Correlation between pretreatment and follow-up infarct volume using CT perfusion imaging: the Bayesian versus singular value decomposition method.

PURPOSE: Pretreatment ischemic core volume is conceptually equal to follow-up infarct volume (FIV) in patients with successful recanalization. However, there is sometimes an absolute volume difference (AD) between pretreatment core volume and FIV. The aim was to compare the AD values between the Bayesian and the singular value decomposition (SVD) methods with time from onset-to-imaging in acute ischemic stroke (AIS) patients undergoing mechanical thrombectomy. METHODS: Consecutive AIS patients were included if they had the following: (1) anterior large vessel occlusion (internal carotid or middle cerebral artery); (2) within 24 h of onset; (3) pretreatment CT perfusion (CTP); (4) successful recanalization (mTICI ≥ 2b); and (5) 24-h diffusion-weighted imaging (DWI). FIV was measured on 24-h DWI. The AD value between FIV and the pretreatment core volume was calculated for Bayesian and SVD methods. Spearman's rank correlation coefficient (rho) was calculated as appropriate. RESULTS: In the 47 patients enrolled (25 men; median age 78 years; median baseline National Institutes of Health Stroke Scale, 22), the median time from onset-to-imaging and onset-to-recanalization was 136 and 220 min, respectively. Shorter onset-to-imaging time was correlated with a larger AD value, and more trend was seen in the SVD method (rho = - 0.28, p = 0.05) compared with the Bayesian method (rho = - 0.08). A larger pretreatment core volume was correlated with a larger AD value, and this tendency was slightly stronger for the SVD (rho = 0.63, p < 0.01) than for the Bayesian (rho = 0.32, p = 0.03) method. CONCLUSIONS: The Bayesian method might be more correlated with FIV than the SVD method in patients with a large ischemic lesion immediately after stroke onset, but not perfect.

Improving Acute In-Hospital Stroke Care by Reorganization of an In-Hospital Stroke Code Protocol.

BACKGROUND AND PURPOSE: Delays in recognition and assessment of in-hospital strokes (IHS) can lead to poor outcomes. The aim was to examine whether reorganized IHS code protocol can reduce treatment time. METHODS: IHS code protocol was developed, educational workshops were held for medical personnel. In the protocol, any medical personnel should directly consult a stroke neurologist before any diagnostic studies. Time intervals were compared between the pre- and post-implementation periods and between direct consultation with a stroke neurologist (DC group) and non-DC group in the post-implementation period. RESULTS: A total of 145 patients were included (pre, 42; post, 103). Time from recognition to stroke neurologist assessment (91 vs. 35 min, p = 0.002) and time from recognition to neuroimaging (123 vs. 74, p = 0.013) were significantly lower in the post-implementation period. Time from stroke neurologist assessment to groin puncture was significantly lower (135 vs. 81, p = 0.037). In the post-implementation period, DC group showed significant time savings from last known well (LKW) to recognition (93 vs. 260, p = 0.001), LKW to stroke neurologist assessment (145 vs. 378, p = 0.001), and recognition to stroke neurologist assessment (16 vs. 76, p < 0.001) compared with non-DC group. CONCLUSIONS: Reorganization of IHS code protocol reduced time from stroke recognition to assessment and treatment time. Reorganized IHS code and direct consultation with a stroke neurologist improved the initial response time.

Tokyo Metropolitan Stroke Emergency Medical Services for Interventional Stroke Treatment: The Tama-REgistry of Acute Thrombectomy (TREAT) Study.

OBJECTIVE: It is not clear how patients with large vessel occlusion (LVO) who have undergone mechanical thrombectomy (MT) were transported to hospitals by emergency medical services. Here, we describe the current status of the stroke delivery system in a large city. METHODS: We investigated data from 328 patients (male, n = 199; average age, 74.8 ± 12.9 years) who underwent MT at 12 facilities in the Tama area of Tokyo, between January 2015 and December 2017. The patients were classified according to the destination institution as Stroke A eligible (group A, n = 266 [8.2%]), Tertiary critical care center (group T; n = 35 [10.7%]), and other destinations such as emergency rooms (group O; n = 27 [8.2%]), and then reasons for using Emergency Medical Service (EMS) services and outcomes were compared among the groups. RESULTS: Rates of milder stroke, and middle cerebral artery occlusion were significantly higher in group A than T, whereas that of vertebral-basilar artery occlusion was significantly lower in group A than in groups T and O. The amount of elapsed time from door to picture (DTP) was significantly lower in group A. The time from onset to recanalization, as well as rates of successful recanalization and favorable outcomes (90-day modified Rankin scale 0-2) did not significantly differ regardless of destination. CONCLUSIONS: Most patients with LVO in the Tama area were categorized into group A. DTP was significantly lower in group A.

Widening Time Disparities between Two Paradigms: Tama-REgistry of Acute Endovascular Thrombectomy.

BACKGROUND: The Tama-REgistry of Acute endovascular Thrombectomy (TREAT) is a multicenter registry of endovascular thrombectomy in the Tama area of Tokyo. The objective of this study was to confirm the real-world status of 2 paradigms of transportation. METHODS: This was a retrospective analysis of data from TREAT. Patients were divided into 2 groups and 2 periods: directly admitted to an endovascular thrombectomy-capable center (ECC; group D)/secondary transfer from a non-ECC (group S), and the first period/the second period. Transfer distance, workflow metrics, and clinical outcomes were analyzed. RESULTS: A total of 326 patients, including 264 in group D and 62 in group S, were analyzed. The median distance from the onset-to-ECC was 3.62km for group D and 7.87km for group S (P < .001). The median onset-to-needle (OTN) time was longer for group S (168 minutes) than group D (138 minutes; P = .006). The median onset-to-reperfusion (OTR) time was significantly shorter for group D (247 minutes) than for group S (304 minutes; P = .029). With respect to the 2 periods, there was no significant difference in onset-to-puncture time between the 2 groups in the first period (207 minutes versus 243.5 minutes, respectively, P = .50), while there was one in the second period (164 minutes versus 246.5 minutes, respectively, P = .02). CONCLUSIONS: This region-wide registry study showed longer OTN and OTR times, with no improvement of the time course over time in patients transported via non-ECCs. These results should be used to create a regional medical policy for the management of acute ischemic stroke.

Subcutaneous Heparin Therapy for Patients with Cancer-Associated Stroke.

BACKGROUND: Anticoagulation therapy, particularly subcutaneous heparin therapy, is recommended for cancer-associated thrombosis. However, not starting or discontinuing anticoagulation was not rare. The aim of the present study was to examine the practical issues related to anticoagulation therapy and effects of subcutaneous heparin therapy for cancer-associated stroke. METHODS: Patients with cancer-associated stroke in our stroke center between October 2014 and August 2017 who were diagnosed as having acute ischemic stroke based on diffusion-weighted imaging were retrospectively enrolled. Baseline clinical characteristics, heparin injection, reasons for no subcutaneous heparin therapy, and clinical outcomes were collected. RESULTS: A total of 59 patients with cancer-associated stroke (75 ± 10 years old, male 42%) were enrolled. Lung cancer was the most frequently observed cancer (n = 17, 29%), followed by gastric cancer (n = 8, 14%) and pancreatic cancer (n = 8, 14%). Of the 19 patients (32%) who underwent subcutaneous heparin therapy, it was discontinued in 9 (47%), mainly because of patients' medical conditions (deterioration of cancer or hemorrhagic complication). Ten patients with long-term subcutaneous heparin therapy did not have stroke recurrence. In contrast, among nine patients who discontinued subcutaneous heparin therapy, three (33%) had recurrence of ischemic stroke. Of the 40 patients without subcutaneous heparin therapy, the main reasons for no subcutaneous heparin therapy were the patients' medical conditions (n = 22, 55%). CONCLUSIONS: Although subcutaneous heparin therapy was given to only one third of cancer-associated stroke patients, long-term subcutaneous heparin therapy might prevent recurrence of cancer-associated stroke.

Thrombectomy for Stroke at 6-24 hours without Perfusion CT Software for Patient Selection.

BACKGROUND: Although, thrombectomy for stroke more than 6 hours after onset supported by automated perfusion computed tomography (CT) software (RAPID, iSchemaView) is effective, this software is not available in Japan. This study aimed to elucidate the efficacy of thrombectomy 6-24 hours after onset in our patient cohort using conventional imaging mismatch. METHODS: Of 586 ischemic stroke patients who underwent thrombectomy registered from January 2015 to December 2017, patients with occlusion of the intracranial internal carotid artery or middle cerebral artery, who had last been known to be well 6-24 hours earlier and who had a prestroke modified Rankin scale (mRS) score 0 or 1 were enrolled. Clinical outcomes were the scores of the utility-weighted (UW) mRS, which ranges from 0 (death) to 10 (no symptom or disability), and the rate of functional independence (mRS score of 0-2) at 90 days. RESULTS: This study sample included 31 patients. The median baseline National Institutes of Health Stroke Scale score was 17 (interquartile range [IQR], 13-20), and the median Diffusion-Weighted Imaging-Alberta Stroke Program Early CT Score was 7 (IQR, 5-8). The median interval between the time that the patient was last known well and revascularization was 741 (IQR, 641-818) minutes. The mean UW mRS score at 90 days was 5.3, the rate of functional independence was 32%, and the 90-day mortality rate was 13%. CONCLUSIONS: Thrombectomy 6-24 hours after onset which can be performed with conventional imaging mismatch might be secured for improving functional independence in stroke patients.

Onset to Reperfusion Time Was Not Important in Mechanical Thrombectomy for Elderly Patients: A Retrospective Multicenter Study in Tama Area, Tokyo.

BACKGROUND: Mechanical thrombectomy (MT) has become the standard of care for acute ischemic stroke with large vessel occlusion; however, evidence remains insufficient for MT for elderly patients, especially with respect to factors affecting their outcomes. METHODS: This study was a retrospective analysis of a multicenter registry of MT, called Tama Registry of Acute Endovascular Thrombectomy. Patients were divided by their age into 2 groups: Nonelderly (NE; < 80) and elderly (E; ≥80). Factors related to a good outcome (modified Rankin scale score ≤2) were examined in each group. Onset to reperfusion time (OTR) was stratified into 4 categories: category 1, 0 - ≤180 min; category 2, > 180 - ≤360 min; category 3, > 360 min or onset time not identified; and category 4, effective recanalization not achievable. RESULTS: 143 NE patients and 78 E patients were included in this study. The E group had less chance of achieving a good outcome (NE group 51%, E group 35%; p = 0.024). In the NE group, lower OTR category was an independent prognostic factor for good outcome (p = 0.037, OR = 1.09). However, in the E group, OTR category was not a significant predictor on multivariate analysis. Instead, effective recanalization (p = 0.0081, OR 1.40) and lower National Institute of Health Stroke Scale score at presentation (p = 0.0032, OR 1.02) were the independent predictors. CONCLUSIONS: In MT for elderly patients, effective recanalization improved the patients' outcome but OTR affected less. Further studies are warranted to establish the appropriate patient selection and treatment strategies.

Predictable Value of Functional Independence Measure Differs between Anterior and Posterior Circulation Ischemic Strokes.

BACKGROUND: The functional independence measure (FIM) is a standard tool to provide a detailed evaluation of ADL of patients with disabilities. This study aimed to show the differences in FIM scores as an outcome predictor between patients with anterior circulation (AC) and posterior circulation (PC) strokes. METHODS: Consecutive patients with acute ischemic stroke hospitalized within 7 days after onset were investigated. Baseline NIHSS scores, 1st-FIM (< 72 h after -admission to stroke unit), 2nd-FIM (< 72 h before discharge), and modified Rankin Scale (mRS) scores were collected. Logistic regression analyses were used to identify predictors of a favorable outcome (mRS 0-2) at 3-month after stroke. RESULTS: Three hundred eighty-five patients (median age, 78 years; male, 59%; median length of stroke unit stay, 20 days) were included. The median baseline NIHSS, 1st- and 2nd-FIM scores were 4 (interquartile range 2-9), 65 (33-91), and 98 (54-122) respectively. Baseline NIHSS (3 vs. 4, p = 0.01) and mRS score at 3-month (1 vs. 2, p = 0.01) were lower, and 1st-FIM (75 vs. 64, p < 0.01) and 2nd-FIM (113 vs. 95, p = 0.01) were higher in 82 patients with PC than 303 patients with AC strokes. On multivariate logistic regression analysis, 2nd-FIM score was an independent predictor of favorable outcomes in both PC (OR 1.18, 95% CI 1.04-1.48, p < 0.01) and AC (OR 1.12, 95% CI 1.06-1.20, p < 0.01) strokes. The optimal cutoff scores of 2nd-FIM for predicting favorable outcome were 104 for PC (sensitivity 0.82, specificity 0.88) and 93 for AC (0.88-0.90) strokes. CONCLUSIONS: The differences in outcome predictability by FIM score between AC and PC strokes should be considered, although FIM scores at discharge from stroke unit were useful to predict a favorable outcome.

Regionwide Retrospective Survey of Acute Mechanical Thrombectomy in Tama, Suburban Tokyo: A Preliminary Report.

BACKGROUND AND PURPOSE: To improve results of acute thrombectomy, the time from stroke onset to efficient recanalization must be minimized. Studies have confirmed the importance of rapid treatment, workflow, and efficient team-based care for acute thrombectomy in large vessel occlusion. This study examined the challenges facing mechanical thrombectomy in the Tama area (population, 4.3 million), a densely populated urban area of Tokyo, Japan, and analyzed retrospective data from the Tama-REgistry of Acute endovascular Thrombectomy. METHODS: This study was a retrospective observational study using data from Tama-REgistry of Acute endovascular Thrombectomy, a multicenter registry of mechanical thrombectomy for acute ischemic stroke in the Tama area of Tokyo. The survey covered 396 patients with large vessel occlusion who underwent acute thrombectomy between January 2015 and March 2017. Participating facilities are 12 of the 13 recanalization therapy-capable stroke centers. RESULTS: We analyzed 326 cases for which modified Rankin Scale score at 90days was available, of which 264 cases were directly admitted, and 62 cases were transferred from other stroke centers. Median time from stroke onset to hospital arrival was 111 minutes, and from arrival to efficient recanalization was 135 minutes. Efficient recanalization was achieved in 257 cases (78.8%), symptomatic hemorrhage developed in 19 cases (5.8%), and modified Rankin Scale 0-2 at 90days was seen in 129 cases (39.6%). The vast majority of patients (n = 299, 94.3%) were transferred within 10km to the enrolling hospital. CONCLUSIONS: These results provide useful information about the emergent transfer system for patients with large vessel occlusion in a densely populated urban area.

Reconstructive endovascular treatment of ruptured vertebral artery dissection involving the posterior inferior cerebellar artery.

Two cases with ruptured vertebral artery (VA) dissection involving the origin of the posterior inferior cerebellar artery (PICA) are presented. Endovascular proximal occlusion of the dissected segment proximal to the PICA origin was performed, leaving the PICA patent in the acute stage. Stent placement from the PICA to the VA through the contralateral VA and coil embolization were added to the residual dissection in the chronic stage. Rebleedings were not observed. This is the first report of a staged, combined strategy for the treatment of a ruptured PICA involving VA dissection, which enabled preservation of the PICA without bypass surgery.

Effective Education Materials to Advance Stroke Awareness Without Teacher Participation in Junior High School Students.

BACKGROUND: Youth stroke education is promising for the spread of stroke awareness. The aim of this study was to examine whether our stroke awareness teaching materials without teacher's participation can increase student awareness to act fast on suspected stroke signs. METHODS: We used the face, arm, speech, and time (FAST) mnemonic derived from the Cincinnati Prehospital Stroke Scale. Seventy-three students of the second grade and 72 students of the third grade (age range, 13-15 years) in a junior high school were enrolled in the study. The students were divided into 2 groups: students who received a teacher's lesson (group I) and those who did not receive a teacher's lesson (group II). Students in group II watched an animated cartoon and read a Manga comic in class. All students took the educational aids home, including the Manga comic and magnetic posters printed with the FAST message. Questionnaires on stroke knowledge were examined at baseline and immediately and 3 months after receiving the intervention. RESULTS: At 3 months after the intervention, a significant improvement in understanding the FAST message was confirmed in both the groups (group I, 85%; group II, 94%). Significant increases in the knowledge of risk factors were not observed in each group. CONCLUSIONS: Our education materials include a Manga comic, an animated cartoon, and a magnetic poster, without an accompanying teacher's lesson can increase stroke awareness, including the FAST message, in junior high school students.

Stroke education using an animated cartoon and a manga for junior high school students.

BACKGROUND: We investigated whether junior high school students could be educated regarding stroke with an animated cartoon and a Manga that we produced for the purpose of dissemination of this knowledge. METHODS: We produced a 10-minute animated cartoon and a Manga that provided information regarding stroke risk factors, stroke signs and symptoms, and awareness to immediately contact emergent medical service (EMS) on identification of stroke signs and symptoms. From December 2011 to March 2012, 493 students in 15 classes of the first grade (age 12-13 years) of 3 junior high schools were enrolled in the study. Each subject watched the animated cartoon and read the Manga; this was referred to as "training." Lessons about stroke were not given. Questionnaires on stroke knowledge were evaluated at baseline, immediately after the training, and 3 months after the training. RESULTS: The proportion of correct answers given immediately after the training was higher for all questions, except those related to arrhythmia, compared with baseline. Percentage of correct answers given at 3 months was higher than that at baseline in questions related to facial palsy (75% versus 33%), speech disturbance (91% versus 60%), hemiplegia (79% versus 52%), numbness of 1 side (58% versus 51%), calling for EMS (90% versus 85%), alcohol intake (96% versus 72%), and smoking (69% versus 54%). At 3 months after the training, 56% of students answered the FAST (facial droop, arm weakness, speech disturbance, time to call for EMS) mnemonic correctly. CONCLUSIONS: Stroke education using these teaching aids of the animated cartoon and the Manga improved stroke knowledge in junior high school students.

Stroke education program of act FAST for junior high school students and their parents.

BACKGROUND: We produced a stroke education program using the FAST (facial droop, arm weakness, speech disturbance, time to call an ambulance) mnemonic. AIMS: The aim of this study is to examine efficacy of our education program for junior high school students and their parents. METHODS: One hundred ninety students of 3 junior high schools (aged 12-13 years) and their parents were enrolled. Students received a 45-minute lesson of stroke enlightenment using the FAST mnemonic. Enlightenment items, such as a magnet poster, were distributed. Parents were educated indirectly from their child. Surveys of stroke knowledge were examined at baseline, immediately after the lesson, and at 3 months after the lesson. RESULTS: For the students, correct answers at 3 months were significantly higher than those at baseline in questions of facial palsy (98% versus 33%), speech disturbance (98% versus 54%), numbness on one side (64% versus 42%), weakness on one side (80% versus 51%), calling an ambulance (88% versus 60%), alcohol drinking (85% versus 65%), smoking (70% versus 43%), dyslipidemia (58% versus 46%), hyperglycemia (59% versus 48%), and obesity (47% versus 23%). At 3 months, the parents answered more correctly questions of facial palsy (93% versus 66%), calling an ambulance (95% versus 88%), and alcohol drinking (65% versus 51%) than at baseline. At 3 months, 96% of students and 78% of parents answered the FAST mnemonic correctly. CONCLUSIONS: Our stroke education program improved stroke knowledge, especially the FAST message, for junior high school students and their parents.

The effectiveness of a stroke educational activity performed by a schoolteacher for junior high school students.

BACKGROUND: The purpose of this study was to determine whether our stroke education system can help junior high school students acquire stroke knowledge when performed by a schoolteacher. METHODS: A stroke neurologist gave a stroke lesson to 25 students (S group) and a schoolteacher through our stroke education system. After instruction, the schoolteacher performed the same lesson using the same education system to another 75 students (T group). Questionnaires on stroke knowledge were examined at baseline, immediately after the lesson (IL), and at 3 months after the lesson (3M). We analyzed the results of stroke knowledge assessment by linear mixed effects models adjusted for gender and class difference using the student number. RESULTS: We assessed 24 students in the S group and 72 students in the T group. There were no significant differences in the changes of predicted scores of symptoms and risk factors adjusted for gender, class difference, and each student knowledge level until 3M between the 2 groups. Correct answer rates for the meaning of the FAST (facial droop, arm weakness, speech disturbance, time to call 119) at IL were 92% in the S group and 72% in the T group, respectively. At 3M, they were 83% in the S group and 84% in the T group. The correct answer rates of FAST at 3M were not significantly different adjusted for group, gender, class difference, and correct answer rate at IL. CONCLUSIONS: A schoolteacher can conduct the FAST message lesson to junior high school students with a similar outcome as a stroke neurologist using our stroke education system.

Effects of stroke education using an animated cartoon and a manga on elementary school children.

BACKGROUND: Stroke education for the youth is expected to reduce prehospital delay by informing the bystander of appropriate action to take and providing knowledge to prevent onset of stroke in future. Previously, we developed effective teaching materials consisting of an animated cartoon and a Manga for junior high school students. The aim of this study was to evaluate the feasibility and effectiveness of our educational materials for stroke education taught by schoolteachers to elementary school children. METHODS: Using our teaching materials, a 30-minute lesson was given by trained general schoolteachers. Questionnaires on stroke knowledge (symptoms and risk factors) and action to take on identification of suspected stroke symptoms were filled out by school children before, immediately after, and at 3 months after completion of the lesson. RESULTS: A total of 219 children (aged 10 or 11 years) received the stroke lesson. Stroke knowledge significantly increased immediately after the lesson compared with before (symptoms, P < .001; risk factors, P < .001); however, correct answer rates decreased at 3 months immediately after completion of the lesson (symptoms, P = .002; risk factors, P = .045). The proportion of the number of children calling emergency medical service on identifying stroke symptoms was higher immediately after the lesson than baseline (P = .007) but returned to the baseline at 3 months after the lesson. CONCLUSIONS: Stroke lesson by schoolteachers using our teaching materials consisting of an animated cartoon and a Manga that was previously used for junior high school students was feasible for elementary school children. However, revision of the materials is required for better retention of stroke knowledge for children.

Acute Stroke Caused by Progressive Intracranial Artery Stenosis Due to Varicella Zoster Virus Vasculopathy after Chemotherapy for Malignant Lymphoma.

Decreased cell-mediated immunity can reactivate Varicella zoster virus (VZV), which can lead to various neurological complications, including vasculopathy. We herein report the case of a patient with acute stroke with progressive internal carotid artery stenosis due to VZV vasculopathy after chemotherapy for malignant lymphoma. Treatment for VZV vasculopathy improved the stenosis and prevented recurrent stroke. VZV vasculopathy is an important treatable cause of stroke in immunosuppressed patients.

[A case of bilateral medial medullary and left tegmentum of pontine infarction in whom DSA-MR fusion imaging identified infarct-relevant arteries].

We herein reported a patient with acute ischemic stroke in the bilateral medial medullary and the left tegmentum of the pons who presented with various neurological symptoms. Fusing digital subtraction angiography (DSA) and MRI (DSA-MR fusion imaging) could reveal the infarct-relevant arteries. A 41-year-old male presented with headache, bilateral arm's dysesthesia, quadriplegia, left Horner's syndrome, upbeat nystagmus, internuclear ophthalmoplegia and left peripheral facial paralysis. Diffusion weighted MRI (DWI) revealed the high intensity lesion in the bilateral medial medullary and the left tegmentum of the pons. MRA showed right vertebral artery (VA) occlusion. A high intensity on T1 weighted imaging was shown on the right VA vessel wall. DSA-MR fusion imaging revealed the anterior spinal artery (ASA) occlusion proximal to the infarction. The stenosis was located at the origin of the right VA perforating branch distributing into the infarct lesion. The steno-occlusive lesion of ASA and VA perforating branch due to VA dissection resulted in infarction in the pontomedullary junction and caused various neurological symptoms. DSA-MR fusion imaging would prove the radiological anatomy of infarct-relevant arteries and clarify the etiology of ischemic stroke.

Predictors of intracranial hemorrhage in acute ischemic stroke after endovascular thrombectomy.

BACKGROUND: Limited data are available regarding the predictors, clinical relevance, and bleeding rate by surgical devices of intracranial hemorrhage after endovascular thrombectomy. This is partially explained by the difference in the classification and definition of hemorrhage among studies. The purpose of this study was to identify the predictors of hemorrhagic transformation and isolated subarachnoid hemorrhage after endovascular thrombectomy. METHODS: This was a retrospective, multicenter observational cohort study of consecutive patients who underwent endovascular thrombectomy between January 2015 and December 2018. Univariate and logistic regression analyses were performed to determine the predictors, the impact on clinical outcomes, and the bleeding rate by surgical devices of hemorrhagic transformation and isolated subarachnoid hemorrhage. RESULTS: Among 610 eligible patients, hemorrhagic transformations occurred in 93 (15.2%). Fourteen patients (2.3%) were classified as having symptomatic intracranial hemorrhage. Isolated subarachnoid hemorrhage was found in 60 (9.8%) patients. In the logistic regression analyses, diabetes mellitus (odds ratio: 1.92; 95% confidence interval: 1.06-3.49) was associated with hemorrhagic transformation, and the number of device passes (odds ratio: 1.33; 95% confidence interval: 1.11-1.59) was associated with isolated subarachnoid hemorrhage. Both hemorrhagic transformation and isolated subarachnoid hemorrhage were associated with poor 90-day functional outcomes. There was a significant correlation between treatment with stent retrievers and isolated subarachnoid hemorrhage. CONCLUSIONS: Patients with diabetes mellitus were vulnerable to hemorrhagic transformation, whereas those who underwent several attempts of thrombectomy were susceptible to isolated subarachnoid hemorrhage. Both hemorrhage types worsened the functional outcome. Treatment with the stent retriever was significantly associated with postprocedural isolated subarachnoid hemorrhage.

Efficacy and Safety of Mechanical Thrombectomy for Occlusion of the Second Segment of the Middle Cerebral Artery : Retrospective Analysis of the Tama-REgistry of Acute endovascular Thrombectomy (TREAT).

BACKGROUND: The efficacy of mechanical thrombectomy in the treatment of occlusions of the second segment of the middle cerebral artery (M2) has not been firmly established. METHODS: This study analyzed data from patients who had undergone mechanical thrombectomy for the first segment of the middle cerebral artery (M1) and M2 occlusion from the Tama-REgistry of Acute endovascular Thrombectomy (TREAT) between January 2015 and March 2017, which is a multicenter database in the Tama area of Tokyo, Japan. The M1 and M2 occlusions were compared in order to evaluate the safety and efficacy of M2 thrombectomy. RESULTS: A total of 515 patients were registered, whereby 160 patients with M1 occlusion and 51 patients with M2 occlusion were included. While the puncture-to-reperfusion time was longer in the M2 occlusions (median 43 min, range 30-61 min vs. median 60 min, range 38-79 min, p = 0.01), no significant differences were seen in the proportion of patients with successful reperfusion, postoperative hemorrhagic complications and good outcome (modified Rankin scale ≤2 at 90 days). Younger age was the only independent factor associated with good outcome in patients with M2 occlusions as determined by the multivariate analysis (p = 0.033, odds ratio 0.91, 95% confidence interval 0.83-0.99). CONCLUSION: The outcome and the safety profile of mechanical thrombectomy for M2 occlusions are favorable and comparable to those of the M1 occlusion thrombectomy.

Orbital Arteriovenous Fistula around the Optic Nerve Treated by Transvenous Embolization.

Intraorbital arteriovenous fistula (AVF) is a very rare disease; therefore an optimal treatment strategy has not yet been established. Here we describe the use of high-resolution cone-beam computed tomography (CBCT) and selective angiography to visualize the detailed anatomy of orbital vessels. The information provided by the intraoperative imaging led to a change in treatment strategy and eventually to successful transvenous coil embolization. A 55-year-old man presented with a 4 months history of right exophthalmos, chemosis and diplopia. Magnetic resonance (MR) imaging demonstrated a dilated superior orbital vein. Cerebral angiography showed an intraorbital AVF fed by the branch of the ophthalmic artery and drainage to the superior orbital vein (SOV) and inferior orbital vein (IOV). Superselective angiography and high-resolution CBCT with diluted contrast medium clarified that feeders of the AVF came from the first segment of the ophthalmic artery, and the shunt located surrounding an optic nerve sheath. Transvenous embolization via IOV with coils occluded the AVF. Detailed analysis of intraorbital vessels using high-resolution CBCT and selective angiography led to successful treatment by transvenous coil embolization.