIHSS change of -8.5 ± 7.3), of whom 11 (48%) were completely independent at discharge. CONCLUSIONS: In real-world clinical practice, IV alteplase for unclear-onset stroke patients with DWI-FLAIR mismatch provided safe and efficacious outcomes comparable to those in previous trials. Additional mechanical thrombectomy was performed safely in them.

Evaluation of cholesterol crystals in carotid plaque by dual energy computed tomography.

Cholesterol crystals (CCs) in carotid plaques might be an indicator of vulnerability, although they have not been fully investigated and non-invasive methods of assessment have not been established. This study examines the validity of assessing CCs using dual-energy computed tomography (DECT) that uses X-rays with different tube voltages for imaging, allowing material discrimination. We retrospectively evaluated patients who had undergone preoperative cervical computed tomography angiography and carotid endarterectomy between December 2019 and July 2020. We developed CC-based material decomposition images (MDIs) by scanning CCs crystallized in the laboratory using DECT. We compared the percentage of CCs in stained slides defined by cholesterol clefts with the percentage of CCs displayed by CC-based MDIs. Thirty-seven pathological sections were obtained from 12 patients. Thirty-two sections had CCs; of these, 30 had CCs on CC-based MDIs. CC-based MDIs and pathological specimens showed a strong correlation. Thus, DECT allows the evaluation of CCs in carotid artery plaques.

Identifying large vessel occlusion using the hyperdense artery sign in patients treated with mechanical thrombectomy.

OBJECTIVES: The hyperdense artery sign on non-contrast computed tomography-reconstructed images is useful for identifying large vessel occlusion in acute ischemic stroke. This study aimed to assess its efficacy in patients with large vessel occlusion treated with mechanical thrombectomy. MATERIALS AND METHODS: This retrospective and prospective single-centered study from June 2019 to May 2021 evaluated the use of non-contrast computed tomography-reconstructed images for detecting hyperdense artery sign to identify large vessel occlusion from June 2020 to May 2021. We registered consecutive potential candidates for mechanical thrombectomy due to suspected stroke and assessed the accuracy of hyperdense artery sign on non-contrast computed tomography-reconstructed images for large vessel occlusion in the hyperacute setting. Non-contrast computed tomography images were reconstructed into maximum intensity projection images with iterative reconstruction algorithms to detect hyperdense artery signs. We compared the door-to-puncture time and functional outcome at 90 days before and after employing non-contrast computed tomography-reconstructed images in patients with large vessel occlusion treated with mechanical thrombectomy. RESULTS: The cohort included 82 patients, wherein 47 were treated with mechanical thrombectomy. The sensitivity (96%) and specificity (94%) of hyperdense artery sign on non-contrast computed tomography-reconstructed images for large vessel occlusion were performed. The door-to-puncture time was significantly shortened after using non-contrast computed tomography-reconstructed images (49 versus 28 min, p = 0.001), but the functional outcome at 90 days remained unchanged. CONCLUSIONS: Non-contrast computed tomography-reconstructed images, as a vascular imaging tool for mechanical thrombectomy, can reduce workflow time in hospitals by identifying large vessel occlusion with high sensitivity and specificity.

A case of ischemic stroke accompanied by multiple arterial dissections associated with Klippel-Feil syndrome.

OBJECTIVES: To describe the case of an ischemic stroke patient with Klippel-Feil syndrome who developed multiple aneurysms and discuss the mechanism of aneurysm development. MATERIALS AND METHODS: A 44-year-old man presented with dizziness, left hemiparesis, and left-sided numbness and was admitted to our department. He developed multiple aneurysms at the bilateral vertebral artery (VA) and bilateral internal carotid artery. RESULTS: We diagnosed the etiology of his brain infarction as an embolic stroke caused by left VA dissection or the large thrombosed aneurysm. Furthermore, we considered that arterial dissection or Hox gene mutation was associated with the development of multiple aneurysms. CONCLUSION: While previous reports have described single aneurysm, this is the first report of multiple aneurysms associated with Klippel-Feil syndrome.

Association of Admission Hyperglycemia with Clinical Outcomes in Japanese Patients with Acute Large Vessel Occlusion Stroke: A post hoc Analysis of the Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2.

INTRODUCTION: Admission hyperglycemia is an indicator of poor functional prognosis in acute stroke, but investigations of its prevalence and effects on the outcomes of acute large vessel occlusion in real-world, large-scale studies are limited, especially in Asian population. OBJECTIVE: We aimed to elucidate the relationship between admission hyperglycemia and outcomes in a prospective multicenter registry in Japan. METHODS: We analyzed data from the Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism (RESCUE) Japan Registry 2, which was a prospective, multicenter registry that enrolled patients from 46 centers in Japan. Admission hyperglycemia was defined as blood glucose level >140 mg/dL. The relationships between clinical outcomes and admission hyperglycemia were analyzed in all 1,932 assessable patients. A favorable functional outcome, defined as a modified Rankin Scale score of 0-2 at day 90, as well as mortality within 90 days and symptomatic intracranial hemorrhage (SICH) within 72 h, was analyzed. We performed subgroup analyses of the adjusted variables to investigate the association between hyperglycemia and favorable outcome in relation to each variable. RESULTS: Admission hyperglycemia was present in 687 (35.6%) of the assessable patients and in 420 (26.9%) of the 1,561 patients without diabetes. A favorable outcome was significantly less frequent in the hyperglycemia group than in the no-hyperglycemia group (33.2% vs. 47.6%, adjusted odds ratio [OR]: 0.60, 95% confidence interval [CI]: 0.47-0.76). The mortality rates were 12.8% and 6.8% in the hyperglycemia and no-hyperglycemia groups, respectively. The incidence of SICH within 72 h was higher in the hyperglycemia group than in the no-hyperglycemia group (4.4% vs. 1.9%, adjusted OR: 2.54, 95% CI: 1.36-4.82). Hyperglycemia was associated with unfavorable outcomes in almost all subgroups. CONCLUSIONS: Admission hyperglycemia in Japanese patients with large vessel occlusion stroke is associated with an unfavorable functional outcome at 90 days, mortality within 90 days, and the occurrence of SICH within 72 h.

Hypertrophic Pachymeningitis Related Brain Infarction in Synovitis-Acne-Pustulosis-Hyperostosis Osteomyelitis Syndrome.

A 50-year-old woman with a history of synovitis-acne-pustulosis-hyperostosis osteomyelitis (SAPHO) syndrome was admitted for left unilateral neglect, dysarthria, and left hemiparesis. Brain MRI showed multiple infarctions in the territory of the right middle cerebral artery and gadolinium enhancement of the thickened frontotemporal dura mater on the right side. MR angiography showed significant narrowing of the cavernous segment of the right internal carotid artery. The right internal carotid artery stenosis was thought to originate from hypertrophic pachymeningitis associated with SAPHO syndrome. This is the first report of brain infarction due to internal carotid artery stenosis caused by hypertrophic pachymeningitis associated with SAPHO syndrome.

Clinical Outcome of Patients With Large Vessel Occlusion and Low National Institutes of Health Stroke Scale Scores: Subanalysis of the RESCUE-Japan Registry 2.

Background and Purpose- The treatment and prognosis of acute large vessel occlusion with mild symptoms have not been sufficiently studied. The present study aimed to investigate the clinical or radiological predictors of clinical outcome in patients with stroke with mild symptoms due to acute large vessel occlusion. Methods- Of 2420 patients with acute large vessel occlusion in the RESCUE-Japan Registry 2 (Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism-Japan Registry 2), a multicenter prospective registry in Japan, patients with modified Rankin Scale scores of 0 to 2 before onset and initial National Institutes of Health Stroke Scale (NIHSS) scores of 0 to 5 were examined in post hoc analysis. We examined the clinical and radiological characteristics associated with a favorable outcome (modified Rankin Scale score, 0-2 at 90 days) using multivariate analysis, as well as the factors associated with a favorable outcome in patients treated with endovascular therapy. Results- We analyzed 272 patients (median age, 73 years; median NIHSS score on admission, 3). Eighty-six (31.6%) patients were treated with intravenous recombinant tissue-type plasminogen activator, 54 (19.9%) underwent endovascular therapy, and 208 (76.5%) showed a favorable outcome. In multivariate analysis, age <75 years (odds ratio [OR], 2.42 [95% CI, 1.30-4.50]), initial NIHSS score 0 to 3 (OR, 3.08 [95% CI, 1.59-5.98]), intravenous recombinant tissue-type plasminogen activator (OR, 2. 86 [95% CI, 1.32-6.21]), and blood glucose level ≤140 mg/dL (OR, 2.37 [95% CI, 1.22-4.60]) were independently associated with a favorable outcome. However, endovascular therapy was not associated with a favorable outcome (OR, 1.65 [95% CI, 0.71-3.88]). Among 54 patients treated with endovascular therapy, good reperfusion status was more common in the favorable outcome group (88.6% versus 60.0%; P<0.05). Conclusions- Younger age, lower initial NIHSS score, intravenous recombinant tissue-type plasminogen activator, and absence of hyperglycemia were independently associated with a favorable outcome in patients with acute large vessel occlusion with low NIHSS scores. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT02419794.

Proximal Common Carotid Artery Stenosis Induced by Repetitive Mechanical Compression: A Case Report.

OBJECTIVES: Arterial branches and curvatures, such as the common carotid artery (CCA) origin and carotid bifurcation, are usual sites of atherosclerosis, which leads to carotid artery stenosis. Atherosclerosis may occur due to repetitive compression. Stenosis localized to the proximal segment away from the CCA origin and bifurcation is rare. Here, we describe the case of a patient with right proximal CCA stenosis induced by repetitive compression. METHODS: We studied an acute stroke patient who worked for a long time as a geographical surveyor carrying a tripod on his right shoulder. We found severe eccentric stenosis composed of thick plaque in the right proximal CCA, away from the right CCA origin. However, there was no finding of CCA dissection or vasculitis. RESULTS: The patient was diagnosed with ischemic stroke due to artery-to-artery embolization from the right CCA stenosis, which we believed was due to repetitive compression by the tripod. CONCLUSIONS: Repetitive mechanical stimuli can cause stenotic lesions at atypical vascular sites.

Quantitative characterization of carotid plaque components using MR apparent diffusion coefficients and longitudinal relaxation rates at 3T: A comparison with histology.

BACKGROUND: There is limited evidence of parametric MR mapping to characterize carotid plaques associated with cerebral ischemic events. PURPOSE: To explore the apparent diffusion coefficients (ADCs) and longitudinal relaxation rates (R1 ) of carotid plaques, including areas of hemorrhage, lipid-rich/necrotic core (LR/NC) without hemorrhage, and fibrous tissue (Fbr) STUDY TYPE: Prospective. SUBJECTS: Twelve patients who underwent carotid endarterectomy. FIELD STRENGTH/SEQUENCE: R1 was measured using double angle Look-Locker acquisition on 3T systems. Single-shot spin-echo echo-planar imaging with fat suppression and outer-volume suppression (OVS-DWEPI) with b values of 10 and 500 s/mm2 was used for diffusion-weighted imaging. ASSESSMENT: A phantom study using diluted gadolinium solutions and polyvinyl alcohol solutions was used to validate the two protocols. Regions of interest (ROIs) were manually outlined on MR images for areas of LR/NC, hemorrhage, and Fbr based on histological cross-sections. Pixel-based R1 and ADC values in the ROIs were plotted for each component. The probability density function of the plots determined the optimum contours to separate the three components in the ADC-R1 plane. The LR/NC, hemorrhage, and Fbr regions were mapped on MR images based on the above results and compared to histological results. STATISTICAL TESTS: The R1 values of the phantom measurements were tested using Bland-Altman analysis. The accuracies of the MRI classification were calculated. RESULTS: R1 values <8 s-1 calculated using our method agreed with those calculated using an inversion-recovery fast-spin-echo sequence (error, ≤0.1 s-1 ). ADC values obtained using OVS-DWEPI were 4.1% higher than those obtained using standard echo-planar imaging. LR/NC (R1 , 0.4-1.2 s-1 ; ADC, 0-1.5 µm2 /ms), hemorrhage (R1 ≥ 1.5 s-1 ; ADC, 0.5-1.5 µm2 /ms), and Fbr (R1 , 0.2-0.8 s-1 ; ADC, 1.5-2.9 µm2 /ms) were separated on the plots. The accuracies of MRI classification were LR/NC, 0.86; hemorrhage, 0.79; and Fbr, 0.77. CONCLUSION: The combination of ADC and R1 values measured using our method enabled differentiation among LR/NC, hemorrhage, and Fbr. LEVEL OF EVIDENCE: 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;48:1657-1667.

A Case of Intrathoracic Carotid Bifurcation Without Klippel-Feil Syndrome.

BACKGROUND: Intrathoracic carotid bifurcation is a rare vascular anomaly, with only 8 cases reported. This vascular anomaly was recently correlated with Klippel-Feil syndrome, a rare congenital disorder involving fusion of the cervical vertebrae. METHODS: A 70-year-old deaf mute man was admitted to our department because of right hemiparesis and right sensory disturbance. He displayed no abnormalities associated with Klippel-Feil syndrome. Diffusion-weighted imaging revealed acute multiple infarcts in bilateral hemispheres. Computed tomography angiography showed that the left common carotid artery bifurcated at the T2 vertebral level. No significant stenosis was seen in the carotid arteries. Transesophageal echocardiography confirmed a complicated atheromatous lesion at the aortic arch. RESULTS: This case was diagnosed with aortogenic brain embolism, incidentally accompanied by left intrathoracic carotid bifurcation without Klippel-Feil syndrome. CONCLUSIONS: Intrathoracic carotid bifurcation can occur in cases without Klippel-Feil syndrome. The knowledge of this anatomic variation is important in evaluating vascular lesions of the carotid arteries in patients with stroke.

Damage to the Left Precentral Gyrus Is Associated With Apraxia of Speech in Acute Stroke.

BACKGROUND AND PURPOSE: Apraxia of speech (AOS) is a motor speech disorder, which is clinically characterized by the combination of phonemic segmental changes and articulatory distortions. AOS has been believed to arise from impairment in motor speech planning/programming and differentiated from both aphasia and dysarthria. The brain regions associated with AOS are still a matter of debate. The aim of this study was to address this issue in a large number of consecutive acute ischemic stroke patients. METHODS: We retrospectively studied 136 patients with isolated nonlacunar infarcts in the left middle cerebral artery territory (70.5±12.9 years old, 79 males). In accordance with speech and language assessments, the patients were classified into the following groups: pure form of AOS (pure AOS), AOS with aphasia (AOS-aphasia), and without AOS (non-AOS). Voxel-based lesion-symptom mapping analysis was performed on T2-weighted images or fluid-attenuated inversion recovery images. Using the Liebermeister method, group-wise comparisons were made between the all AOS (pure AOS plus AOS-aphasia) and non-AOS, pure AOS and non-AOS, AOS-aphasia and non-AOS, and pure AOS and AOS-aphasia groups. RESULTS: Of the 136 patients, 22 patients were diagnosed with AOS (7 patients with pure AOS and 15 patients with AOS-aphasia). The voxel-based lesion-symptom mapping analysis demonstrated that the brain regions associated with AOS were centered on the left precentral gyrus. CONCLUSIONS: Damage to the left precentral gyrus is associated with AOS in acute to subacute stroke patients, suggesting a role of this brain region in motor speech production.

Paradoxical Brain Emboli Related to Heparin-Induced Thrombocytopenia after Catheter Ablation.

BACKGROUND: Thromboembolism associated with catheter ablation of atrial fibrillation has been considered to be derived from catheters, ablation sites, or a left atrial appendage. Paradoxical brain embolism due to iatrogenic shunt after catheter ablation has yet to be described. METHODS: We described a patient with atrial fibrillation who developed acute ischemic stroke while coughing 36 hours after successful catheter ablation. He had venous thrombosis due to heparin-induced thrombocytopenia and a right-to-left shunt, likely due to a trans-septal puncture during catheter ablation. RESULTS: The final diagnosis was paradoxical brain embolism associated with heparin-induced thrombocytopenia. CONCLUSIONS: In addition to anticoagulation, we should pay attention to deep venous thrombosis including preventive intermittent compression for high-risk patients to reduce the risk of stroke after catheter ablation.

Incidence of cardioembolic stroke including paradoxical brain embolism in patients with acute ischemic stroke before and after the Great East Japan Earthquake.

BACKGROUND: The incidence of heart disease or deep vein thrombosis (DVT) reportedly increased after the Great East Japan Earthquake. We hypothesized that the incidence of cardioembolic stroke (CES) including paradoxical brain embolism (PBE) among patients with acute stroke would increase after the earthquake due to cessation of antithrombotic therapy or the increase in heart disease and DVT associated with the evacuation. The aim of this study is to evaluate the changes in the prevalence of DVT and the incidence of CES including PBE in acute ischemic stroke before and after the earthquake. METHODS: We retrospectively studied 1,044 consecutive ischemic stroke patients (73.1 ± 12.5 years old, male 61.5%) who were admitted to a comprehensive stroke center (from January 2010 through March 2012) located in the earthquake disaster area within 7 days after stroke onset. The prevalence of DVT and the incidence of CES including PBE were compared before and after the earthquake of 11 March 2011. RESULTS: The median of the initial National Institutes of Health Stroke Scale (NIHSS) scores was 4 (interquartile range: 1-8). Two hundred and eighty-two patients (27.0% of those surveyed) were diagnosed with CES. After adjustment for sex, age, NIHSS score, and patient's residential address, the proportion of CES patients was significantly increased after the earthquake (odds ratio, OR 1.61, 95% confidence interval, 95% CI: 1.20-2.17). Eighty-nine patients (8.5% of those surveyed) had DVT. Compared with 2010 findings, the prevalence of DVT was significantly increased in the fourth quarter of 2011 and the first quarter of 2012 (OR 1.85, 95% CI: 1.05-3.24). Nineteen (1.8% of those surveyed) were diagnosed with PBE. The proportion of PBE patients was also significantly increased in the second half of 2011 (OR 3.69, 95% CI: 1.28-12.1). CONCLUSIONS: The incidence of CES was significantly increased after the earthquake, compared with the period before the earthquake. We encountered more PBE in the period from 3 to 9 months after the earthquake and found more DVT in the acute ischemic stroke patients in the period from 6 through 12 months after the earthquake. In these types of disasters, we have to ensure the distribution of drugs, including antithrombotics, and support the prevention of DVT in the refugees.

A dilated surface appearance on basiparallel anatomic scanning-magnetic resonance imaging is a useful tool for the diagnosis of spontaneous vertebral artery dissection in lateral medullary infarction.

Spontaneous dissection of the vertebral artery (VA) is a major vascular lesion causing lateral medullary infarction (LMI). A dilated surface appearance of the VA is a feature of VA dissection and can be observed on basiparallel anatomic scanning (BPAS)-magnetic resonance imaging (MRI). The aim of this study was to validate BPAS-MRI in the diagnosis of VA dissection in patients with LMI. The subjects of the present study were 41 consecutive patients with LMI within 7 days of onset. The diagnosis of VA dissection was made with the clinical criteria-based diagnosis. Percent (%) dilatation of the VA on BPAS-MRI was calculated by comparing the maximum surface diameter of the intracranial VA to the diameter of the distal normal surface of the VA. Fourteen patients (34%) were diagnosed with VA dissection. The optimal cutoff % dilatation of the VA for dissection was more than 169%. The sensitivity and specificity of % dilatation of VA more than 169% and aneurysmal dilatation, stenosis, or occlusion on magnetic resonance angiography (MRA) for VA dissection were 92.9% and 81.5%, respectively. BPAS-MRI combined with time-of-flight-MRA is a useful tool for the diagnosis of VA dissection in patients with acute LMI.

Successful Recanalization by Intravenous Thrombolysis in a Patient With Calcified Cerebral Emboli With Major Vessel Occlusion: A Case Report.

A 69-year-old man, with a history of left superficial temporal artery-middle cerebral artery bypass due to cerebral infarction by left internal carotid artery occlusion, was hospitalized with acute right hemispatial neglect and left hemiparesis. Diffusion-weighted imaging showed a high-intensity lesion in the right insular cortex. Although there seemed to be no arterial occlusion in magnetic resonance angiography (MRA), non-contrast computed tomography (CT) on admission showed calcification in the right Sylvian fissure. As hyperacute ischemic stroke within 4.5 hours after onset, we used an intravenous recombinant tissue plasminogen activator, and his symptoms improved. Follow-up MRA revealed recanalization of the right M2 branches with distal migration of calcification. Although calcification was identified on non-contrast CT in the initial assessment, the diagnosis of middle cerebral artery occlusion was missed. Therefore, arterial occlusion should be considered when calcification is observed in the brain sulcus. This case also illustrated that intravenous thrombolysis may be effective even in calcified cerebral emboli with major vessel occlusion.

Amyloid accumulation in cases of suspected comorbid cerebral amyloid angiopathy and isolated cortical venous thrombosis.

BACKGROUND AND AIM: The differentiation of isolated cortical venous thrombosis (ICVT) from cerebral amyloid angiopathy (CAA) can be difficult because both diseases share similar neurological symptoms and imaging findings. N-methyl-11C-2-(4'-methylaminophenyl)-6-hydroxybenzo-thiazole (11C-PiB) positron emission tomography (PET) functions as a diagnostic modality for CAA by detecting amyloid deposition. The present prospective study evaluated amyloid deposition using 11C-PiB-PET in consecutive patients with suspected ICVT. METHOD: This study was a prospective observational study. Patients who attended or were hospitalized between May 2019 and March 2020 were included in the analysis. Consecutive patients who met the criteria for suspicion of ICVT were enrolled in the study, and the clinical course, symptoms, imaging findings (including magnetic resonance imaging), and the 11C-PiB-PET findings of each case were analyzed. RESULTS: The study cohort included four patients (64-82 years of age, all women). In one younger patient, 11C-PiB-PET afforded no findings suggestive of CAA, whereas the remaining three patients exhibited 11C-PiB-PET findings suggestive of CAA. CONCLUSION: Although 11C-PiB-PET would be a reasonable modality for distinguishing ICVT from CAA, especially in younger patients, it might be difficult to differentiate ICVT from CAA in elderly patients because of the potential deposition of amyloid. CLINICAL TRIAL REGISTRATION: URL: https://www.umin.ac.jp/ctr/ Unique identifier: UMIN 000037101.

Effect of cilostazol in the treatment of acute ischemic stroke in the lenticulostriate artery territory.

BACKGROUND: Cilostazol, an inhibitor of phosphodiesterase 3, has various pleiotropic effects besides its antiplatelet activity. This study examined the efficacy of cilostazol for the treatment of acute perforating artery infarction. METHODS: In this prospective, randomized, open-label, blinded-end point trial, 100 patients with cerebral infarction in the territory of the lenticulostriate arteries were enrolled within 48 h of onset. Patients were randomly treated with both cilostazol and ozagrel for 14 days (n = 50, cilostazol group) or ozagrel alone for 14 days (n = 50, control group). The primary end point was the proportion of favorable outcomes 30 days after randomization as defined by a modified Rankin Scale (mRS) score of 0-2. Secondary end points included the incidence of neurological deterioration (an increase of ≥ 2 on the National Institutes of Health Stroke Scale within 7 days). RESULTS: Favorable outcomes (mRS scores 0-2) were similar in both groups (81.3 and 82.0% in the cilostazol and control groups, respectively). The incidence of neurological deterioration was lower in the cilostazol group than the control group (12.5 and 16.0%, respectively) with a 21.9% relative risk reduction, although the difference was not statistically significant. CONCLUSIONS: Cilostazol did not prevent the neurological deterioration of perforating artery infarction.

Rapid Evaluation of Large Vessel Occlusion for Mechanical Thrombectomy Using Carotid Duplex Ultrasound.

Objectives This study clarified the usefulness of carotid duplex ultrasound (CDU) in evaluating large vessel occlusion (LVO) in patients with acute stroke planned to be treated with mechanical thrombectomy (MT). Methods This study was single-center, prospective, observational trial. If the ratio of end-diastolic velocity in the common carotid arteries was ≥1.4, or diastolic flow in the affected internal carotid artery (ICA) was absent on CDU, patients were immediately transferred to the angio-suite without additional cerebrovascular imaging. Clinical parameters, including time metrics and outcomes, were evaluated in participants. Patients We enrolled stroke patients with a National Institutes of Health Stroke Scale score ≥6 and Alberta Stroke Program Early CT score ≥6 in whom MT could be initiated within 6 hours of the stroke onset. Results Among 140 patients screened during the study period, 48 were ultimately enrolled. Twenty-seven patients were diagnosed with LVO by CDU alone. CDU offered 83% sensitivity and 82% specificity for identifying the occlusion of the ICA or M1 segment of the middle cerebral artery. Among the 29 total patients treated with MT, 20 (67%) showed a modified Rankin Scale score ≤2 at 90 days. The door-to-puncture time was significantly shorter in patients evaluated by CDU alone (34 minutes) than in those evaluated by magnetic resonance angiography after CDU (47.5 minutes, p<0.001). Conclusion CDU might reduce the time metrics for early initiation of MT with good sensitivity and specificity in identifying LVO.