Comparing Low- or Standard-Dose Alteplase in Endovascular Thrombectomy: Insights From a Nationwide Registry.

BACKGROUND: Timely intravenous thrombolysis and endovascular thrombectomy are the standard reperfusion treatments for large vessel occlusion stroke. Currently, it is unknown whether a low-dose thrombolytic agent (0.6 mg/kg alteplase) can offer similar efficacy to the standard dose (0.9 mg/kg alteplase). METHODS: We enrolled consecutive patients in the multicenter Taiwan Registry of Endovascular Thrombectomy for Acute Ischemic Stroke who had received combined thrombolysis (within 4.5 hours of onset) and thrombectomy treatment from January 2019 to April 2023. The choice of low- or standard-dose alteplase was based on the physician's discretion. The outcomes included successful reperfusion (modified Thrombolysis in Cerebral Infarction score, 2b-3), symptomatic intracerebral hemorrhage, 90-day modified Rankin Scale score, and 90-day mortality. The outcomes between the 2 groups were compared using multivariable logistic regression and inverse probability of treatment weighting-adjusted analysis. RESULTS: Among the 2242 patients in the Taiwan Registry of Endovascular Thrombectomy for Acute Ischemic Stroke, 734 (33%) received intravenous alteplase. Patients in the low-dose group (n=360) were older, had more women, more atrial fibrillation, and longer onset-to-needle time compared with the standard-dose group (n=374). In comparison to low-dose alteplase, standard-dose alteplase was associated with a lower rate of successful reperfusion (81% versus 87%; adjusted odds ratio, 0.63 [95% CI, 0.40-0.98]), a numerically higher incidence of symptomatic intracerebral hemorrhage (6.7% versus 3.9%; adjusted odds ratio, 1.81 [95% CI, 0.88-3.69]), but better 90-day modified Rankin Scale score (functional independence [modified Rankin Scale score, 0-2], 47% versus 31%; adjusted odds ratio, 1.91 [95% CI, 1.28-2.86]), and a numerically lower mortality rate (9% versus 15%; adjusted odds ratio, 0.73 [95% CI, 0.43-1.25]) after adjusting for covariates. Similar results were observed in the inverse probability of treatment weighting-adjusted models. The results were consistent across predefined subgroups and age strata. CONCLUSIONS: Despite the lower rate of successful reperfusion and higher risk of symptomatic intracerebral hemorrhage with standard-dose alteplase, standard-dose alteplase was associated with a better functional outcome in patients receiving combined thrombolysis and thrombectomy.

An optimization model for reducing thrombectomy center rotations while maintaining medical accessibility.

BACKGROUND/PURPOSE: This study addresses the delicate balance between healthcare personnel burnout and medical accessibility in the context of endovascular thrombectomy (EVT) services in urban areas. We aimed to determine the minimum number of hospitals providing EVT on rotation each day without compromising patient access. METHODS: Employing an optimization model, we developed shift schedules based on patient coverage rates and volumes during the pre-pandemic (2016-2018) and pandemic (2019-2021) periods. Starting with a minimum of two hospitals on duty per day, we gradually increased to a maximum of eight. Patient coverage rates, defined as the proportion of patients meeting bypass criteria and transported to rotating hospitals capable of EVT, were the primary outcomes. Sensitivity analyses explored the impact of varying patient transport intervals and accumulating patients over multiple years. RESULTS: Results from 7024 patient records revealed patient coverage rates of 92.5% (standard deviation [SD] 2.8%) during the pre-pandemic and 91.4% (SD 2.8%) during the pandemic, with at least two rotating hospitals daily. No significant differences were observed between schedules based on the highest patient volume and coverage rate months. A patient coverage rate of 98.99% was achieved with four rotating hospitals per day during the pre-pandemic period, with limited improvement beyond this threshold. Changing patient transport intervals and accumulating patients over six years (p = 0.83) had no significant impact on coverage rates. CONCLUSION: Our optimization model supports reducing the number of daily rotating hospitals by half while preserving a balance between patient accessibility and alleviating strain on medical teams.

Diagnostic performance of computed tomography-digital subtraction angiography and conventional magnetic resonance imaging for evaluating the vascularity of osseous spinal tumors.

BACKGROUND AND PURPOSE: Patients with hypervascular spinal tumors may have severe blood loss during tumor resection, which increases the risks of perioperative morbidity and mortality. However, the preoperative evaluation of tumor vascularity may be challenging; moreover, the reliability of the data obtained in conventional preoperative noninvasive imaging is debatable. In this study, we compared conventional magnetic resonance imaging (MRI) and subtraction computed tomography angiography (CTA) in terms of their performance in vascularity evaluation. The catheter digital subtraction angiography (DSA) technique was used as a reference standard. METHODS: This study included 123 consecutive patients with spinal tumor who underwent subtraction CTA, catheter DSA, and subsequent surgery between October 2015 and October 2021. Data regarding qualitative and semiquantitative subtraction CTA parameters and conventional MRI signs were collected for comparison with tumor vascularity graded through catheter DSA. The diagnostic performance of qualitative CTA, quantitative CTA, and conventional MRI in assessing spinal tumor vascularity was analyzed. RESULTS: Qualitative subtraction CTA was the best noninvasive imaging modality in terms of diagnostic performance (area under the receiver operating characteristic curve [AUROC], 0.95). Quantitative CTA was relatively inferior (AUROC, 0.87). MRI results had low reliability (AUROC, 0.51 to 0.59). Intratumoral hemorrhage and prominent foraminal venous plexus were found to be the specific signs for hypervascularity (specificity 93.2%). CONCLUSIONS: Qualitative subtraction CTA offers the highest diagnostic value in evaluating spinal tumor vascularity, compared to quantitative CTA and MRI. Although conventional MRI may not be a reliable approach, certain MRI signs may have high specificity, which may be crucial for assessing spinal tumor vascularity.

Prevalence and clinical features of carotid artery web in patients undergoing endovascular thrombectomy for acute ischemic stroke.

PURPOSE: Carotid artery web (CaW) is a rare focal fibromuscular dysplasia that can lead to embolic strokes with large vessel occlusion. This condition can be effectively treated with endovascular thrombectomy (EVT). Our study aims to assess the prevalence of CaW among patients with acute ischemic stroke (AIS) who underwent EVT and to compare the clinical characteristics of CaW with other carotid artery pathologies. METHODS: We enrolled consecutive patients with AIS who underwent EVT at a single medical center and two regional teaching hospitals in Taiwan from September 2014 to December 2021. We compared CaW with carotid dissection (CaD) and carotid large artery atherosclerosis (CaLAA) in terms of patient demographics and thrombus histological findings. RESULTS: Of the 576 AIS patients who underwent EVT, four (mean age: 50 years) were diagnosed with CaW, resulting in a prevalence of 0.69%. Among these four patients, three experienced successful reperfusion after EVT and achieved functional independence (defined as a modified Rankin Scale score ≤2) three months post-stroke. Importantly, none of the CaW patients suffered a recurrent stroke within one year. Patients with CaW were younger than those with CaD or CaLAA, and exhibited fewer vascular risk factors. Additionally, CaW was associated with distal occlusion sites. The thrombus composition in CaW patients was similar to that in CaD patients. CONCLUSIONS: In conclusion, CaW is a rare finding among Asian patients with carotid artery disease who undergo for AIS. It is more prevalent in younger patients with a limited number of vascular risk factors.

Efficacy of preoperative embolization for metastatic spinal tumor surgery using angiographic vascularity assessment.

OBJECTIVES: Preoperative embolization (PE) for metastatic spinal tumors is a method of minimizing intraoperative blood loss during aggressive surgery. This study specified angiographic standards and investigated the influence of these and other factors on blood loss in patients with spinal metastases and various pathologies. METHODS: The cohort comprised 126 consecutive patients receiving PE from 2015 to 2021. Their clinical, surgical, and angiographic characteristics were reviewed. Standard angiographic grading was used for vascularity assessment. Degree of embolization was divided into complete (≥ 90%), near complete (67 to < 90%), and partial (< 67%). Logistic regression analysis was used to investigate factors predictive of massive blood loss (> 2500 mL). A proportional odds model was used to assess factors predictive of the degree of embolization. RESULTS: Mean intraoperative blood loss was 1676 mL. Among the patients, 62 had hypervascular tumors and 64 had nonhypervascular tumors, according to the angiographic classification. Intraoperative blood loss differed significantly with embolization degree, both overall (p < 0.001) and in the hypervascular and nonhypervascular groups (p = 0.01 and 0.03). Angiographic hypervascularity, spinal metastasis invasiveness index, and embolization degree were significant predictors of massive blood loss in univariate analysis, but only embolization degree was significant in multivariate analysis. Only the presence of the radiculomedullary artery at the target level was significant in both the univariate and multivariate analyses for embolization degree. CONCLUSIONS: In addition to pathological classification, angiographic vascularity assessment is valuable. Although complete embolization is a reasonable goal, it is challenging to achieve in cases of visible radiculomedullary artery. KEY POINTS: • Angiography has a supplementary role in vascularity assessment for spinal metastatic surgery. • Better embolization degree is associated with less intraoperative blood loss in both angiographic hypervascular and nonhypervascular groups. • Presence of radiculomedullary artery in the target level causes worse embolization outcome.

The Extent of Tumor Invasion and Therapeutic Embolization Are Associated with Recurrent Hemorrhage in Patients with External Carotid Artery Blowout Syndrome.

PURPOSE: To explore the optimal strategies of therapeutic embolization for patients with carotid blowout syndrome in the external carotid artery (ECA), who may also present with arterial tumor invasion or necrosis extending to the internal carotid artery (ICA) or common carotid artery (CCA). MATERIALS AND METHODS: The study included 110 patients with ECA blowout between 2005 and 2022. Antecedent cross-sectional imaging features were examined, including tumor size, extent of arterial invasion, and air-containing necrosis. Patients were divided into Groups 1 (n = 53, simultaneous ICA/CCA invasion + ECA therapeutic embolization), 2 (n = 18, simultaneous ICA/CCA invasion + ECA-ICA/CCA therapeutic embolization), and 3 (n = 39, no ICA/CCA invasion + ECA therapeutic embolization). Kaplan-Meier and multivariable Cox regression analyses were performed to evaluate associations of clinical, imaging, and therapeutic embolization characteristics with recurrent bleeding. RESULTS: Multivariable Cox regression revealed that Group 1 was independently associated with a higher risk of recurrent bleeding than that in Group 2 (adjusted hazard ratio, 6.3; 95% CI, 1.7‒23.4; P = .005) and Group 3 (adjusted hazard ratio, 3.8; 95% CI, 1.8‒8.3; P = .001). In the subgroup with simultaneous ICA/CCA invasion, air-containing necrosis around the ICA/CCA was independently associated with recurrent bleeding after therapeutic embolization of the ECA (adjusted hazard ratio, 5.0; 95% CI, 1.8‒13.6; P = .002). CONCLUSIONS: In patients with ECA blowout treated with therapeutic embolization, there was a lower risk of recurrent bleeding when the extents of arterial invasion and therapeutic embolization were concordant. Air-containing necrosis around the ICA/CCA was associated with recurrent bleeding, so extensive therapeutic embolization to the ICA/CCA should be evaluated in such patients.

Air-containing necrosis as the imaging predictor for imminent carotid blowout in patients with head and neck cancer.

BACKGROUND AND PURPOSE: Carotid blowout syndrome (CBS) is a devastating complication of head and neck cancer (HNC). In this study, we describe radiological features that can predict imminent (<6 months) carotid blowout in patients with HNC. METHODS: Cross-sectional CT or MRI were interpreted from 25 treated HNC patients with acute CBS and 50 treated HNC patients without CBS (controls). The tumor size and the distance from the tumor to the carotid trunk was measured. The following imaging findings of the tumor were also recorded: carotid trunk involvement, enhancement pattern, and the presence of air-containing necrosis. The odds ratios of imminent CBS for each imaging finding were estimated using a multivariable logistic regression model. RESULTS: Compared to the controls, the CBS group had larger tumors (49 ± 18 mm vs. 38 ± 18 mm, p = 0.017), tumors closer to the carotid trunk (0.5 ± 1.7 mm vs. 8.2 ± 14.2 mm, p < 0.001), a higher prevalence of 360° involvement (60% vs. 18%, p < 0.001), more heterogeneous enhancement patterns (84% vs. 50% p < 0.001), and more air-containing necrosis (40% vs. 2% p < 0.001). After multivariable adjustment, the presence of air-containing necrosis remained a significant risk factor for imminent CBS (OR: 20.1, 95% CI: 1.98-204.00; p = 0.011). CONCLUSION: The presence of air-containing necrosis is associated with a higher risk of imminent CBS. This characteristic imaging finding should be evaluated in the follow-up CT or MRI of HNC patients for early warning.

Expanding resources of endovascular thrombectomy: An optimization model.

BACKGROUND/PURPOSE: Recently optimized models for selecting the locations of hospitals capable of providing endovascular thrombectomy (EVT) did not consider the accuracy of the prehospital stroke scale assessment and possibility of secondary transport. Our study aimed to propose a new model for selecting existing hospitals with intravenous thrombolysis capability to become EVT-capable hospitals. METHODS: A sequential order was provided to upgrade hospitals providing intravenous thrombolysis, using a mixed integer programming model based on current medical resource allocation. In addition, we drafted a centralized plan to redistribute existing EVT resources by redetermining locations of EVT-capable hospitals. Using historical data of 7679 on-scene patients with suspected stroke, the model was implemented to determine the hospital that maximizes the number of patients receiving EVT treatment within call-to-definitive-treatment time. RESULTS: All suspected stroke patients were sent to EVT-capable hospitals directly under the current medical resource allocation model. After upgrading one additional hospital to become an EVT-capable hospital, the percentage of patients receiving definitive treatment within the standard call-to-definitive-treatment time was elevated from 68.82% to 72.97%. In the model, assuming that there is no hospital providing EVT, all patients suspected of stroke will be sent to EVT-capable hospitals directly after upgrading three or more hospitals to be able to provide treatment. CONCLUSION: All patients eligible for acute stroke treatment are sent to EVT-capable hospitals in the simulation under the current medical resource allocation model. This model can be utilized to provide insights for capacity redistribution in other regions.

Plasma neurofilament light chain level predicts outcomes in stroke patients receiving endovascular thrombectomy.

BACKGROUND: Timely endovascular thrombectomy (EVT) significantly improves outcomes in patients with acute ischemic stroke (AIS) with large vessel occlusion type. However, whether certain central nervous system-specific plasma biomarkers correlate with the outcomes is unknown. We evaluated the temporal changes and prognostic roles of the levels of these biomarkers in patients with AIS undergoing EVT. METHODS: We enrolled 60 patients who received EVT for AIS and 14 controls. The levels of plasma biomarkers, namely neurofilament light chain (NfL), glial fibrillary astrocytic protein (GFAP), tau, and ubiquitin C-terminal hydrolase L1 (UCHL1), were measured with an ultrasensitive single molecule array before, immediately after, and 24 h after EVT (T1, T2, and T3, respectively). The outcomes of interest were death or disability at 90 days (defined as a modified Rankin Scale score of 3-6) and types of hemorrhagic transformation (hemorrhagic infarction or parenchymal hemorrhage). RESULTS: Of the 180 blood samples from the 60 patients who received EVT, the plasma NfL, GFAP, and UCHL1 levels at T1 were significantly higher than those of the controls, and the levels of all four biomarkers were significantly higher at T3. Patients with parenchymal hemorrhage had a significantly higher rate of increase in GFAP (Pinteraction = 0.005) and UCHL1 (Pinteraction = 0.007) levels compared with those without parenchymal hemorrhage. In a multivariable analysis with adjustment for age, sex, National Institute of Health Stroke Scale score, history of atrial fibrillation, and recanalization status, higher NfL levels at T1 (odds ratio [OR] 2.05; 95% confidence interval [CI], 1.03-4.08), T2 (OR, 2.08; 95% CI, 1.05-4.01), and T3 (OR, 3.94; 95% CI, 1.44-10.79) were independent predictors of death or disability at 90 days. CONCLUSION: Among patients with AIS who received EVT, those with hemorrhagic transformation exhibited significant increase in plasma GFAP and UCHL1 levels over time. Higher plasma NfL were predictive of unfavorable functional outcomes.

Angiographic early hyperemia in the middle cerebral artery territory after thrombectomy is associated with favorable clinical outcome in anterior circulation stroke.

OBJECTIVES: Angiographic cortical early hyperemia (EH) is frequently observed after endovascular thrombectomy (EVT) for large vessel occlusion (LVO) stroke. The aim of the study is to investigate the relationship between EH and clinical outcomes. METHODS: Between January 2015 and September 2018, consecutive patients who underwent EVT for anterior circulation LVO stroke with optimal recanalization (modified thrombolysis in cerebral infarction 2b or 3) were included. Angiographic studies after immediate reperfusion were used for analysis for cortical EH sign. Clinical functional outcomes were evaluated with the modified Rankin Scale (mRS) at 90 days. Safety outcomes, including mortality and intracerebral hemorrhage, were assessed. The association of EH between clinical functional and safety outcomes was analyzed. RESULTS: A total of 143 patients were analyzed (mean age: 71 years; median National Institutes of Health Stroke Scale score: 18). A positive EH sign was observed in 88 (62%) patients. Good functional outcome at 90 days was significantly different between the EH+ and EH- groups (p = .0157). Intracerebral hemorrhage and mortality did not differ between groups. In multivariate logistic regression analysis, EH was an independent predictor for good clinical outcome (mRS ≤ 2, odds ratio: 3.49, p = .0034) in addition to young age. CONCLUSION: Results revealed that the presence of EH is associated with better clinical outcome at 90 days, but not associated with increased hemorrhagic complication. These findings with clinically relevant implications require further validation. KEY POINTS: • Angiographic cortical hyperemia is a common finding immediately after endovascular thrombectomy. • Presence of cortical hyperemia is an independent prognostic factor for good clinical outcome. • Hemorrhagic complication is not associated with cortical hyperemia.

External validation of prehospital stroke scales for emergent large vessel occlusion.

BACKGROUND: It is suggested that a prehospital scale should be utilized to identify patients with emergent large vessel occlusion (ELVO). We aimed to perform external validation of nine ELVO scales. METHODS: This single center retrospective observational study included patients with ischemic stroke visiting the emergency department (ED) within 6 h of symptom onset. Participants were excluded if individual items of the National Institute of Health Stroke Scale scores were not recorded or they did not receive brain computed tomography angiography or magnetic resonance imaging before intravenous thrombolysis or endovascular thrombectomy, and within 24 h of ED admission. The first definition of ELVO was emergent occlusion of the internal carotid artery (ICA) and middle cerebral artery segment 1 (M1). The second definition was emergent occlusion of ICA, M1, basilar artery, middle cerebral artery segment 2, anterior cerebral artery segment 1, and posterior cerebral artery segment 1. Area under the receiver operating characteristic curve (AUROC) was constructed to examine discrimination. The sensitivity, specificity, positive predictive value, and negative predictive value of the nine scales under the two ELVO definitions were calculated. RESULTS: A total of 1231 patients were included in the study. No significant differences were observed in the AUROC under the two ELVO definitions. However, sensitivity values of these scales were largely different, ranging from 44.56% to 93.68% under the first ELVO definition. The sensitivity values among scales were also different under the second ELVO definition. CONCLUSION: Stakeholders in the community should choose suitable scales according to their own system conditions.

Safety and efficacy of the transbrachial approach for endovascular thrombectomy in patients with acute large vessel occlusion stroke.

BACKGROUND: The transbrachial approach (TBA) is an alternative method to the transfemoral approach (TFA). We herein aimed to evaluate the safety and efficacy of the TBA for endovascular thrombectomy (EVT) in patients with acute large vessel occlusion stroke. METHODS: We reviewed the records of 297 patients who had undergone EVT from January 2015 to July 2019. Eighteen patients who had undergone 19 procedures were included. Indications for arterial access, devices, recanalization rates, complication rates, and clinical outcomes were evaluated. RESULTS: There were 15 and 4 cases of anterior and posterior circulation stroke, respectively. The mean patient age was 80.1 years. Eight patients were male. The median National Institutes of Health Stroke Scale score was 18. The total procedure duration tended to be longer when the TBA was used after failure of the TFA (n = 6, 32%, median: 60.5 min) than when the TBA was used as the first treatment approach (n = 13, 68%, median: 22 min). Optimal recanalization (a modified Thrombolysis in Cerebral Infarction score of 2b or 3) was achieved for 15 procedures. Local complications were observed in two cases: one with brachial artery pseudoaneurysm and another with brachial artery occlusion. Three patients with anterior circulation stroke exhibited good clinical outcomes (modified Rankin score ≤ 2) at 90 days. Symptomatic intracranial hemorrhage occurred in one patient. Mortality was noted in four patients. CONCLUSION: The TBA for EVT is a suitable alternative when adoption of the TFA is difficult or impossible.

Early recurrence of ischemic stroke in patients receiving endovascular thrombectomy.

BACKGROUND/PURPOSE: Endovascular thrombectomy (EVT) is effective in treating acute ischemic stroke associated with large vessel occlusion. Early recurrence of ischemic stroke (ERIS) after EVT, however, is a devastating event and could worsen the condition of patient. Current study aimed to investigate the prevalence and risk factors of ERIS after EVT. METHODS: The medical records of all patients receiving EVT at a single medical center were reviewed and analyzed. ERIS was defined as presentation of newly developed neurological deficits in previously recanalized vascular territory or another vascular territory that was not initially involved within 30 days of the index stroke. RESULTS: From January 2015 to September 2018, a total of 200 patients (71.6 ± 12.3 years, male 49%) had received EVT and 17 patients (8.5%) developed ERIS. Presence of valvular heart disease was the only clinical factor associated with ERIS (OR: 4.26, 95% CI: 1.16-17.7). Patients with ERIS had significantly worse modified Rankin scale at 3 months (common OR: 3.11, 95% CI: 1.18-8.73) and were independently associated with mortality (OR: 7.73, 95% CI: 2.00-30.6). Ten of 17 patients with ERIS had received repeated EVT and all achieved good recanalization without procedure-related complications or symptomatic intracerebral hemorrhage. CONCLUSION: ERIS in patients receiving EVT was not rare, especially in those with valvular heart disease, and was associated with worse outcome. Nevertheless, they could be safely treated by repeated EVT.

Fibrin and Platelet-Rich Composition in Retrieved Thrombi Hallmarks Stroke With Active Cancer.

BACKGROUND AND PURPOSE: We aim to investigate whether histopathologic examination of thrombi retrieved from acute ischemic stroke patients undergoing endovascular treatment could distinguish cancer-related stroke from other etiologies. METHODS: Thrombi from patients undergoing endovascular treatment were analyzed. The etiology of stroke was divided into cardioembolism, large artery atherosclerosis, and active cancer groups. All selected thrombi were subjected to hematoxylin and eosin staining. The percentages of fibrin/platelets, red blood cells, and white blood cells within a thrombus were quantified. RESULTS: One-hundred fifty-two patients (active cancer, 19; cardioembolism, 107; large artery atherosclerosis, 26) were included. Thrombi from the active cancer group exhibited a higher fibrin/platelet composition than did those from the cardioembolism and large artery atherosclerosis groups (median, 85.7% versus 43.9% and 42.5%; P<0.001). Fibrin/platelet composition was the only independent factor (odds ratio, 1.05 [95% CI, 1.02-1.08]) in differentiating cancer-related stroke from stroke caused by cardioembolism and large artery atherosclerosis. A fibrin/platelet proportion of ≥65% accurately predicted cancer-related stroke (area under the curve, 0.84; P<0.001). CONCLUSIONS: In thrombi retrieved from patients undergoing endovascular treatment, a high fibrin/platelet composition was a probable indicator of cancer-related stroke.

Contrast-Induced Encephalopathy After Endovascular Thrombectomy for Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Contrast-induced encephalopathy (CIE) is a rare and underrecognized complication after endovascular thrombectomy (EVT) for acute ischemic stroke. This study investigated the incidence and risk factors of CIE in patients who underwent EVT. METHODS: Consecutive patients with acute ischemic stroke who received EVT between September 2014 and December 2019 at 2 medical centers were included. CIE was diagnosed on clinical criteria of neurological deterioration or delayed improvement within 24 hours after the procedure that was unexplained by the infarct or hemorrhagic transformation and radiological criterion of edematous change extending beyond the infarct core accompanied by contrast staining. RESULTS: Of 421 patients with acute ischemic stroke who received EVT, 7 (1.7%) developed CIE. The manifestations included worsening of focal neurological signs, coma, and seizure. Patients with CIE were more likely to experience contrast-induced acute kidney injury than were those without CIE, but the volume of contrast medium was comparable between the two groups. The independent risk factors for CIE included renal dysfunction (defined as an estimated glomerular filtration rate <45 mL/min per 1.73 m2; odds ratio, 5.77 [95% CI, 1.37-24.3]; P=0.02) and history of stroke (odds ratio, 4.96 [95% CI, 1.15-21.3]; P=0.03). Patients with CIE were less likely to achieve favorable functional outcomes (odds ratio, 0.09 [95% CI, 0.01-0.87]; P=0.04). CONCLUSIONS: CIE should be suspected in patients with clinical worsening after EVT accompanied by imaging evidence of contrast staining and edematous changes, especially in patients with renal dysfunction or history of stroke.

Endovascular Treatment Outcome and CT Angiography Findings in Acute Basilar Artery Occlusion with and without Underlying Intracranial Atherosclerotic Stenosis.

PURPOSE: To compare clinical characteristics and treatment outcomes of intra-arterial thrombectomy (IAT) in acute basilar artery occlusion (BAO) with and without underlying intracranial atherosclerotic stenosis (ICAS) and to investigate the usefulness of preprocedural CT angiography findings in the diagnosis of ICAS. MATERIALS AND METHODS: Twenty patients who received IAT for acute BAO between September 2014 and March 2019 were included. Additional therapies such as angioplasty, stent placement, and tirofiban infusion were provided while treating ICAS. Clinical and angiographic results of treatment were recorded. Preprocedural CT angiography findings in ICAS and non-ICAS groups were compared to assess (i) basilar tip opacification, (ii) partial occlusion, (iii) presence of convex border, (iv) occlusion segment longer than two thirds of the basilar artery or 20 mm, (v) dense basilar artery, and (vi) wall calcification in the occluded segment. RESULTS: Among the 20 patients (mean age, 71.3 y; mean stroke score, 24.8), optimal recanalization was achieved in 19 (95%). Three patients had good clinical outcomes. There were 6 patients with underlying ICAS. No difference was observed between ICAS and non-ICAS groups in terms of optimal angiographic recanalization and good outcome. On CT angiography, basilar tip occlusion (100% vs 29%), partial occlusion (100% vs 83%), and long occlusion length (100% vs 14%) significantly differed between the groups (P ≤ .01). CONCLUSIONS: In acute BAO, underlying ICAS does not affect optimal recanalization rate or clinical outcome. Preprocedural CT angiography is a potentially useful tool to detect it.

Anti-p53 Autoantibody Detection in Automatic Glass Capillary Immunoassay Platform for Screening of Oral Cavity Squamous Cell Carcinoma.

The incidence of oral squamous cell carcinoma (OSCC), which is one of the most common cancers worldwide, has been increasing. Serum anti-p53 autoantibody is one of the most sensitive biomarkers for OSCC. Currently, the most commonly used method on clinical screening platforms is the enzyme-linked immunosorbent assay, owing to its high specificity and repeatability. However, conducting immunoassays on 96-well plates is typically time consuming, thereby limiting its clinical applications for fast diagnosis and immediate prognosis of rapidly progressive diseases. The present study performed immunoassays in glass capillaries of 1-mm internal diameter, which increases the surface to volume ratio of the reaction, to shorten the time needed for immunoassay. The immunoassay was automated while using linear motorized stages and a syringe pump. The results indicated that, when compared with the 96-well plate immunoassay, the glass capillary immunoassay decreased the reaction time from typical 120 min to 45 min, reduced the amount of reagent from typical 50 µL to 15 µL, and required only simple equipment setup. Moreover, the limit of detection for glass capillary anti-p53 autoantibody immunoassay was 0.46 ng mL-1, which is close to the 0.19 ng mL-1 value of the conventional 96-well plate assay, and the glass capillary method had a broader detection range. The apparatus was used to detect the serum anti-p53 autoantibody concentration in clinical patients and compare its results with the conventional 96-well plate method results, which suggested that both of the methods detect the same trend in the relative concentration of serum anti-p53 autoantibody in healthy individuals or patients with OSCC.

BRAF protein immunoprecipitation, elution, and digestion from cell extract using a microfluidic mixer for mutant BRAF protein quantification by mass spectrometry.

This study utilized a microfluidic mixer for the sample pretreatment of cell extracts for target protein quantification by mass spectrometers, including protein immunoprecipitation and protein enzymatic digestion. The time of sample pretreatment was reduced and thus the throughput of quantitative mutant proteins was increased by using the proposed method. Whole cell lysates of the cancer cell line HT-29 with gene mutations were used as the sample. The target protein BRAF was immunoprecipitated using magnetic beads in a pneumatic micromixer. Purified protein was then eluted and digested by trypsin in another two micromixers to yield peptide fragments in the solution. Using stable isotope-labeled standard as the internal control, wild-type and mutant BRAF proteins were quantified using mass spectrometry, which could be used for cancer screening. Compared with conventional methods in which protein immunoprecipitation lasts overnight, the micromixer procedure takes only 1 h, likely improving the throughput of mutant BRAF protein quantification by mass spectrometry. Graphical abstract Three micromixers were used to reduce the sample pretreatment time of cell extracts for target protein quantification by mass spectrometers, including protein immunoprecipitation, protein elution, and protein enzymatic digestion.

Diagnostic accuracy of CTA and MRI/MRA in the evaluation of the cortical venous reflux in the intracranial dural arteriovenous fistula DAVF.

PURPOSE: Computed tomography angiography (CTA) and magnetic resonance imaging/angiography (MRI/MRA) are used for the diagnosis of intracranial dural arteriovenous fistulas (DAVFs). The purpose of this study was to compare the diagnostic accuracy of CTA and magnetic resonance imaging/angiography (MRI/MRA) for detection of cortical venous reflux (CVR) in intracranial DAVFs. METHODS: The records of patients with angiography-confirmed intracranial DAVFs who also received CTA and MRI/MRA from January 2008 to July 2016 were reviewed. CTA and MRI/MRA were reviewed for signs of CVR, and the diagnostic accuracy of individual signs was evaluated by receiver operating curve (ROC) analysis. RESULTS: A total 108 patients were included in this study. CTA signs of CVR included abnormal dilatation, early enhancement, and the presence of a medullary or pial vein. MRI/MRA signs of CVR included abnormal dilatation, early enhancement, flow-related enhancement, flow void, and medullary or pial venous collaterals. The sensitivity of individual CTA signs ranged from 62 to 96%, and specificities from 79 to 94%. The sensitivities of individual MRI/MRA signs ranged from 58 to 83%, and specificities from 77 to 93%. The area under ROC curve (AUC) of CTA and MRI/MRA were 0.91 and 0.87, respectively (P = 0.04 in direct comparison). In subgroup analysis, CTA had better diagnostic accuracy for higher grade disease (P = 0.05) and non-aggressive manifestation (P = 0.04). CONCLUSIONS: Both CTA and MRI/MRA have good diagnostic accuracy for detection of CVR in patients with intracranial DAVFs. There is modest evidence that CTA is better than MRI/MRA.

Rapid fabrication method of a microneedle mold with controllable needle height and width.

The main issue of transdermal drug delivery is that macromolecular drugs cannot diffuse through the stratum corneum of skin. Many studies have pursued micro-sized needles encapsulated with drugs to overcome this problem, as these needles can pierce the stratum corneum and allow drugs to enter the circulatory system of the human body. However, most microneedle fabrication processes are time-consuming and require expensive equipment. In this study, we demonstrate a rapid method for fabricating a microneedle mold using drawing lithography and a UV-cured resin. The mold was filled with a water-soluble material, polyvinylpyrrolidone (PVP), which was then demolded to produce a water-soluble microneedle array. The results of an in vitro skin insertion test using PVP microneedles and pig ear skin demonstrated the feasibility of the microneedle mold. In addition, by controlling the viscosity of the UV-cured resin through various heat treatments, microneedles with different heights and aspect ratios were produced. Compared with other methods, this technology significantly simplifies and accelerates the mold fabrication process. In addition, the required equipment is relatively simple and inexpensive. Through this technology, we can rapidly fabricate microneedle molds with controllable dimensions for various applications.