Imaging follow-up strategy after endovascular treatment of Intracranial aneurysms: A literature review and guideline recommendations.

OBJECTIVE: Endovascular coil embolization is the primary treatment modality for intracranial aneurysms. However, its long-term durability remains of concern, with a considerable proportion of cases requiring aneurysm reopening and retreatment. Therefore, establishing optimal follow-up imaging protocols is necessary to ensure a durable occlusion. This study aimed to develop guidelines for follow-up imaging strategies after endovascular treatment of intracranial aneurysms. METHODS: A committee comprising members of the Korean Neuroendovascular Society and other relevant societies was formed. A literature review and analyses of the major published guidelines were conducted to gather evidence. A panel of 40 experts convened to achieve a consensus on the recommendations using the modified Delphi method. RESULTS: The panel members reached the following consensus: 1. Schedule the initial follow-up imaging within 3-6 months of treatment. 2. Noninvasive imaging modalities, such as three-dimensional time-of-flight magnetic resonance angiography (MRA) or contrast-enhanced MRA, are alternatives to digital subtraction angiography (DSA) during the first follow-up. 3. Schedule mid-term follow-up imaging at 1, 2, 4, and 6 years after the initial treatment. 4. If noninvasive imaging reveals unstable changes in the treated aneurysms, DSA should be considered. 5. Consider late-term follow-up imaging every 3-5 years for lifelong monitoring of patients with unstable changes or at high risk of recurrence. CONCLUSIONS: The guidelines aim to provide physicians with the information to make informed decisions and provide patients with high-quality care. However, owing to a lack of specific recommendations and scientific data, these guidelines are based on expert consensus and should be considered in conjunction with individual patient characteristics and circumstances.

Hypofractionated stereotactic radiosurgery for dural arteriovenous fistula in the superior sagittal sinus: case report and review of the literature.

Stereotactic radiosurgery (SRS) for dural arteriovenous fistula (dAVF) in the superior sagittal sinus (SSS) is not an established treatment because of relatively poor efficacy and a latency period for treatment effects. Hypofractionated SRS for these lesions has not yet been reported. A 65-year-old man presented with intermittent paraparesis. Brain magnetic resonance imaging (MRI) revealed acute infarction in the premotor and motor cortex of both frontal convexities. Cerebral angiography demonstrated extensive dAVF in the middle and posterior third SSS, associated with an occlusion in the middle third. Transfemoral arterial Onyx embolization was performed through the right middle meningeal arteries, and cerebral venous reflux (CVR) disappeared from the middle third of the SSS. However, the remnant dAVF in the posterior third of the SSS and CVR in the posterior parietal and occipital lobes remained. Novalis SRS was performed on remnant the dAVF with 35 Gy in 5 fractions. Seven months after Novalis SRS, symptoms improved and cortical engorged vessel gradually disappeared on brain MRI. The patient recovered completely at 22 months post-radiosurgery. SRS for dAVF in the SSS could provide an alternative treatment option. Hypofractionated SRS showed a good result in our case.

Hypofractionated stereotactic radiosurgery for aggressive vertebral haemangioma and useful follow-up imaging modality: case report and review of the literature.

We report the use of an advanced magnetic resonance image (MRI) sequence to detect the treatment response after SRS for aggressive vertebral haemangioma (VH). A 63-year-old female patient presented with back pain, bilateral lower extremity weakness (grade IV), and sensory change in the saddle area. MRI revealed a vertebral body mass compressing the spinal cord at T10, which had high T2 and low T1 signal intensity. Three-dimensional volumetric sagittal time-resolved imaging of contrast kinetics (TRICKS) abdominal magnetic resonance angiography (MRA) showed it to be hypervascular. SRS with the Novalis beam shaping system (BrainLAB; Heimstetten®, Germany) was performed on the gross tumor volume of 14.954 mL. 30 Gy was given to the 90% isodose line in 5 fractions. Seven days later, the patient underwent decompressive laminectomy for weakness. Seven months later, the patient's motor weakness was improved to allow for unassisted gait, and back pain and sensory changes resolved. Follow-up MRI revealed no significant change on T1 and T2 signal intensity images. However, TRICKS abdominal MRA demonstrated disapprearance of the hypervascularity. Seven years after SRS, the same signal intensity images showed shrinkage of the mass and resolution of compression of the spinal cord, and the signal intensity of the T1 image was changed to iso- and high signal intensity.

Comparison of methods for evaluation of upper esophageal sphincter (UES) relaxation duration: Videofluoroscopic swallow study versus high-resolution manometry.

This study aims to compare the 2 methods of upper esophageal sphincter (UES) relaxation measurement and determine which method has better diagnostic value in UES relaxation impairment The study included 140 patients with pharyngeal dysphagia who underwent both videofluoroscopic swallow study (VFSS) and high-resolution manometry (HRM). Feeding method was determined to oral or non-oral feeding based on the severity of dysphagia; 103 patients were in oral feeding group and 37 were in non-oral feeding group. UES relaxation duration was measured using VFSS and HRM, respectively. Receiver-operating characteristic curve analysis was conducted to validate the UES relaxation duration in determination of feeding method. UES relaxation duration was more decreased in non-oral feeding group than in oral feeding group on both VFSS and HRM. Receiver-operating characteristic analysis revealed that the optimal cutoff value of UES relaxation duration to determine feeding method (oral or non-oral feeding) was 0.42 seconds on VFSS and 0.44 seconds on HRM. The sensitivity for feeding method was higher in VFSS than HRM (83.5% vs 70.9%), while the specificity was higher in HRM than VFSS (48.6% vs 54.1%). VFSS and HRM have complementary ability in evaluating UES relaxation duration in patients with oropharyngeal dysphagia.

Effect of distal access catheter tip position on angiographic and clinical outcomes following thrombectomy using the combined stent-retriever and aspiration approach.

PURPOSE: Mechanical thrombectomy using the stent-retriever in conjunction with the distal access catheter may improve the rates of successful revascularization and clinical outcomes in patients with acute stroke. We aimed to compare two different thrombectomy techniques, according to the position of the distal access catheter tip in the combined stent-retriever and aspiration approach. METHODS: In this retrospective study, patients with middle cerebral artery occlusion treated with the combined technique were divided into two groups based on the tip position of the distal access catheter: distal group (catheter placed adjacent to the thrombus) and proximal group (catheter placed in the cavernous segment of the internal carotid artery below the ophthalmic artery). Baseline characteristics, angiographic results, and clinical outcomes were compared. RESULTS: Eighty-three patients (distal group, n = 45; proximal group, n = 38) were included. Higher complete reperfusion was observed in the distal group (unweighted analysis: 66.7% vs. 42.1%, p = 0.025; weighted analysis: 74.0% vs. 28.8%; p = 0.002). In the multivariate analysis, the distal tip position was independently associated with complete reperfusion (unweighted analysis: aOR, 4.10; 95% CI, 1.40-11.98; p = 0.01; weighted analysis: aOR, 5.20; 95% CI, 1.72-15.78; p = 0.004). The distal group also showed more favorable clinical outcomes and early neurological improvement (unweighted analysis: 62.2% vs. 55.3%; p = 0.521, 60% vs. 50%; p = 0.361, respectively; weighted analysis: 62.7% vs. 61.1%; p = 0.877, 66% vs. 45.7%; p = 0.062, respectively). However, more arterial dissections were observed in the distal group (8.9%, n = 4 vs. 2.6%, n = 1; p = 0.36). In the distal group, one patient with vascular injury died due to complications. No cases of emboli in new territory were observed. CONCLUSIONS: Distal tip position of the distal access catheter has a significant impact on reperfusion in patients with acute ischemic stroke. However, there was also a higher rate of vascular injury as the catheter was advanced further. If advancement to the target lesion is too difficult, placing it in the cavernous internal carotid artery may be a viable method without complications.

Safety and Efficacy of Minimally Invasive Stereotactic Aspiration with Multicatheter Insertion Compared with Conventional Craniotomy for Large Spontaneous Intracerebral Hemorrhage (≥50 mL).

BACKGROUND: Conventional craniotomy (CC) is generally favored for treating large intracerebral hemorrhage (ICH), but the feasibility of minimally invasive stereotactic aspiration for large ICH is controversial. We investigated the efficacy and safety of stereotactic aspiration with multicatheter insertion (SAMCI) for large ICH (≥50 mL). METHODS: In January 2014, we implemented SAMCI for large ICH. The inclusion criteria for SAMCI were as follows: 1) spontaneous supratentorial ICH, 2) ICH volume ≥50 mL, 3) Glasgow Coma Scale score ≥5, and 4) no bilateral fixed dilated pupils. Forty-seven patients who underwent SAMCI from January 2014 to July 2018 composed the SAMCI group, and 34 patients who underwent CC between January 2010 and December 2013 and retrospectively met the inclusion criteria for SAMCI composed the control group (CC group). RESULTS: The mean preoperative ICH volume in the SAMCI and CC groups was 73.1 ± 22.8 and 72.4 ± 21.5 mL, respectively. There were no significant differences between the groups in baseline characteristics except for ICH location. The deep portion of the ICH was higher in the SAMCI group than in the CC group. Postoperative mortality and rebleeding rates were significantly lower in the SAMCI group than in the CC group (4.3% vs. 26.5% and 0% vs. 14.7%, respectively; P < 0.05). Logistic regression analysis showed that SAMCI contributed to a decrease in the mortality rate (odds ratio, 0.04; P = 0.008). CONCLUSIONS: SAMCI is a feasible therapeutic option for large ICH and has low complication rates.

Safety and Efficacy of Hypothermia (34°C) after Hemicraniectomy for Malignant MCA Infarction.

OBJECTIVE: The beneficial effect of hypothermia after hemicraniectomy in malignant middle cerebral artery (MCA) infarction has been controversial. We aim to investigate the safety and clinical efficacy of hypothermia after hemicraniectomy in malignant MCA infarction. METHODS: From October 2012 to February 2016, 20 patients underwent hypothermia (Blanketrol III, Cincinnati Sub-Zero, Cincinnati, OH, USA) at 34°C after hemicraniectomy in malignant MCA infarction (hypothermia group). The indication of hypothermia included acute cerebral infarction >2/3 of MCA territory and a Glasgow coma scale (GCS) score <11 with a midline shift >10 mm or transtentorial herniation sign (a fixed and dilated pupil). We retrospectively collected 27 patients, as the control group, who had undergone hemicraniectomy alone and simultaneously met the inclusion criteria of hypothermia between January 2010 and September 2012, before hypothermia was implemented as a treatment strategy in Dong-A University Hospital. We compared the mortality rate between the two groups and investigated hypothermia-related complications, such as postoperative bleeding, pneumonia, sepsis and arrhythmia. RESULTS: The age, preoperative infarct volume, GCS score, National institutes of Health Stroke Scale score, and degree of midline shift were not significantly different between the two groups. Of the 20 patients in the hypothermia group, 11 patients were induced with hypothermia immediately after hemicraniectomy and hypothermia was initiated in 9 patients after the decision of hypothermia during postoperative care. The duration of hypothermia was 4±2 days (range, 1 to 7 days). The side effects of hypothermia included two patients with arrhythmia, one with sepsis, one with pneumonia, and one with hypotension. Three cases of hypothermia were discontinued due to these side effects (one sepsis, one hypotension, and one bradycardia). The mortality rate of the hypothermia group was 15.0% and that of the control group was 40.7% (p=0.056). On the basis of the logistic regression analysis, hypothermia was considered to contribute to the decrease in mortality rate (odds ratio, 6.21; 95% confidence interval, 1.04 to 37.05; p=0.045). CONCLUSION: This study suggests that hypothermia after hemicraniectomy is a viable option when the progression of patients with malignant MCA infarction indicate poor prognosis.

Thrombolysis in Large Diffusion-Weighted Imaging Lesions: Lower Chance but Still a Chance.

BACKGROUND: We sought to investigate whether early thrombolytic treatment can result in favorable functional outcome even in patients with large diffusion-weighted imaging (DWI) lesions. MATERIALS AND METHODS: We analyzed 566 patients who received intravenous alteplase within 4.5 hours from onset, initially underwent DWI and magnetic resonance angiography, and had acute infarction confined to anterior circulation. DWI lesion volumes were measured semiautomatically. The association between DWI lesion volume and 3-month outcome in patients who achieved early recanalization was assessed. The DWI lesion volume cutoff, which predicts unfavorable outcome despite recanalization, was determined. In patients with large DWI lesions, the distributions of modified Rankin Scale (mRS) score were compared according to the recanalization status. RESULTS: Four hundred thirty-six patients achieved early recanalization. Among these patients, 283 (65%) patients had a favorable functional outcome (mRS score 0-2). DWI lesion volume (odds ratio [OR], 1.38 per 10 mL; 95% confidence interval [CI], 1.22-1.56) was an independent variable associated with poor outcome, along with hypertension (OR, 1.87; 95% CI, 1.12-3.10), National Institutes of Health Stroke Scale (NIHSS) score (OR, 1.13; 95% CI, 1.08-1.19), and onset-to-needle time (OR, 1.08 per 10 minutes; 95% CI, 1.03-1.13). The DWI lesion of 60 mL or higher highly predicted an unfavorable outcome with a positive predictive value of 95.3%. In patients with a DWI lesion of 60 mL or higher, recanalization had no benefit for an mRS score of 0-2 but was significantly associated with an mRS score of 0-3 (OR, 4.64; 95% CI, 1.08-19.97). CONCLUSIONS: Despite early recanalization, the probability of favorable outcome is low in patients with a DWI lesion of 60 mL or higher. Nevertheless, the benefit of recanalization still persists in large DWI lesions.

Factors associated with early dramatic recovery following successful recanalization of occluded artery by endovascular treatment in anterior circulation stroke.

Endovascular treatment (EVT) significantly increases the recanalization rate and improves functional outcomes in acute ischemic stroke. However, despite successful recanalization by EVT, some stroke patients demonstrate no early dramatic recovery (EDR). We assessed factors associated with EDR following recanalization by EVT. We included subjects with anterior circulation stroke treated with EVT who met the following criteria: Thrombolysis in Cerebral Ischemia scores (TICI) 2b-3 after EVT, lesion volume <70mL as seen on the pre-treatment diffusion-weighted imaging (DWI) scan and a baseline NIHSS score ≥6. EDR was defined as a ≥8-point reduction in the NIHSS score, or NIHSS score of 0 or 1 measured 24h following treatment. Multivariate regression analyses were performed to identify the predictors associated with EDR. Of the 102 patients (mean age, 64.3years; median National Institutes of Health Stroke Scale score, 14), EDR was achieved in 39 patients (38.2%). The median DWI lesion volume was 12mL (interquartile range, 5-25mL). Median onset-to-recanalization time in these patients was 320min (interquartile range, 270-415min). Logistic regression analysis identified a higher initial NIHSS score (OR 1.17, 95% CI 1.03-1.33, P=0.016) and shorter time from onset to recanalization (OR 0.99, 95% CI 0.986-0.997, P=0.003), to be independently associated with EDR. In the setting of pretreatment DWI lesion volume <70mL, a higher initial NIHSS score and faster time from onset to recanalization may be important predictors of EDR following successful EVT.

Patient Selection and Clinical Efficacy of Urgent Superficial Temporal Artery-Middle Cerebral Artery Bypass in Acute Ischemic Stroke Using Advanced Magnetic Resonance Imaging Techniques.

BACKGROUND: Selected patients with acute ischemic stroke might benefit from superficial temporal artery-middle cerebral artery (STA-MCA) bypass, but the indications for urgent STA-MCA bypass are unknown. OBJECTIVE: To report our experiences of urgent STA-MCA bypass in patients requiring urgent reperfusion who were ineligible for other reperfusion therapies, using advanced magnetic resonance imaging (MRI) techniques. METHODS: The inclusion criteria for urgent STA-MCA bypass were as follows: acute infarct volume <70 mL with a ratio of perfusion/diffusion lesion volume ≥1.2, and a regional cerebral blood volume ratio >0.85. From January 2013 to October 2015, 21 urgent STA-MCA bypass surgeries were performed. The control group included 19 patients who did not undergo bypass surgery mainly due to refusal of surgery or the decision of the neurologist. Clinical and radiological data were compared between the surgery and control group. RESULTS: The median age of the control group (70 years, interquartile range [IQR] 58-76) was higher than that of the surgery group (62 years, IQR 49-66), but the median preoperative diffusion and perfusion lesion volumes of the surgery group (13.8 mL, IQR 7.5-26.0 and 120.9 mL, IQR 84.9-176.0, respectively) were higher than those of the control group (5.6 mL, IQR 2.1-9.1 and 69.7 mL, IQR 23.9-125.3, respectively). Sixteen (76.2%) patients in the surgery group and 2 (10.5%) patients in the control group had favorable outcomes ( P < .001). Logistic regression analysis identified bypass surgery as the strongest predictive factor. CONCLUSION: STA-MCA bypass can be used as a therapeutic tool for acute ischemic stroke. Advanced MRI techniques are helpful for selecting patients and for decision making.

Efficacy of Adjuvant 10% Hypertonic Saline in Transforaminal Epidural Steroid Injection: A Retrospective Analysis.

BACKGROUND: Chronic lower back pain with or without radiculopathy represents an important medical, social, and economic problem. Many treatment modalities and techniques, including surgery and epidural administration of steroids, have been used to manage this pain. Hypertonic saline, which has been used as an adjunct to percutaneous epidural adhesiolysis, can also be injected via a transforaminal approach in expectation of longer-lasting effects. OBJECTIVES: This study aimed to determine the effect of adding hypertonic saline to conventional transforaminal epidural steroid injections (TFEI) to provide pain relief for chronic radiculopathy patients. STUDY DESIGN: A retrospective study. SETTING: Pain clinic of a university hospital. METHODS: Between January 2010 and December 2013, the medical records of 246 patients (94 in the hypertonic group, 153 in the control group) who received transforaminal epidural block were reviewed and analyzed. The hypertonic group received 10% sodium chloride solution added to lidocaine, triamcinolone, and hyaluronidase. Outcomes on pain reduction were measured using a numerical rating scale (NRS) and the responder rate at baseline, one, 3, and 6 months after procedure. RESULTS: The estimated difference in NRS scores from baseline throughout a 6-month follow-up period in the hypertonic group were significantly higher (P = 0.0003). The proportion of substantial responders (41.9% vs. 34.6% at one month, 40.9% vs. 26.8% at 3 months, and 33.3% vs. 14.4% at 6 months, respectively, P = 0.0058) and substantial/moderate responders (71.0% vs. 58.8% at one month, 65.6% vs. 40.4% at 3 months, and 48.4% vs. 20.3% at 6 months, respectively, P < 0.0001) were significantly higher in the hypertonic group. The Oswestry disability index (ODI) was not different between the groups (P = 0.2697). LIMITATIONS: Retrospective design without a control group. CONCLUSIONS: Hypertonic saline provides more superior and longer lasting pain relieving effects when added to TFEIs.Key words: Back pain, epidural injections, epidural steroids, hypertonic saline, lumbar, radiculopathy, transforaminal.

Method to Reduce the False-Positive Rate of Loss of Resistance in the Cervical Epidural Region.

Background. The cervical epidural space can be detected by the loss of resistance (LOR) technique which is commonly performed using air. However, this technique using air has been associated with a high false-positive LOR rate during cervical interlaminar epidural steroid injections (CIESIs). Objective. We investigated whether the detection of LOR with contrast medium might reduce the false-positive LOR rate on the first attempt. Methods. We obtained data retrospectively. A total of 79 patients were divided into two groups according to the LOR technique. Groups 1 and 2 patients underwent CIESI with the LOR technique using air or contrast medium. During the procedure, the injection technique (median or paramedian approach), final depth, LOR technique (air or contrast), total number of LOR attempts, and any side effects were recorded. Results. The mean values for the total number of LOR attempts were 1.38 ± 0.65 (Group 1) and 1.07 ± 0.25 (Group 2). The false-positive rate on the first attempt was 29.4% and 6.6% in Groups 1 and 2, respectively (P = 0.012). Conclusions. The use of contrast medium for LOR technique is associated with a lower rate of false-positivity compared with the use of air.

Predictors of the Treatment Response of Spontaneous Intracranial Hypotension to an Epidural Blood Patch.

Spontaneous intracranial hypotension (SIH) is characterized by postural headache because of low cerebrospinal fluid (CSF) pressure. Brain magnetic resonance imaging (MRI) and radioisotope (RI) cisternography can be used to identify the site of a CSF leakage. Although autologous epidural blood patch (EBP) is a very effective treatment modality, some patients require a repeat autologous EBP. We investigated whether autologous EBP responses correlate with surrogate markers of quantitative findings.All cases of autologous EBP for SIH from January 2006 to December 2014 were enrolled. The demographic variables, number of EBPs, pain scores, RI cisternography (early visualization of bladder activity), and MRI findings (subdural fluid collections, pachymeningeal enhancement, engorgement of venous structures, pituitary hyperemia, and sagging of the brain) were reviewed.Patients with early bladder activity on RI cisternography had a tendency to need a higher number of autologous EBPs. Only sagging of the brain and no other variables showed a statistically significant negative correlation with the number of autologous EBPs.The response to autologous EBP may be related to the radiologic findings of early bladder activity on RI cisternography and sagging of the brain on MRI.

Impact of Prehospital Intervention on Delay Time to Thrombolytic Therapy in a Stroke Center with a Systemized Stroke Code Program.

BACKGROUND: The use of emergency medical services (EMS) and notification to hospitals by paramedics for patients with suspected stroke are crucial determinants in reducing delay time to acute stroke treatment. The aim of this study is to investigate whether EMS use and prehospital notification (PN) can shorten the time to thrombolytic therapy in a stroke center with a systemized stroke code program. METHODS: Beginning in January 2012, stroke experts in our stroke center received direct calls via mobile phone from paramedics prenotifying the transport of patients with suspected stroke. We compared baseline characteristics and prehospital/in-hospital delay time in stroke patients treated with intravenous recombinant tissue plasminogen activator for 44 months with and without EMS use and/or PN. RESULTS: Intravenous thrombolytic therapy was performed on 274 patients. Of those patients, 215 (78.5%) were transported to the hospital via EMS and 59 (21.5%) were admitted via private modes of transportation. The patients who used EMS had shorter median onset-to-arrival times (62 minutes versus 116 minutes, P < .001). There was no difference in in-hospital delay time between the 2 groups. In 28 cases (13%) of EMS transport, EMS personnel called the clinical staff to notify the incoming patient. Prenotification by EMS was associated with shorter median door-to-imaging time (9 minutes versus 12 minutes, P = .045) and door-to-needle time (20 minutes versus 29 minutes, P = .011). CONCLUSIONS: We found that EMS use reduces prehospital delay time. However, EMS use without prenotification does not shorten in-hospital processing time in a stroke center with a systemized stroke code program.

Safety of coil occlusion of the parent artery for endovascular treatment of anterior communicating artery aneurysm.

Many studies lay emphasis on the clinical importance of perforating branches of the anterior communicating artery (ACoA) and report that vascular damage of the perforators from ACoA aneurysm during surgery cause subsequent postoperative amnesia. The purpose of our study was to analyze the safety of parent artery occlusion for ACoA aneurysm coiling based on the anatomical features of the ACoA complex in 13 patients with 13 ACoA aneurysms. All patients underwent coiling of the aneurysm sac and ACoA. Aneurysm characteristics including size, dome-to-neck ratio, anterior/posterior orientation of the aneurysm dome with respect to the axis of the pericallosal artery, location of the aneurysm neck with respect to the A1-A2 segment of the anterior cerebral artery (ACA) or the ACoA, and the presence of hypoplasia/aplasia of A1 segment were assessed. The aneurysm neck was located directly on the ACoA in five aneurysms (38%), whereas eight (62%) had the neck located at the A1-A2 junction. Of the five patients whose aneurysm neck was located in the ACoA, four patients had infarcts in the basal forebrain. Three of the patients complained of amnesia. None of the aneurysms with the neck located at the A1-A2 junction were associated with infarction. There has been little evidence thus far that parent vessel occlusion of ACoA aneurysms is a safe method for the treatment of aneurysms. Patients with the aneurysm neck located at the A1-A2 junction and without A1 aplasia, who were treated with aneurysm sac and ACoA embolism, were potentially safe.

Thrombectomy using a stent retriever with artificially induced vertebral artery vasospasm in a patient with acute basilar artery occlusion: a case report.

An acute basilar artery occlusion is not an uncommon cause of stroke. It represents 6-10% of large vessel strokes and has been associated with poor clinical outcomes. Multimodal treatments have been introduced to recanalise a basilar artery occlusion successfully. However, all mechanical thrombectomy devices are not always usable in an emergent situation. We present a case of basilar artery occlusion treated with a stent retriever assisted by a vertebral artery vasospasm. We attempted thrombectomy with a stent retriever several times. However, the captured thrombus was not pulled out and migrated to the distal basilar artery and posterior cerebral artery due to anterograde flow of the vertebral artery. We carefully advanced the catheter into the distal vertebral artery and generated a vasospasm. The vertebral artery vasospasm reduced the forward flow significantly like a balloon-guided catheter. The thrombus was pulled out with the stent.

High residual platelet reactivity (HRPR) for adenosine diphosphate (ADP) stimuli is a determinant factor for long-term outcomes in acute ischemic stroke with anti-platelet agents: The meaning of HRPR after ADP might be more prominent in large atherosclerotic infarction than other subtypes of AIS.

High residual platelet activation (HRPA) after ADP stimuli has associated with recurrent vascular events in acute atherothrombosis with the use of antiplatelet agents (APAs). However, there has been little evidence supporting this association in acute ischemic stroke (AIS). In this study, we evaluated the influences of HRPR after ADP stimuli on the 1-year incidence of recurrent cardiovascular events and mortality in AIS with APAs. We conducted an observational, referral center cohort study on 968 AIS patients with APAs from January 2010 to December 2013 who were evaluated using optical platelet aggregometry (OPA). All patients received the dual APA combination of aspirin and clopidogrel or aspirin alone. We evaluated their platelet function 5 days after hospital admission using OPA. HRPR after ADP stimuli was defined as platelet aggregation of 70 % or greater according to OPA after 10 µM ADP stimuli. The primary endpoint was a composite of all causes of death, myocardial infarction, and stroke at the 1-year follow-up. The secondary endpoints were each component of the primary endpoint. The event rate of primary endpoint was 11.3 % (109/968). Its rate was significantly higher in the patients with HRPR (16.7 %) than in those without (9.7 %). HPRP was independently associated with the primary endpoint (OR = 1.97, CI 1.22-3.18, p < 0.01). According to the AIS subtype, the presence of HRPR was independently significant for the occurrence of the primary endpoint in the large artery atherosclerosis (LAA) subtype only (OR = 2.26, CI 1.15-4.45, p = 0.02). In this study, the presence of HRPR after ADP stimuli is associated with a poor long-term outcome after acute ischemic stroke. In particular, the influence of this factor might be more prominent in LAA compared with other types of AIS.

Relative CBV ratio on perfusion-weighted MRI indicates the probability of early recanalization after IV t-PA administration for acute ischemic stroke.

BACKGROUND: We hypothesized that the relative cerebral blood volume (rCBV) ratio on perfusion-weighted imaging (PWI) using MRI might serve as a predictor of early recanalization (ER) after intravenous tissue plasminogen activator (IV t-PA) administration for acute ischemic stroke. METHODS: Patients with acute middle cerebral artery (MCA) ischemic stroke (IS) were enrolled in the study. They were evaluated by MRI, including PWI and diffusion-weighted imaging, before administration of IV t-PA and underwent digital subtraction angiography (DSA) of the brain within 2 h after t-PA administration. We compared the rCBV ratio on PWI between patients with and without ER on DSA and investigated the proportion of patients with an excellent outcome at 90 days after t-PA administration (modified Rankin Scale score 0-1) among those with and without ER. RESULTS: 85 patients with acute MCA IS were included; 16 patients (18.8%) experienced ER on DSA after IV t-PA administration. Patients with ER more frequently had an excellent outcome at 90 days than those without ER. The rCBV ratio on PWI was higher in the ER group (1.01±0.21, p<0.01) than in the non-ER group (0.82±0.18). After adjusting for the presence of atrial fibrillation and the serum glucose level, the rCBV ratio on PWI (OR 1.07; 95% CI 1.02 to 1.12; p<0.01) was a significant independent indicator of ER. CONCLUSIONS: The results of this study suggest that the rCBV ratio on PWI might serve as a useful indicator of ER after IV t-PA administration.

Vasospastic Amaurosis Fugax Diagnosed by Cerebral Angiography.

UNLABELLED: We report a case of recurrent monocular blindness presumed to be caused by vasospasm, demonstrated by digital subtraction angiography. CASE REPORT: A 65-year-old man presented with recurrent visual loss in the left eye for 2 years. He had histories of hypertension, cigarette smoking, and May-Thurner syndrome. The symptom occurred variably from twice a day to once a week and usually lasted for 5 minutes. Brain magnetic resonance imaging, magnetic resonance angiography, and ophthalmologic evaluation did not reveal any abnormality. Cerebral digital subtraction angiography was performed. On the left internal carotid angiogram, vasospasm occurred in the cervical portion of the left internal carotid artery and, subsequently, the blood flow to the left ophthalmic artery diminished. This phenomenon was reproducible and, in the absence of vasospasm, the ophthalmic artery was well visualized with no steno-occlusive lesion. Examination of the carotid duplex showed diffuse luminal narrowing and increased flow velocities in the left cervical internal carotid artery without atherosclerotic plaque. Treatment was started with nimodipine, which markedly reduced the attacks. CONCLUSION: We assumed that vasomotor instability, which made the vessels vulnerable to spasm, may have caused a recurrent ocular symptom in our patient.

FIBTEM of Thromboelastometry does not Accurately Represent Fibrinogen Concentration in Patients with Severe Hypofibrinogenemia During Liver Transplantation.

BACKGROUND: Among rotation thromboelastometry (ROTEM®) parameters, the maximum clot firmness (MCF) of EXTEM (MCFEX), INTEM (MCFIN) and FIBTEM (MCFFIB) are influenced by both the platelet count and fibrinogen concentration. We evaluated the relative contribution of laboratory variables to MCF amplitude and determined whether the severity of hypofibrinogenemia could affect the relationship between these variables during liver transplantation (LT). MATERIAL AND METHODS: Retrospective ROTEM® assays with simultaneous laboratory tests in 282 patients receiving LT were analyzed. Relative contribution of platelet and fibrinogen to MCF was assessed and a subgroup analysis based on fibrinogen concentration was performed. RESULTS: Platelet count accounted for 60% of the variability in both MCFEX and MCFIN, whereas fibrinogen concentration explained 12% and 9%, respectively. In subgroup analysis, platelets accounted for 56-57% of MCFEX and MCFIN variability with fibrinogen <100 mg/dL, and 59% of the variability with fibrinogen ≥100 mg/dL. Fibrinogen was the primary determinant of MCFFIB, accounting for 73% of the variability. However, in severe hypofibrinogenemia (fibrinogen<100 mg/dL), fibrinogen explained only 22% of MCFFIB variability. CONCLUSIONS: Regardless of the fibrinogen concentration, the platelet count is a constant primary determinant of the MCFEX and MCFIN during LT. However, MCFFIB may predict the fibrinogen concentration less reliably in cases of severe hypofibrinogenemia.