Regional Disparities in Prehospital Delay of Acute Ischemic Stroke: The Korean Stroke Registry.

BACKGROUND: Late hospital arrival keeps patients with stroke from receiving recanalization therapy and is associated with poor outcomes. This study used a nationwide acute stroke registry to investigate the trends and regional disparities in prehospital delay and analyze the significant factors associated with late arrivals. METHODS: Patients with acute ischemic stroke or transient ischemic attack between January 2012 and December 2021 were included. The prehospital delay was identified, and its regional disparity was evaluated using the Gini coefficient for nine administrative regions. Multivariate models were used to identify factors significantly associated with prehospital delays of >4.5 h. RESULTS: A total of 144,014 patients from 61 hospitals were included. The median prehospital delay was 460 min (interquartile range, 116-1912), and only 36.8% of patients arrived at hospitals within 4.5 h. Long prehospital delays and high regional inequality (Gini coefficient > 0.3) persisted throughout the observation period. After adjusting for confounders, age > 65 years old (adjusted odds ratio [aOR] = 1.23; 95% confidence interval [CI], 1.19-1.27), female sex (aOR = 1.09; 95% CI, 1.05-1.13), hypertension (aOR = 1.12; 95% CI, 1.08-1.16), diabetes mellitus (aOR = 1.38; 95% CI, 1.33-1.43), smoking (aOR = 1.15, 95% CI, 1.11-1.20), premorbid disability (aOR = 1.44; 95% CI, 1.37-1.52), and mild stroke severity (aOR = 1.55; 95% CI, 1.50-1.61) were found to independently predict prehospital delays of >4.5 h. CONCLUSION: Prehospital delays were lengthy and had not improved in Korea, and there was a high regional disparity. To overcome these inequalities, a deeper understanding of regional characteristics and further research is warranted to address the vulnerabilities identified.

Erratum: A Patient With Fahr's Disease Who Presented Prominent Visuospatial Dysfunction.

[This corrects the article on p. 117 in vol. 22, PMID: 37545866.].

Association of high-estimated glomerular filtration rate with the severity of ischemic stroke during non-vitamin K antagonist oral anticoagulants therapy: a nationwide cohort study.

Aim: While the relationship between impaired kidney function and non-vitamin K antagonist oral anticoagulants (NOACs) is well established, there is limited research exploring the association between an elevated estimated glomerular filtration rate (eGFR) and the efficacy of NOACs, especially concerning the outcomes of acute ischemic stroke (AIS). This study aimed to examine the association between higher-than-normal eGFR and the severity of AIS during the use of NOACs using a nationwide multicenter stroke registry in Korea. Material and methods: This study utilized data from the Korean Stroke Registry (KSR) database, examining information from 2,379 patients with AIS, who had atrial fibrillation (AF) and a history of utilizing NOACs prior to hospitalization due to incident stroke occurring between 2016 and 2021. Patients with a history involving two or more types of anticoagulants or one or more forms of antiplatelet agents were excluded. Baseline characteristics, medical history, medication usage, CHADS2-VASc score, and the anticoagulation and risk factors in atrial fibrillation (ATRIA) score were evaluated. Renal function was assessed using eGFR levels and calculated with the Cockcroft-Gault equation. The severity of stroke was measured by the National Institutes of Health Stroke Scale as an outcome. For sensitivity analysis, further evaluation was performed using eGFR levels according to the modification of diet in renal disease (MDRD) study equation. Results: The mean age of subjects was 76.1 ± 8.9 years. The moderate-to-severe stroke severity group exhibited an elevation in creatinine levels. The eGFR of 60 to 89 mL/min/1.73 m2 group was associated with a decreased risk of moderate-to-severe stroke severity [hazard ratio (HR)] (0.77, 95% confidence interval (CI) [0.61, 0.98], p = 0.031) compared to the eGFR≥90 mL/min/1.73 m2 group. An increment of 10 units in eGFR was marginally associated with an increased risk of moderate-to-severe stroke severity (HR: 1.03, 95% CI [1.00, 1.07], p = 0.054). Conclusion: The study revealed that individuals with eGFR ≥ 90 mL/min/1.73 m2 had an association linked to an increased risk of moderate-to-severe stroke severity. Our study suggests that patients taking NOACs with higher-than-normal eGFR levels may have an increased severity of AIS.

Preventive effects of ginseng against atherosclerosis and subsequent ischemic stroke: A randomized controlled trial (PEGASUS trial).

Background: Korean Red Ginseng (KRG) extract has been shown to have beneficial effects in patients with atherosclerosis, suggesting that KRG extract may be effective in preventing subsequent ischemic stroke in patients with severe atherosclerosis. Methods: This double-blind, placebo-controlled trial randomized patients with severe atherosclerosis in major intracranial arteries or extracranial carotid artery, to ginseng group and placebo group. They were given two 500-mg KRG tablets or identical placebo tablets twice daily for 12 months according to randomization. The primary endpoint was the composite of cerebral ischemic stroke and transient ischemic attack during 12 months after randomization. The secondary endpoints were change in volumetric blood flow of the intracranial vessels and the incidence of newly developed asymptomatic ischemic lesions. Any adverse events were monitored. Results: Fifty-eight patients were randomized from June 2016 to June 2017, 29 to ginseng and 29 to placebo, and 52 (28 and 24, respectively) completed the study. One patient in the placebo group, but none in the ginseng group, experienced ischemic symptoms (p = 0.46). Changes in volumetric blood flow and the presence of ischemic brain lesions did not differ significantly in the two groups, and none of these patients experienced adverse drug reactions. Conclusion: Ginseng was well tolerated by patients with severe atherosclerosis, with these patients showing good compliance with ginseng dosing. Ginseng did not show significant effects compared with placebo, although none of the ginseng-treated patients experienced ischemic events. Long-term studies in larger patient populations are required to test the effect of ginseng.

Etiology-Related Outcome of Endovascular Therapy in Posterior Circulation Stroke Compared to Anterior Circulation Stroke.

BACKGROUND AND PURPOSE: We investigated the impact of stroke etiology on the endovascular treatment (EVT) procedure and clinical outcome of posterior circulation stroke (PCS) patients with EVT compared to anterior circulation stroke (ACS) patients. METHODS: We retrospectively analyzed ischemic stroke patients who underwent EVT between January 2012 and December 2020. Enrolled ACS and PCS patients were compared according to etiologies (intracranial arterial steno-occlusion [ICAS-O], artery-to-artery embolic occlusion [AT-O], and cardioembolic occlusion [CA-O]). EVT procedure and favorable clinical outcomes at 3 months (modified Rankin Scale 0-2) were compared between the ACS and PCS groups for each etiology. RESULTS: We included 419 patients (ACS, 346; PCS, 73) including 88 ICAS-O (ACS, 67; PCS, 21), 66 AT-O (ACS, 50; PCS, 16), and 265 CA-O (ACS, 229; PCS, 36) patients in the study. The onset-to-recanalization time was longer in the PCS group than in the ACS group (median 628.0 minutes vs. 421.0 minutes, P=0.01). In CA-O patients, the door-to-puncture time was longer, whereas the puncture-to-recanalization time was shorter in the PCS group than in the ACS group. The proportions of successful recanalization and favorable clinical outcomes were similar between the ACS and PCS groups for all three etiologies. Low baseline National Institutes of Health Stroke Scale (NIHSS) scores and absence of intracerebral hemorrhage at follow-up imaging were associated with favorable clinical outcomes in both groups, whereas successful recanalization (odds ratio, 11.74; 95% confidence interval, 2.60 to 52.94; P=0.001) was only associated in the ACS group. CONCLUSIONS: The proportions of successful recanalization and favorable clinical outcomes were similar among all three etiologies between PCS and ACS patients who underwent EVT. Initial baseline NIHSS score and absence of hemorrhagic transformation were related to favorable outcomes in the PCS and ACS groups, whereas successful recanalization was related to favorable outcomes only in the ACS group.

Long-Term Changes in Post-Stroke Depression, Emotional Incontinence, and Anger.

BACKGROUND AND PURPOSE: Long-term changes in post-stroke depression (PSD), post-stroke emotional incontinence (PSEI), and post-stroke anger (PSA) have rarely been studied. METHODS: This is a sub-study of EMOTION, a randomized, placebo-controlled trial, that examined the efficacy of escitalopram on PSD, PSEI, and PSA in patients with stroke. We interviewed patients at the long-term period (LTP) using predefined questionnaires: Montgomery-Åsberg depression rating scale (MADRS) for PSD, modified Kim's criteria for PSEI, and Spielberger trait anger scale for PSA. Additionally, the ENRICHD Social Support Instrument (ESSI) for the social support state and the modified Rankin Scale (mRS) were measured. We investigated the changes in and factors behind PSD, PSEI, and PSA at LTP. RESULTS: A total of 222 patients were included, and the median follow-up duration was 59.5 months (interquartile range, 50 to 70). Compared to the data at 6 months post-stroke, the prevalence of PSEI (11.7% at 6 months, 6.3% at LTP; P=0.05) and mean anger score (21.62, 16.24; P<0.01) decreased, while the prevalence of PSD (35.6%, 44.6%; P=0.03) and mean MADRS (6.16, 8.67; P<0.01) increased at LTP. ESSI was associated with PSD and PSA, but not with PSEI. The effect of the baseline National Institutes of Health Stroke Scale score on PSD decreased over time. The effect of low social support on PSD was greater than that of mRS at LTP. CONCLUSIONS: The prevalence and degree of PSD significantly increased, while those of PSEI and PSA decreased at LTP. PSD in this stage appeared to be more closely associated with a lack of social support than patients' physical disabilities.

Reperfusion Therapy in Acute Ischemic Stroke with Active Cancer: A Meta-Analysis Aided by Machine Learning.

OBJECTIVES: While the prevalence of active cancer patients experiencing acute stroke is increasing, the effects of active cancer on reperfusion therapy outcomes are inconclusive. Thus, we aimed to compare the safety and outcomes of reperfusion therapy in acute stroke patients with and without active cancer. MATERIALS AND METHODS: A comprehensive literature search was conducted for studies comparing the effects of intravenous thrombolysis (IVT) or endovascular treatment (EVT) in ischemic stroke patients with and without active cancer. The literature was screened using both a manual and machine learning algorithm approach. The outcomes evaluated were symptomatic intracerebral hemorrhage (sICH), all-type intracerebral hemorrhage (aICH), successful recanalization, favorable outcomes (modified Rankin Scale, 0-2), and mortality. We calculated the pooled odds ratio (OR) and 95% confidence interval (CI) using the random-effects model from the included studies. RESULTS: Seven studies were analyzed in this meta-analysis. IVT (n = 1012) was associated with an increased risk of sICH (OR, 9.80; 95% CI, 3.19-30.13) in the active cancer group. However, no significant differences in aICH, favorable outcomes, and mortality were found between groups. Although sICH and successful recanalization in the EVT group (n = 2496) were similar, we observed fewer favorable outcomes (OR, 0.55; 95% CI, 0.33-0.93) and a high prevalence of mortality (OR, 2.91; 95% CI, 1.89-4.47) in the active cancer group. CONCLUSIONS: Reperfusion therapy may benefit selected patients with acute ischemic stroke with active cancer, considering the comparable clinical outcomes of IVT and procedure-related outcomes of EVT. These results should be cautiously interpreted and confirmed in future well-designed large-scale studies.

Timing of Thrombosis in Embolization of Unruptured Intracranial Aneurysms : Tirofiban as Rescue Treatment.

PURPOSE: Thrombosis is one of the main complications of endovascular treatment for unruptured intracranial aneurysms (UIA). This article reports the timing and initial location of thrombosis and prognosis after the use of tirofiban for performing coil embolization for UIA. METHODS: This study retrospectively collected 1686 cases of intracranial aneurysms treated with coil embolization from January 2013 to February 2018. Ruptured cases were excluded. The presumed causes and timing of thrombosis, the response after tirofiban administration and the modified Rankin scale (mRS) score at 3 months were reviewed. RESULTS: Of the 26 patients 76% were female and middle cerebral artery and basilar artery aneurysms accounted for 7 cases. The initial location of thrombosis was related to the stent (n = 14, 53.8%) or coil (n = 12, 46.2%). Of the patients 19 (73.1%) developed thrombosis during the procedure, and 5 patients (19.2%) developed it within 1 day of the procedure. Median duration between the thrombotic procedure and initial thrombosis was 38.5 min, 12 patients were symptomatic but more than half completely recovered after using tirofiban. Good clinical outcome (mRS 0-2) was seen in 92.3%. In the subgroup analysis, median time from the first thrombotic procedure to initial thrombosis within 1 day was 38.0 min (stent-related group) and 35.0 min (coil-related group, p = 0.651). CONCLUSION: In most cases of embolization for UIA, thrombosis requiring the use of tirofiban occurs intraprocedurally or on the first day after the procedure. Careful observation of thrombosis during the procedure is important and tirofiban should be used for a better outcome even if the infarction progresses.

Endovascular Treatment in Patients with Cerebral Artery Occlusion of Three Different Etiologies.

BACKGROUND AND PURPOSE: The outcome of endovascular treatment (EVT) may differ depending on the etiology of arterial occlusion. This study aimed to assess the differences in EVT outcomes in patients with intracranial arterial steno-occlusion (ICAS-O), artery-to-artery embolism (AT-O), and cardiac embolism (CA-O). METHODS: We retrospectively analyzed 330 patients with ischemic stroke who underwent EVT between January 2012 and August 2017. Patients were classified according to the etiology. The clinical data, EVT-related factors, and clinical outcomes were compared. The modified Rankin Scale (mRS) score at 3 months, determined using ordinal logistic regression (shift analysis), was the primary outcome. RESULTS: CA-O (n=149) was the most common etiology, followed by ICAS-O (n=63) and AT-O (n=49). Age, initial National Institutes of Health Stroke Scale (NIHSS) score, and rate of hemorrhagic transformation were significantly higher in patients with CA-O compared to AT-O and ICAS-O. The time from onset-to-recanalization was the shortest in the CA-O (356.0 minutes) groups, followed by the AT-O (847.0 minutes) and ICAS-O (944.0 minutes) groups. The rates of successful recanalization, mRS distribution, and favorable outcomes at 3 months (mRS 0-2; CA-O, 36.9%, AT-O, 53.1%; and ICAS-O, 41.3%) did not differ among the three groups. Baseline NIHSS score (odds ratio, 0.87; 95% confidence interval, 0.83 to 0.91) could independently predict a favorable shift in mRS distribution. CONCLUSIONS: The functional outcomes of ICAS-O and AT-O were similar to those of CA-O, despite the delay in symptom onset-to-recanalization, suggesting that the therapeutic time window may be extended in these patients.

Safety and Effectiveness of Percutaneous Low-Dose Thrombin Injection for Femoral Puncture Site Pseudoaneurysms in Neurointervention: Single-Center Experience.

PURPOSE: We present ultrasound-guided percutaneous low-dose thrombin (200-250 IU) injection for the treatment of iatrogenic femoral pseudoaneurysms. Second, we compared patient and procedure factors between subcutaneous hematoma and pseudoaneurysm groups. MATERIALS AND METHODS: From April 2012 to May 2018, 8425 patients underwent neurointervention. Among these patients, 18 had small subcutaneous hematomas and 6 had pseudoaneurysms. Pseudoaneurysms in the neck and entire sac were visualized, and low-dose thrombins were injected while visualizing a "whirlpool" hyperechoic core in the pseudoaneurysm sac. Subcutaneous hematomas were treated with simple compression. We compared the following parameters between the subcutaneous hematoma group and pseudoaneurysm group: sex, age, body mass index (BMI), type of procedure, heparin usage, sheath size, procedure time, and number of previous neurointervention procedures with the Mann-Whitney U test. RESULTS: Most of the pseudoaneurysms were successfully occluded with 200 IU of thrombin (n=5). Only 1 pseudoaneurysm required a slightly higher thrombin concentration (250 IU, n=1). During the short-term follow-up, no residual sac was observed and no surgical repair was necessary. Pain in the groin region was alleviated. During the 1-month follow-up, no evidence of pseudoaneurysm recurrence nor subcutaneous hematoma was noted. Patient factors (sex, age, and BMI) and procedure factors (heparin usage, sheath size, procedure time, number of previous procedures) were not statistically different between the subcutaneous hematoma and pseudoaneurysm groups. CONCLUSION: Ultrasound-guided percutaneous low-dose thrombin injection (200-250 IU) is safe, effective, and less invasive for treating iatrogenic femoral pseudoaneurysm in neurointervention.

Post-stroke cognitive impairment as an independent predictor of ischemic stroke recurrence: PICASSO sub-study.

INTRODUCTION: To devise appropriate preventive strategies after stroke, knowledge of the association between post-stroke cognitive impairment (PSCI) and prognosis of stroke patients is important. We investigated the association between PSCI and the vascular outcomes in patients with ischemic stroke with best medical care considering their risk factors and adherence to medications. METHODS: Of the 1534 ischemic stroke patients who randomly assigned to aspirin or cilostazol treatment with best medical therapy by the PICASSO (PreventIon of CArdiovascular events in iSchemic Stroke patients with high risk of cerebral hemOrrhage) trial, 1240 with baseline mini-mental state examination (MMSE) scores were analysed retrospectively. The patients were classified into three groups based on MMSE scores. Recurrence of ischemic stroke, stroke of any type and composite of major vascular events were compared among them. RESULTS: Of the 1240 patients, 376 had MMSE scores of 28-30 (highest tertile), 419 had scores of 24-27 (middle tertile) and 445 had scores of 0-23 (lowest tertile). The average time from stroke onset to MMSE examination was 31.8 days. By trend analysis, lower tertile of MMSE score was significantly associated with recurrent ischemic stroke (p = 0.0017), stroke of any type (p = 0.0053) and composite vascular outcome (p = 0.0122). After adjustment for covariates, PSCI was independently associated with risk of recurrent ischemic stroke (HR 2.40, 95% confidence interval 1.12-5.14). CONCLUSIONS: Cognitive impairment was associated with recurrence of ischemic stroke in high risk patients during adequate medical therapy including antiplatelet therapy. However, the other vascular events were not.

Intra-arterial thrombectomy for acute ischaemic stroke patients with active cancer.

BACKGROUND AND PURPOSE: This study aimed to evaluate the efficacy of intra-arterial thrombectomy (IAT) and prognosis for acute ischaemic stroke patients with active cancer. METHODS: We retrospectively reviewed 253 patients who underwent IAT within 24 h after stroke onset between January 2012 and August 2017. We classified the patients into active cancer (n = 26) and control groups (n = 227) and compared clinical data. Primary outcome was a modified Rankin scale score at 3 months with ordinal logistic regression (shift analysis). RESULTS: Initial National Institutes of Health Stroke Scale (NIHSS) and rate of successful recanalisation did not differ between groups, but the active cancer group showed poor outcomes at 3 months on shift analysis (P = 0.001). The independent predictors of poor prognosis were age [adjusted common odds ratio (aOR) 1.03, 95% confidence interval (CI) 1.01-1.05], baseline NIHSS (aOR 1.14, 95% CI 1.09-1.19), baseline C-reactive protein level (aOR 1.14, 95% CI 1.03-1.25), any cerebral haemorrhage (aOR 1.92, 95% CI 1.21-3.06), and active cancer (aOR 2.35, 95% CI 1.05-5.25). Mortality at 90 days was 30.8% in the cancer group and 8.8% in the control group (P = 0.003). CONCLUSIONS: Although baseline characteristics and recanalisation rate after IAT up to 24 h after stroke onset were similar between acute ischaemic stroke patients with active cancer and without any cancer, stroke-related death and short-term outcome were significantly poorer in patients with active cancer than the controls. Post-procedural haemorrhage and active cancer itself were independent predictors of a decrease in functional independence at 3 months.

Stent-Assisted Coil Embolization of MCA Bifurcation Aneurysms at a Hypoplastic M1 Branch by Use of Hook Technique.

BACKGROUND: We describe the Hook technique enabling coil embolization in unfavorable M1 bifurcation aneurysms and analyze the morphologic variations in M1 bifurcation to evaluate how often such aneurysms can be seen. METHODS: Among 42 MCA aneurysms treated by stent-assisted coil embolization, aneurysms arising at the acute-angled hypoplastic M1 branch (n = 14) were treated by the Hook technique, in which a short stent was deployed only to protect the aneurysm neck after microcatheter selection of the hypoplastic M2, followed by subsequent coiling of the aneurysm. Outcome was evaluated, including Raymond classification, coil packing density, final modified Rankin Scale (mRS), and recurrence. Separately, 100 middle cerebral artery (MCA) bifurcation aneurysms were analyzed to assess the proportion of such unfavorable aneurysms. RESULTS: Procedural success of the Hook technique was obtained in 13 of 14 patients (93%). A mean packing density of 30% was achieved. Magnetic resonance angiographic follow-up at a median 4 months (range, 1-26 months) showed complete occlusion in 11 patients and residual neck filling in 3 patients. There was no clinical event (mRS = 0) over a median 17 months (range, 2-26 months) of clinical follow-up. One patient had a thrombotic occlusion during the procedure, which was resolved after tirofiban infusion, without evidence of an infarct or deficit. Of the 100 MCA bifurcation aneurysms, aneurysm arising in asymmetric hypoplastic M2 division was the most common type (48%). CONCLUSIONS: The Hook technique enabled stent-assisted coiling of M1 bifurcation aneurysm with extension along the asymmetric hypoplastic M2 division and also securing the M2 branch.

Cigarette Smoking Preferentially Affects Intracranial Vessels in Young Males: A Propensity-Score Matching Analysis.

PURPOSE: Cigarette smoking (CS) is one of the major risk factors of cerebral atherosclerotic disease, however, its level of contribution to extracranial and intracranial atherosclerotic stenosis (ECAS and ICAS) was not fully revealed yet. The purpose of our study was to assess the association of CS to cerebral atherosclerosis along with other risk factors. MATERIALS AND METHODS: All consecutive patients who were angiographically confirmed with severe symptomatic cerebral atherosclerotic disease between January 2002 and December 2012 were included in this study. Multivariate logistic regression analyses were performed to identify risk factors for ECAS and ICAS. Thereafter, CS group were compared to non-CS group in the entire study population and in a propensity-score matched population with two different age-subgroups. RESULTS: Of 1709 enrolled patients, 794 (46.5%) had extracranial (EC) lesions and the other 915 (53.5%) had intracranial (IC) lesions. CS group had more EC lesions (55.8% vs. 35.3%, P<0.001) whereas young age group (<50 years) had more IC lesion (84.5% vs. 47.6%, P<0.001). In multivariate analysis, seven variables including CS, male, old age, coronary heart disease, higher erythrocyte sedimentation rate, multiple lesions, and anterior lesion were independently associated with ECAS. In the propensity-score matched CS group had significant more EC lesion compared to non-CS group (65.7% vs. 47.9%) only in the old age subgroup. CONCLUSION: In contrast to a significant association between CS and severe symptomatic ECAS shown in old population, young patients did not show this association and showed relatively higher preference of ICAS.

DWI-pc-ASPECT score in basilar artery occlusion: is 6 points or less always indicative of a bad outcome?

BACKGROUND AND PURPOSE: The prognosis of patients with acute basilar arterial occlusion after endovascular reperfusion therapy with diffusion-weighted imaging - posterior circulation-Alberta Stroke Program Early Computed Tomography Score (DWI-pc-ASPECTS) of 6 or less remains unclear. We aimed to assess the characteristics and prognosis of endovascular reperfusion therapy in patients with acute basilar arterial occlusion and DWI-pc-ASPECTS of 6 or less. METHODS: We analysed data collected from 1 January 2012 to 31 January 2018 in a prospective neuro-interventional registry of consecutive patients treated with endovascular reperfusion therapy. Clinical and imaging data on patients with DWI-pc-ASPECTS of 6 or less who underwent endovascular reperfusion therapy for acute basilar arterial occlusion were collected for this study. A good clinical outcome was defined as a modified Rankin scale of 2 or less at 90 days. RESULTS: Forty-five acute basilar arterial occlusion patients with DWI-pc-ASPECTS of 6 or less were included. Among them, 11 (24.4%) patients had a good clinical outcome at 90 days. Patients with a good clinical outcome had less severe neurological symptoms at presentation (National Institutes of Health Stroke Scale (NIHSS) 19.0 (12.0-25.0) vs. 8.0 (6.0-11.5); P = 0.003) and were younger (72.5 years (57.0-80.0 years) vs. 63.0 years (55.5-69.0 years), P = 0.096) than those with a poor clinical outcome. The symptomatic intracranial haemorrhage rate was significantly higher in the poor clinical outcome group (13 (38.2%)) than in the good clinical outcome group (0 (0.0%)) (P = 0.045). In particular, in patients aged over 70 years, a favourable outcome was low (18 (52.9%) vs. 1 (9.1%); P = 0.027) even after successful recanalisation. In a multivariate model, a low initial NIHSS score (odds ratio 1.21; 95% confidence interval 1.07-1.44; P = 0.0093) and age over 70 years (odds ratio 15.27; 95% confidence interval 1.85-379.79; P = 0.0321) were independent predictors of poor clinical outcome. CONCLUSIONS: Even with DWI-pc-ASPECTS of 6 or less, good clinical outcome can be achieved after endovascular reperfusion therapy. Relatively mild initial symptoms and younger age can predict a better outcome in acute basilar arterial occlusion patients with DWI-pc-ASPECTS of 6 or less.

Evolution of acute lacunar lesions in terms of size and shape: a PICASSO sub-study.

The imaging definition of lacunar infarcts is variable, particularly regarding their size and the presence of cavitation. We investigated the changes of diameter and evolution pattern of acute lacunar infarcts, and the factors associated with the evolution pattern. Patients with acute single subcortical hemispheric or brainstem ischemic lesions of penetrating arterial territories were included. Maximal diameters on initial diffusion-weighted image (DWI) and follow-up fluid-attenuated inversion recovery image (FLAIR), which performed > 12 months after initial DWI, were semi-automatically measured. Clinical characteristics were compared according to evolution patterns on follow-up FLAIR, classified as cavitated, focal lesion without cavitation, and disappeared. Five hundred nine patients were included. Mean time to follow-up was 31.3 ± 13.7 months. Mean diameter of acute lacunar lesions decreased from 12.9 ± 4.4 to 8.5 ± 4.8 mm during follow-up. Lesions of 58.2% patients remained as cavitated, 18.3% as focal lesion without cavitation, and 23.6% disappeared. Initial NIHSS score (p = 0.005), diameter of initial lesion (p < 0.001), number of slices showing acute lesion on DWI (p < 0.001), progression of white matter lesion (p < 0.001), number of acute lesions involving gray matter (p = 0.008) and lesion location (p < 0.001) were different among three groups. After adjustment for covariates, diameter of the acute lesion, initial number of old lacunes, and anterior lesion location were associated with the appearance of cavitation. Initial lesion diameter and posterior lesion location were associated with the disappearance. We observed reduction of the acute lacunar lesion diameter in 86%. There were predictive factors of disappearance and cavitation of acute lacunar infarction.

Cerebral Microbleeds in the Patients With Acute Stroke Symptoms.

Background: Some patients with acute stroke symptoms do not show hyperintensities on diffusion-weighted image (DWI). A few case reports have indicated that acutely developed cerebral microbleeds (CMBs) might cause focal symptoms. This study sought to investigate the incidence and characteristics of symptomatic CMBs in the patients with acute stroke symptoms but without DWI ischemic lesions. Methods: We enrolled the patients with acute stroke symptoms who underwent magnetic resonance imaging including DWI and gradient echo (GRE) sequences within 7 days after symptom onset, at our prospective stroke registry. We then identified patients without DWI-positive ischemic lesions but with CMBs in the relevant brain regions. Results: Between January 2005 and February 2012, we identified 235 DWI-negative transient ischemic attack (n = 221) and stroke (n = 14) patients from 2129 consecutive patients at our registry. In total, 16 patients had CMBs corresponding to the focal symptoms. Among these 16 patients, 12 patients showed a hyperintense rim on DWI around a microbleed suspected to be related to focal symptoms; of the 12 patients, 7 experienced stroke symptoms for more than 24 h. However, the symptoms in the remaining patients (5 patients with the hyperintense rim and 4 patients without the hyperintense rim) improved within 24 h. Conclusion: Symptomatic microbleeds are infrequent but not rare in the patients with acute stroke symptoms. Perihematomal edema around an acute CMB can cause a hyperintense rim on DWI. Our results suggest that a combination of DWI and GRE imaging can help diagnose acute symptomatic CMBs.