Futile recanalization in patients with basilar artery occlusion: assessment of the underlying etiology and the role of perfusion imaging.

BACKGROUND: Futile recanalization (FR) after endovascular therapy (EVT) is common in basilar artery occlusion (BAO). The purpose of this study was to investigate the predictors of FR in the posterior circulation with an emphasis on the role of perfusion imaging and its relation to the underlying etiology. METHODS: We included BAO patients who had pretreatment perfusion imaging and successful recanalization after EVT. Patients were dichotomized into futile and non-futile groups according to the favorable functional outcome at 90 days (modified Rankin Scale (mRS) 0-3). Perfusion abnormalities were assessed using an automated software for Tmax volume measurement and identification of hypoperfusion area based on Tmax>6 s involvement of the pons-midbrain-thalamus (PMT), cerebellum, and temporo-occipital lobe. RESULTS: Of the 134 enrolled patients, the incidence of FR was 47.8% (64/134). Multivariate logistic analysis showed that a higher National Institutes of Health Stroke Scale (NIHSS) score on admission (adjusted OR (aOR) 1.066; 95% CI 1.011 to 1.125), a longer onset-to-recanalization time (aOR 1.002; 95% CI 1.001 to 1.004), incomplete recanalization (aOR 3.909; 95% CI 1.498 to 10.200), and PMT hypoperfusion (aOR 4.444; 95% CI 1.203 to 16.415) were independent predictors of FR. In patients with embolic occlusion of etiology, PMT hypoperfusion was associated with FR (aOR 8.379; 95% CI 1.377 to 50.994), whereas intracranial atherosclerotic stenosis (ICAS)-related occlusion was not (p=0.587). CONCLUSIONS: In patients with BAO, the likelihood of FR is associated with PMT hypoperfusion on pretreatment perfusion imaging. In particular, PMT hypoperfusion may be used as an imaging predictor of FR in patients with embolic cause of BAO.

Effectiveness of endovascular treatment for in-hospital stroke vs. community-onset stroke: a propensity score-matched analysis.

BACKGROUND: The effectiveness of endovascular treatment for in-hospital stroke remains debatable. We aimed to compare the outcomes between patients with in-hospital stroke and community-onset stroke who received endovascular treatment. METHODS: This prospective registry-based cohort study included consecutive patients who underwent endovascular treatment from January 2013 to December 2022 and were registered in the Selection Criteria in Endovascular Thrombectomy and Thrombolytic Therapy study and Yonsei Stroke Cohort. Functional outcomes at day 90, radiological outcomes, and safety outcomes were compared between the in-hospital and community-onset groups using logistic regression and propensity score-matched analysis. RESULTS: Of 1,219 patients who underwent endovascular treatment, 117 (9.6%) had in-hospital stroke. Patients with in-hospital onset were more likely to have a pre-stroke disability and active cancer than those with community-onset. The interval from the last known well to puncture was shorter in the in-hospital group than in the community-onset group (155 vs. 355 min, p<0.001). No significant differences in successful recanalization or safety outcomes were observed between the groups; however, the in-hospital group exhibited worse functional outcomes and higher mortality at day 90 than the community-onset group (all p<0.05). After propensity score matching including baseline characteristics, functional outcomes after endovascular treatment did not differ between the groups (OR: 1.19, 95% CI 0.78-1.83, p=0.4). Safety outcomes did not significantly differ between the groups. CONCLUSION: Endovascular treatment is a safe and effective treatment for eligible patients with in-hospital stroke. Our results will help physicians in making decisions when planning treatment and counseling caregivers or patients.

Cancer Prediction With Machine Learning of Thrombi From Thrombectomy in Stroke: Multicenter Development and Validation.

BACKGROUND: We aimed to develop and validate machine learning models to diagnose patients with ischemic stroke with cancer through the analysis of histopathologic images of thrombi obtained during endovascular thrombectomy. METHODS: This was a retrospective study using a prospective multicenter registry which enrolled consecutive patients with acute ischemic stroke from South Korea who underwent endovascular thrombectomy. This study included patients admitted between July 1, 2017 and December 31, 2021 from 6 academic university hospitals. Whole-slide scanning was performed for immunohistochemically stained thrombi. Machine learning models were developed using transfer learning with image slices as input to classify patients into 2 groups: cancer group or other determined cause group. The models were developed and internally validated using thrombi from patients of the primary center, and external validation was conducted in 5 centers. The model was also applied to patients with hidden cancer who were diagnosed with cancer within 1 month of their index stroke. RESULTS: The study included 70 561 images from 182 patients in both internal and external datasets (119 patients in internal and 63 in external). Machine learning models were developed for each immunohistochemical staining using antibodies against platelets, fibrin, and erythrocytes. The platelet model demonstrated consistently high accuracy in classifying patients with cancer, with area under the receiver operating characteristic curve of 0.986 (95% CI, 0.983-0.989) during training, 0.954 (95% CI, 0.937-0.972) during internal validation, and 0.949 (95% CI, 0.891-1.000) during external validation. When applied to patients with occult cancer, the model accurately predicted the presence of cancer with high probabilities ranging from 88.5% to 99.2%. CONCLUSIONS: Machine learning models may be used for prediction of cancer as the underlying cause or detection of occult cancer, using platelet-stained immunohistochemical slide images of thrombi obtained during endovascular thrombectomy.

Basilar tip morphology: impact on mechanical thrombectomy for acute distal basilar artery occlusion.

BACKGROUND: The morphology of the basilar artery tip (BAT) varies between patients. The morphologic anatomy of the BAT could affect the efficacy of mechanical thrombectomy (MT). METHODS: 108 patients with acute distal basilar artery occlusion (dBAO) who underwent MT from January 2013 to December 2021 were retrospectively analyzed. These patients were divided into two groups based on their BAT morphology: those with symmetrical cranial or caudal fusion of the BAT (symmetric group) and those with asymmetrical fusion of the BAT (asymmetric group). Morphological variables and angiographic and clinical outcomes were compared between the two groups. RESULTS: Of the 108 enrolled patients, 42 were in the asymmetric group. Compared with the symmetric group, the asymmetric group had significantly larger BAT diameter (mean 3.5±1.0 mm vs 4.3±1.1 mm, P=0.001) and basilar artery tip/trunk ratio (1.2±0.2 vs 1.7±0.2, P<0.001). The asymmetric group showed a significantly lower rate of complete reperfusion (71.2% vs 40.5%, P=0.002) and first pass effect (FPE) (51.5% vs 21.4%, P=0.002) than the symmetric group. The BAT asymmetry was an independent predictor of failed FPE (OR 0.299, 95% CI 0.098 to 0.918, P=0.035) and failed complete reperfusion (OR 0.275, 95% CI 0.087 to 0.873, P=0.029). CONCLUSIONS: The efficacy of MT for dBAO differs according to the anatomic morphology of the BAT. The asymmetric BAT was frequently encountered in dBAO patients and was independently associated with a reduced likelihood of complete reperfusion and FPE.

Preprocedural determination of an occlusion pathomechanism in endovascular treatment of acute stroke: a machine learning-based decision.

OBJECTIVE: To evaluate whether an occlusion pathomechanism can be accurately determined by common preprocedural findings through a machine learning-based prediction model (ML-PM). METHODS: A total of 476 patients with acute stroke who underwent endovascular treatment were retrospectively included to derive an ML-PM. For external validation, 152 patients from another tertiary stroke center were additionally included. An ML algorithm was trained to classify an occlusion pathomechanism into embolic or intracranial atherosclerosis. Various common preprocedural findings were entered into the model. Model performance was evaluated based on accuracy and area under the receiver operating characteristic curve (AUC). For practical utility, a decision flowchart was devised from an ML-PM with a few key preprocedural findings. Accuracy of the decision flowchart was validated internally and externally. RESULTS: An ML-PM could determine an occlusion pathomechanism with an accuracy of 96.9% (AUC=0.95). In the model, CT angiography-determined occlusion type, atrial fibrillation, hyperdense artery sign, and occlusion location were top-ranked contributors. With these four findings only, an ML-PM had an accuracy of 93.8% (AUC=0.92). With a decision flowchart, an occlusion pathomechanism could be determined with an accuracy of 91.2% for the study cohort and 94.7% for the external validation cohort. The decision flowchart was more accurate than single preprocedural findings for determining an occlusion pathomechanism. CONCLUSIONS: An ML-PM could accurately determine an occlusion pathomechanism with common preprocedural findings. A decision flowchart consisting of the four most influential findings was clinically applicable and superior to single common preprocedural findings for determining an occlusion pathomechanism.

The Efficacy of Alternate Systemic Intravenous Chemotherapy and Intra-arterial Chemotherapy Approach for Eye Globe Salvage in Retinoblastoma.

PURPOSE: The advances in the treatment of retinoblastoma have enabled salvaging the globe in advanced stages with intra-arterial chemotherapy (IAC). We developed a strategy of alternate application of systemic intravenous chemotherapy (IVC) and IAC (referred to as alternate systemic IVC and IAC; ASIAC) to reduce central nervous metastases during IAC and examined its efficacy and safety in eye globe salvage in this study. MATERIALS AND METHODS: Between January 2010 and February 2021, 43 eyes of 40 patients received ASIAC treatment for retinoblastoma at the Yonsei Cancer Center, Yonsei University Health System. Their medical records were reviewed retrospectively to evaluate the eye salvage rate (ESR), defined from diagnosis to enucleation. High-risk retinoblastoma was defined as group D or E by the International Classification of Retinoblastoma. RESULTS: The study enrolled 38 and five cases of high-risk and low-risk retinoblastoma, respectively. In total, 178 IAC and 410 IVC courses were administered, with a median of 4 (interquartile range [IQR], 3.0 to 5.0) IAC and 9 (IQR, 6.0 to 11) IVC courses per eye, respectively. The 5-year ESR was 60.4%±8.7% for the whole cohort, 100% for low-risk retinoblastoma, and 53.6%±9.8% for high-risk retinoblastoma. Among those diagnosed since 2015, the 5-year ESR for high-risk retinoblastoma was 63.5%±14.0%. Fifteen eyes underwent enucleation; no viable tumor was found in three enucleated eyes. There were no deaths in this cohort. CONCLUSION: Primary IAC-IVC (i.e., ASIAC) for patients with retinoblastoma was tolerable and effective in salvaging the eye and maintaining survival.

Efficacy and safety of stereotactic radiosurgery versus endovascular treatment for symptomatic cavernous sinus dural arteriovenous fistula without ophthalmological emergency: a single-center 10-year experience.

OBJECTIVE: Stereotactic radiosurgery (SRS) is emerging as a treatment option for cavernous sinus dural arteriovenous fistula (CS dAVF); it is less invasive and has a lower complication rate than conventional surgeries. However, little is known regarding the advantages and limitations of SRS compared to those of endovascular treatment (EVT). The aim of this study was to compare the efficacy and safety between EVT and SRS for treatment of CS dAVF. METHODS: Between January 2011 and April 2021, a total of 86 consecutive patients diagnosed with CS dAVF were treated with EVT or SRS. Among them, 8 patients with ophthalmological emergency and 8 without follow-up data at ≥ 12 months were excluded. During the same period, no neurological deficit due to intracranial hemorrhage or seizure was noted in any of the patients. Ultimately, 70 patients (EVT 33, SRS 37) were included in this study. Demographic characteristics, initial clinical presentations, clinical outcomes, and radiological findings were retrospectively reviewed and compared. Procedure-related complications were also assessed after the treatments. RESULTS: The patients' baseline characteristics (except conjunctival symptoms) and angiographic features of CS dAVF were not significantly different between the EVT and SRS groups. Conjunctival symptoms were more frequently noted in the EVT than in the SRS group (69.7% vs 40.5%, p = 0.015). After EVT, initial complete obliteration was achieved in 20 cases (60.6%). Complete obliteration was achieved at 6 months in 86.4% of cases with EVT and in 77.8% of those treated with SRS (p = 0.507), and at 12 months in 86.4% cases with EVT and in 94.4% of those treated with SRS (p = 0.357). Worsening of symptoms developed at 1 month in 24.2% of cases with EVT and in 5.4% of those treated with SRS (p = 0.038); at 6 months in 22.6% of cases with EVT and in 10.8% of those treated with SRS; and at 12 months in 30.0% of cases with EVT and in 13.5% of those treated with SRS (p = 0.099). The angioarchitecture of CS dAVF did not affect angiographic obliteration after SRS. Procedure-related morbidity and mortality occurred more frequently in the EVT than in the SRS group (27.3% vs 8.1%, p = 0.034). CONCLUSIONS: Both EVT and SRS were effective for the treatment of CS dAVF without ophthalmological emergency. However, procedure-related morbidity and mortality was less frequent in SRS than in EVT, and consequently SRS may be more advantageous in terms of safety.

Impact of Renal Function on Short-Term Outcome After Reperfusion Therapy in Patients With Ischemic Stroke.

BACKGROUND: A high and low estimated glomerular filtration rate (eGFR) could affect outcomes after reperfusion therapy for ischemic stroke. This study aimed to determine whether renal function based on eGFR affects mortality risk in patients with ischemic stroke within 6 months following reperfusion therapy. METHODS: This prospective registry-based cohort study included 2266 patients who received reperfusion therapy between January 2000 and September 2019 and were registered in the SECRET (Selection Criteria in Endovascular Thrombectomy and Thrombolytic Therapy) study or the Yonsei Stroke Cohort. A high and low eGFR were based on the Chronic Kidney Disease Epidemiology Collaboration equation and defined, respectively, as the 5th and 95th percentiles of age- and sex-specific eGFR. Occurrence of death within 6 months was compared among the groups according to their eGFR such as low, normal, or high eGFR. RESULTS: Of the 2266 patients, 2051 (90.5%) had a normal eGFR, 110 (4.9%) a low eGFR, and 105 (4.6%) a high eGFR. Patients with high eGFR were younger or less likely to have hypertension, diabetes, or atrial fibrillation than the other groups. Active cancer was more prevalent in the high-eGFR group. During the 6-month follow-up, there were 24 deaths (22.9%) in the high-eGFR group, 37 (33.6%) in the low-eGFR group, and 237 (11.6%) in the normal-eGFR group. After adjusting for variables with P<0.10 in the univariable analysis, 6-month mortality was independently associated with high eGFR (hazard ratio, 2.22 [95% CI, 1.36-3.62]; P=0.001) and low eGFR (HR, 2.29 [95% CI, 1.41-3.72]; P=0.001). These associations persisted regardless of treatment modality or various baseline characteristics. CONCLUSIONS: High eGFR as well as low eGFR were independently associated with 6-month mortality after reperfusion therapy. Kidney function could be considered a prognostic factor in patients with ischemic stroke after reperfusion therapy.

Parathyroid venous sampling for the preoperative localisation of parathyroid adenoma in patients with primary hyperparathyroidism.

Preoperative localisation studies are essential for parathyroidectomy in patients with primary hyperparathyroidism. If the location of abnormal parathyroid glands cannot be identified through non-invasive studies, parathyroid venous sampling (PVS) may be employed. In this study, we evaluated the utility of preoperative PVS in parathyroid surgery. Patients with primary hyperparathyroidism who underwent preoperative PVS at Severance Hospital between January 2015 and June 2020 were identified. Patients for whom the results of non-invasive imaging studies were inconsistent or negative underwent PVS. The results of PVS were compared with operative findings and pathologic results. For 14 patients, the results of preoperative ultrasonography and 99mTc-sestamibi single-photon emission computed tomography (SPECT) were negative; for 20 patients, either the result of only one test was positive, or the results of the two tests were inconsistent. With respect to the lateralisation of diseased adenoma, the results of PVS and pathological examination were inconsistent only for one patient in either group (total: 2/34 patients). This study showed that PVS could be used effectively for preoperative localisation in patients with primary hyperparathyroidism in whom the location of diseased parathyroid glands cannot be determined through non-invasive image studies.

Clinical outcomes of rescue stenting for failed endovascular thrombectomy: a multicenter prospective registry.

BACKGROUND: Mechanical thrombectomy (MT) is a primary endovascular modality for acute intracranial large vessel occlusion. However, further treatment, such as rescue stenting, is occasionally necessary for refractory cases. We aimed to investigate the efficacy and safety of rescue stenting in first-line MT failure and to identify the clinical factors affecting its clinical outcome. METHODS: A multicenter prospective registry was designed for this study. We enrolled consecutive patients who underwent rescue stenting for first-line MT failure. Endovascular details and outcomes, follow-up patency of the stented artery, and clinical outcomes were summarized and compared between the favorable and unfavorable outcome groups. RESULTS: A total of 78 patients were included. Intracranial atherosclerotic stenosis was the most common etiology for rescue stenting (97.4%). Seventy-seven patients (98.7%) were successfully recanalized by rescue stenting. A favorable outcome was observed in 66.7% of patients. Symptomatic intracranial hemorrhage and mortality were observed in 5.1% and 4.0% of patients, respectively. The stented artery was patent in 82.1% of patients on follow-up angiography. In a multivariable analysis, a patent stent on follow-up angiography was an independent factor for a favorable outcome (OR 87.6; 95% CI 4.77 to 1608.9; p=0.003). Postprocedural intravenous maintenance of glycoprotein IIb/IIIa inhibitor was significantly associated with the follow-up patency of the stented artery (OR 5.72; 95% CI 1.45 to 22.6; p=0.013). CONCLUSIONS: In this multicenter prospective registry, rescue stenting for first-line MT failure was effective and safe. For a favorable outcome, follow-up patency of the stented artery was important, which was significantly associated with postprocedural maintenance of glycoprotein IIb/IIIa inhibitors.

Changes in Treatment Patterns and Globe Salvage Rate of Advanced Retinoblastoma in Korea: Efficacy of Intra-Arterial Chemotherapy.

(1) Background: To analyze changes in treatment patterns for advanced retinoblastoma over time and differences in globe salvage rates; (2) Methods: Retrospective, observational case-control study of 97 eyes of 91 patients with advanced retinoblastoma (Group D and E).; (3) Results: Patients were divided into two groups based on whether they were treated before or after intraarterial chemotherapy (IAC) was introduced in our center in 2010. Before 2010, primary treatment pattern was enucleation, which was performed in 57.6% of cases, whereas primary treatment pattern after 2010 was IAC combined with intravenous chemotherapy (IVC), which was performed in 78.1%. Intravitreal chemotherapy (IVitC) has been performed to treat vitreous and subretinal seeding since 2015. The 5-year globe salvage rate of IVC alone was 24.0% for Group D and 0% for Group E, whereas that of IVC-IAC was 50.4% for Group D and 49.7% for Group E. Whether IVitC was performed or not did not significantly contribute to globe salvage rate. There was one metastatic death in the IVC alone group.; (4) Conclusions: Primary treatment pattern changed from enucleation to IAC-based treatment, which can now save nearly half of eyes with advanced retinoblastoma with excellent safety profile and survival rate.

Immediate and Long-Term Outcomes of Reperfusion Therapy in Patients With Cancer.

Background and Purpose: Patients with acute stroke are often accompanied by comorbidities, such as active cancer. However, adequate treatment guidelines are not available for these patients. The purpose of this study was to evaluate the association between cancer and the outcomes of reperfusion therapy in patients with stroke. Methods: We compared treatment outcomes in patients who underwent reperfusion therapy, using a nationwide reperfusion therapy registry. We divided the patients into 3 groups according to cancer activity: active cancer, nonactive cancer, and without a history of cancer. We investigated reperfusion processes, 24-hour neurological improvement, adverse events, 3-month functional outcome, and 6-month survival and related factors after reperfusion therapy. Results: Among 1338 patients who underwent reperfusion therapy, 62 patients (4.6%) had active cancer, 78 patients (5.8%) had nonactive cancer, and 1198 patients (89.5%) had no history of cancer. Of the enrolled patients, 969 patients received intravenous thrombolysis and 685 patients underwent endovascular treatment (316 patients received combined therapy). Patients with active cancer had more comorbidities and experienced more severe strokes; however, they showed similar 24-hour neurological improvement and adverse events, including cerebral hemorrhage, compared with the other groups. Although the functional outcome at 3 months was poorer than the other groups, 36.4% of patients with active cancer showed functional independence. Additionally, 52.9% of the patients with determined stroke etiology showed functional independence despite active cancer. During the 6-month follow-up, 46.6% of patients with active cancer died, and active cancer was independently associated with poor survival (hazard ratio, 3.973 [95% CI, 2.528­6.245]). Conclusions: In patients with active cancer, reperfusion therapy showed similar adverse events and short-term outcomes to that of other groups. While long-term prognosis was worse in the active cancer group than the nonactive cancer groups, not negligible number of patients had good functional outcomes, especially those with determined stroke mechanisms.

Association between flat-panel computed tomography hyperattenuation and clinical outcome after successful recanalization by endovascular treatment.

OBJECTIVE: Hyperattenuation on CT scanning performed immediately after endovascular treatment (EVT) is known to be associated with the final infarct. As flat-panel CT (FPCT) scanning is readily accessible within their angiography suite, the authors evaluated the ability of the extent of hyperattenuation on FPCT to predict clinical outcomes after EVT. METHODS: Patients with successful recanalization (modified Thrombolysis in Cerebral Infarction grade 2b or 3) were reviewed retrospectively. The extent of hyperattenuation was assessed by the Alberta Stroke Program Early CT Score on FPCT (FPCT-ASPECTS). FPCT-ASPECTS findings were compared according to functional outcome and malignant infarction. The predictive power of the FPCT-ASPECTS with initial CT images before EVT (CT-ASPECTS) and follow-up diffusion-weighted images (MR-ASPECTS) was also compared. RESULTS: A total of 235 patients were included. All patients were treated with mechanical thrombectomy, and 45.5% of the patients received intravenous tissue plasminogen activator. The mean (± SD) time from stroke onset to recanalization was 383 ± 290 minutes. The FPCT-ASPECTS was significantly different between patients with a favorable outcome and those without (mean 9.3 ± 0.9 vs 6.7 ± 2.6) and between patients with malignant infarction and those without (3.4 ± 2.9 vs 8.8 ± 1.4). The FPCT-ASPECTS was an independent factor for a favorable outcome (adjusted OR 3.28, 95% CI 2.12-5.01) and malignant infarction (adjusted OR 0.42, 95% CI 0.31-0.57). The area under the curve (AUC) of the FPCT-ASPECTS for a favorable outcome (0.862, cutoff ≥ 8) was significantly greater than that of the CT-ASPECTS (0.637) (p < 0.001) and comparable to that of the MR-ASPECTS (0.853) (p = 0.983). For malignant infarction, the FPCT-ASPECTS was also more predictive than the CT-ASPECTS (AUC 0.906 vs 0.552; p = 0.001) with a cutoff of ≤ 5. CONCLUSIONS: The FPCT-ASPECTS was highly predictive of clinical outcomes in patients with successful recanalization. FPCT could be a practical method to immediately predict clinical outcomes and thereby aid in acute management after EVT.

Evaluation of an optimal cutoff of parathyroid venous sampling gradient for localizing primary hyperparathyroidism.

INTRODUCTION: Parathyroid venous sampling (PVS) has been reported to be a useful adjunctive test in localizing lesions in elusive cases of primary hyperparathyroidism (PHPT). Conventional cutoff (twofold) is now widely being used, but optimal cutoff threshold for PVS gradient based on discriminatory performance remains unclear. MATERIALS AND METHODS: Among a total of 197 consecutive patients (mean age 58.2 years, female 74.6%) with PHPT who underwent parathyroidectomy at a tertiary center between 2012 and 2018, we retrospectively analyzed 59 subjects who underwent PVS for persistent or recurrent disease after previous parathyroidectomy, or for equivocal or negative results from conventional imaging modalities including ultrasonography (US) and Tc99m-Sestamibi SPECT-CT (MIBI). True parathyroid lesions were confirmed by combination of surgical, pathological findings, and intraoperative parathyroid hormone (PTH) changes. Optimal PVS cutoff were determined by receiver-operating characteristics (ROC) analysis with Youden and Liu method. RESULTS: Compared to subjects who did not require PVS, PVS group tends to have lower PTH (119.8 pg/mL vs 133.7 pg/mL, p = 0.075). A total of 79 culprit parathyroid lesions (left 40; right 39) from 59 patients (left 24; right 26; bilateral 9) were confirmed by surgery. The optimal cutoff for PVS gradient was estimated as 1.5-fold gradient (1.5 ×) with sensitivity of 61.8% and specificity of 84%. When 1.5 × cutoff was applied, PVS improved the discrimination for true parathyroid lesions substantially based on area under ROC (0.892 to 0.942, p < 0.001) when added to US and MIBI. CONCLUSION: Our findings suggest that PVS with cutoff threshold 1.5 × can provide useful complementary information for pre-operative localization in selected cases.

Time of day and endovascular treatment decision in acute stroke with relative endovascular treatment indication: insights from UNMASK EVT international survey.

BACKGROUND AND PURPOSE: The decision to proceed with endovascular thrombectomy should ideally be made independent of inconvenience factors, such as daytime. We assessed the influence of patient presentation time on endovascular therapy decision making under current local resources and assumed ideal conditions in acute ischemic stroke with level 2B evidence for endovascular treatment. METHODS AND MATERIALS: In an international cross sectional survey, 607 stroke physicians from 38 countries were asked to give their treatment decisions to 10 out of 22 randomly assigned case scenarios. Eleven scenarios had level 2B evidence for endovascular treatment: 7 daytime scenarios (7:00 am-5:00 pm) and four night time cases (5:01 pm- 6:59 am). Participants provided their treatment approach assuming (A) there were no practice constraints and (B) under their current local resources. Endovascular treatment decisions in the 11 scenarios were analyzed according to presentation time with adjustment for patient and physician characteristics. RESULTS: Participants selected endovascular therapy in 74.2% under assumed ideal conditions, and 70.7% under their current local resources of night time scenarios, and in 67.2% and 63.8% of daytime scenarios. Night time presentation did not increase the probability of a treatment decision against endovascular therapy under current local resources or assumed ideal conditions. CONCLUSION: Presentation time did not influence endovascular treatment decision making in stroke patients in this international survey.

Endovascular treatment decision in acute stroke: does physician gender matter? Insights from UNMASK EVT, an international, multidisciplinary survey.

BACKGROUND AND PURPOSE: Differences in the treatment practice of female and male physicians have been shown in several medical subspecialties. It is currently not known whether this also applies to endovascular stroke treatment. The purpose of this study was to explore whether there are differences in endovascular treatment decisions made by female and male stroke physicians and neurointerventionalists. METHODS: In an international survey, stroke physicians and neurointerventionalists were randomly assigned 10 case scenarios and asked how they would treat the patient: (A) assuming there were no external constraints and (B) given their local working conditions. Descriptive statistics were used to describe baseline demographics, and the adjusted OR for physician gender as a predictor of endovascular treatment decision was calculated using logistic regression. RESULTS: 607 physicians (97 women, 508 men, 2 who did not wish to declare) participated in this survey. Physician gender was neither a significant predictor for endovascular treatment decision under assumed ideal conditions (endovascular therapy was favored by 77.0% of female and 79.3% of male physicians, adjusted OR 1.03, P=0.806) nor under current local resources (endovascular therapy was favored by 69.1% of female and 76.9% of male physicians, adjusted OR 1.03, P=0.814). CONCLUSION: Endovascular therapy decision making between male and female physicians did not differ under assumed ideal conditions or under current local resources.

Usefulness of high-resolution three-dimensional proton density-weighted turbo spin-echo MRI in distinguishing a junctional dilatation from an intracranial aneurysm of the posterior communicating artery: a pilot study.

BACKGROUND: Discriminating a junctional dilatation from a true saccular aneurysm is clinically important. PURPOSE: To evaluate the usefulness of high-resolution three-dimensional proton density-weighted turbo spin-echo magnetic resonance imaging (PD MRI) in distinguishing a junctional dilatation from an aneurysm of the posterior communicating artery (PcomA). METHODS: Eighty-two consecutive patients with 83 PcomA lesions, which were evaluated by time-of-flight (TOF) MR angiography (MRA), PD MRI, and digital subtraction angiography (DSA), were enrolled. These radiologic data were retrospectively and independently reviewed by two neurosurgeons, and each diagnosis based on TOF MRA, PD MRI, and DSA was compared. The diagnostic efficacy (interobserver agreement, intermodality agreement, and diagnostic performance) of PD MRI was compared with that of TOF MRA. RESULTS: PD MRI showed higher AC1 (Gwet's agreement coefficient, PD MRI: 0.8942, 95% CI 0.8204 to 0.968; TOF MRA: 0.7185, 95% CI 0.5753 to 0.8617) and prevalence-adjusted bias-adjusted kappa coefficient (PABAK) (PD MRI: 0.8554, TOF MRA: 0.5904) than TOF MRA for interobserver agreement. For intermodality agreement, PD MRI also showed higher AC1 (PD MRI: 0.9069, 95% CI 0.8374 to 0.9764; TOF MRA: 0.7983, 95% CI 0.6969 to 0.8996) and PABAK (PD MRI: 0.8735, TOF MRA: 0.7289) than TOF MRA. The diagnostic performance of PD MRI was statistically superior to that of TOF MRA in sensitivity, specificity, positive predictive value, and negative predictive value. CONCLUSIONS: PD MRI could provide excellent diagnostic accuracy and better information in distinguishing a junctional dilatation from a true saccular aneurysm of the PcomA compared with TOF MRA.

Significance of angiographic clot meniscus sign in mechanical thrombectomy of basilar artery stroke.

INTRODUCTION: The relationship between the occlusive clot morphology and the efficacy of mechanical thrombectomy (MT) in basilar artery occlusion (BAO) is not well known. Our aim was to evaluate the clinical significance of the clot meniscus sign in patients with acute BAO. METHODS: 89 patients with acute BAO who underwent MT were retrospectively analyzed. The clot meniscus sign was defined as meniscoid/tram-track like antegrade side-wall contrast opacification of the thrombus. Patients were assigned to two groups based on the presence of the clot meniscus sign. The treatment and clinical outcomes were compared. RESULTS: The clot meniscus sign was diagnosed in 62.9% (53/89) of the patients. The meniscus sign (+) group showed a shorter procedure time (55 vs 85 min; p=0.045), higher rate of successful recanalization (89.3% vs 63.6%, p=0.004), higher incidence of first pass effect (32.1% vs 6.1%, p=0.004), and lower number of passes (2 vs 3; p=0.042) when compared with the meniscus sign (-) group. The procedure time (OR 0.972, 95% CI 0.962 to 0.992; p=0.003) and clot meniscus sign (OR 7.920, 95% CI 1.769 to 35.452; p=0.007) were independent predictors of successful recanalization. CONCLUSION: The clot meniscus sign is related to high first pass effect and short procedure time and is a reliable predictor of successful recanalization in patients with acute BAO.

Effects of first pass recanalization on outcomes of contact aspiration thrombectomy.

BACKGROUND: First pass recanalization (FPR, defined as achieving a modified Thrombolysis in Cerebral Ischemia (mTICI) grade 2c/3 with a single pass of a thrombectomy device) effect has not yet been evaluated in contact aspiration thrombectomy (CAT). We evaluated FPR effect on clinical outcomes and FPR predictors in CAT. METHODS: All consecutive patients who underwent frontline CAT for anterior circulation large vessel occlusion with recanalization (mTICI 2b-3) were identified from registries at six stroke centers. The patients were dichotomized into FPR and non-FPR groups. Clinical features and outcomes were compared between the groups. Multivariate analyses were performed to determine whether FPR was independently associated with clinical outcomes and to identify predictors of FPR. RESULTS: Of the 429 patients who underwent frontline CAT, recanalization was successful in 344 patients (80.2%; mean age 68.7±11.0 years; M:F ratio 179:165). The FPR group had a higher rate of good outcome (modified Rankin Scale score 0-2) than the non-FPR group. Furthermore, the good outcome rate was higher in the FPR group than in patients who achieved mTICI 2c/3 with multiple passes or rescue treatment. FPR (OR 2.587; 95% CI 1.237 to 5.413) remained independently associated with good outcomes, in addition to age, baseline National Institute Health Stroke Scale, and coronary artery disease. The use of a balloon guide catheter (OR 3.071; 95% CI 1.699 to 5.550) was the only predictor of FPR. CONCLUSIONS: Patients in the FPR group had better clinical outcomes than the non-FPR group in CAT. FPR was independently associated with a good outcome. The use of a balloon guide catheter was the only predictor of FPR.

Coil-Protected Technique for Liquid Embolization in Neurovascular Malformations.

OBJECTIVE: To evaluate the safety and efficacy of the coil-protected technique for liquid embolization in neurovascular malformations. MATERIALS AND METHODS: Twenty-two patients who underwent coil-protected liquid embolization for symptomatic cranial (n = 13) and spinal (n = 9) arteriovenous fistula (AVF) or arteriovenous malformations (AVMs) were identified. A total of 36 target feeder vessels were embolized with N-butyl cyanoacrylate and/or Onyx (Medtronic). This technique was used to promote delivery of a sufficient amount of liquid embolic agent into the target shunt or nidus in cases where tortuous feeding arteries preclude a microcatheter wedging techniqu and/or to prevent reflux of the liquid embolic agent in cases with a short safety margin. The procedure was considered technically successful if the target lesion was sufficiently filled with liquid embolic agent without unintentional reflux. Angiographic and clinical outcomes were retrospectively evaluated. RESULTS: Technical success was achieved for all 36 target feeders. Post-embolization angiographies revealed complete occlusion in 16 patients and near-complete and partial occlusion in three patients each. There were no treatment-related complications. Of the six patients who showed near-complete or partial occlusion, five received additional treatments: two received stereotactic radiosurgery for cerebral AVM, two underwent surgical removal of cerebral AVM, and one underwent additional embolization by direct puncture for a mandibular AVM. Finally, all patients showed complete (n = 19) or near-complete (n = 3) occlusion of the target AVF or AVM on follow-up angiographies. The presenting neurological symptoms improved completely in 15 patients (68.2%) and partially in seven patients (31.8%). CONCLUSION: The coil-protected technique is a safe and effective method for liquid embolization, especially in patients with various neurovascular shunts or malformations who could not be successfully treated with conventional techniques.