The Janus face of HIF-1α in ischemic stroke and the possible associated pathways.

Stroke is the most devastating disease, causing paralysis and eventually death. Many clinical and experimental trials have been done in search of a new safe and efficient medicine; nevertheless, scientists have yet to discover successful remedies that are also free of adverse effects. This is owing to the variability in intensity, localization, medication routes, and each patient's immune system reaction. HIF-1α represents the modern tool employed to treat stroke diseases due to its functions: downstream genes such as glucose metabolism, angiogenesis, erythropoiesis, and cell survival. Its role can be achieved via two downstream EPO and VEGF strongly related to apoptosis and antioxidant processes. Recently, scientists paid more attention to drugs dealing with the HIF-1 pathway. This review focuses on medicines used for ischemia treatment and their potential HIF-1α pathways. Furthermore, we discussed the interaction between HIF-1α and other biological pathways such as oxidative stress; however, a spotlight has been focused on certain potential signalling contributed to the HIF-1α pathway. HIF-1α is an essential regulator of oxygen balance within cells which affects and controls the expression of thousands of genes related to sustaining homeostasis as oxygen levels fluctuate. HIF-1α's role in ischemic stroke strongly depends on the duration and severity of brain damage after onset. HIF-1α remains difficult to investigate, particularly in ischemic stroke, due to alterations in the acute and chronic phases of the disease, as well as discrepancies between the penumbra and ischemic core. This review emphasizes these contrasts and analyzes the future of this intriguing and demanding field.

TRUST Technique for Neurointervention: A Promising Alternative for Complex Cases.

BACKGROUND: Neurointervention via Transradial Access (TRA) is becoming increasingly popular as experience with this technique increases. However, approximately 8.6-10.3% of complex TRA cases are converted to femoral access due to a lack of support or radial artery spasm. This study aimed to assess the efficacy and safety of the TRUST (trans-radial coaxial catheter technique using a short sheath, Simmons catheter, and Tethys intermediate catheter) technique in interventional procedures via TRA. METHODS: This was a single-center retrospective analysis of 16 patients admitted to our institute between January 2023 to May 2023 to undergo endovascular interventions with the TRUST technique via the TRA. RESULTS: The mean age of the study population was 63.8 years, and 62.5% were male (10/16). The most common procedure was intracranial atherosclerotic stenosis (93.75%, 15/16). All procedures were performed successfully, and the most common procedures in our cohort were ballooning (50.0%, 8/16), stenting (18.75%, 3/16), and both procedures combined (31.25%, 1/16). All procedures were performed using the TRA, and the distal and proximal radial arteries were used for access in 31.35% (5/16) and 68.75% (11/16) of the cases, respectively. Technical success was achieved in all patients and most cases demonstrated mTICI ≥2b recanalization (93.75%, 15/16). In this case, no major access-site complications occurred. CONCLUSION: The TRUST technique is technically safe and feasible and had a high technical success rate and low complication rate in our study. These results demonstrate that the TRUST technique is a promising alternative for patients undergoing complex neurointerventions.

Thymoquinone regulates microglial M1/M2 polarization after cerebral ischemia-reperfusion injury via the TLR4 signaling pathway.

Acute ischemic stroke followed by microglia activation, and the regulation of neuroinflammatory responses after ischemic injury involves microglia polarization. microglia polarization is involved in the regulation of neuroinflammatory responses and ischemic stroke-related brain damage. Thymoquinone (TQ) is an anti-inflammatory agent following ischemic stroke onset. However, the significance of TQ in microglia polarization following acute ischemic stroke is still unclear. We predicted that TQ might have neuroprotective properties by modulating microglia polarization. In this work, we mimicked the clinical signs of acute ischemic stroke using a mouse middle cerebral artery ischemia-reperfusion (I/R) model. It was discovered that TQ treatment decreased I/R-induced infarct volume, cerebral oedema, and promoted neuronal survival, as well as improved the histopathological changes of brain tissue. The sensorimotor function was assessed by the Garica score, foot fault test, and corner test, and it was found that TQ could improve the motor deficits caused by I/R. Secondly, real-time fluorescence quantitative PCR, immuno-fluorescence, ELISA, and western blot were used to detect the expression of M1/M2-specific markers in microglia to explore the role of TQ in the modulation of microglial cell polarization after cerebral ischemia-reperfusion. We found that TQ was able to promote the polarization of microglia with extremely secreted inflammatory factors from M1 type to M2 type. Furthermore, TQ could block the TLR4/NF-κB signaling pathway via Hif-1α activation which subsequently may attenuate microglia differentiation following the cerebral ischemia, establishing a mechanism for the TQ's beneficial effects in the cerebral ischemia-reperfusion model.

Branch-site occlusion sign predicts the embolic origin of acute ischemic stroke: a meta-analysis.

Objective: The study aimed to investigate whether branch-site occlusion (BSO) sign could predict the etiology of acute intracranial large artery occlusion (ILVO) and the stentriever (SR) response. Methods: We systematically reviewed studies that evaluated the predictive role of BSO for the etiology of ILVO-AIS or EVT outcome between 1 January 2000 and 31 August 2022 from PubMed, Embase, and Web of Science. Results: The sensitivity and specificity of BSO sign predicting etiology of ILVO-AIS were 0.87 (95% CI 0.81-0.91) and 0.64 (95% CI 0.33-0.87), respectively. The sensitivity and specificity of BSO sign predicting stentriever response were 0.84 (95% CI 0.63-0.94) and 0.61 (95% CI 0.18-0.92), respectively. Conclusion: The BSO sign could be a valid and precise imaging marker to predict embolism caused ILVO-AIS and recanalization success by SR without rescue therapy.

Increased blood pressure variability during general anaesthesia is associated with worse outcomes after mechanical thrombectomy: a prospective observational cohort study.

OBJECTIVES: Optimal periprocedural blood pressure (BP) management during mechanical thrombectomy (MT) for acute ischaemic stroke is still controversial. The aim of this study was to investigate the association between intraprocedural BP variability (BPV) and outcomes in patients with large vessel occlusion (LVO) following MT with general anaesthesia. DESIGN: A prospective observational cohort study. SETTING: This study was conducted in a single tertiary hospital of Hangzhou in Zhejiang province. PARTICIPANTS: A total of 141 patients with LVO treated with MT were finally included between January 2018 and September 2020. MAIN OUTCOME MEASURES: Intraprocedural BP was recorded every 5 min throughout the procedure. BPV was measured as SD, coefficient of variation (CV), max-min (RANGE) and successive variation. Haemorrhagic transformation was assessed on 24-hour CT images according to European Cooperative Acute Stroke Study III trial. Poor functional outcome was defined as 90-day modified Rankin Scale score 3-6. Binary logistic regression analysis was used to investigate the association of BPV parameters with the incidence of parenchymal haemorrhage (PH) and poor functional outcome. RESULTS: After controlling for age, female, history of smoking, hypertension and atrial fibrillation, baseline National Institutes of Health Stroke Scale, baseline systolic BP (SBP), baseline Alberta Stroke Program Early CT Score, bridging thrombolysis and times of retrieval attempts, the results demonstrated that intraprocedural SBPRANGE (OR 1.029; 95% CI 1.003 to 1.055; p=0.027), SBPSD (OR 1.135; 95% CI 1.023 to 1.259; p=0.017) and SBPCV (OR 1.189; 95% CI 1.053 to 1.342; p=0.005) were independently associated with poor functional outcome. However, the independent association between intraprocedural BPV and PH at 24 hours has not been established in this study. CONCLUSIONS: Increased intraprocedural BPV was more likely to have poor functional outcome in patients with LVO following MT with general anaesthesia. This finding indicates that special precautions should be taken to minimise BP fluctuation during procedure.

TCD hemodynamics findings in the subacute phase of anterior circulation stroke patients treated with mechanical thrombectomy.

Despite mechanical thrombectomy, the prognosis for many patients with anterior circulation ischemic stroke (ACIS) remains poor. This retrospective study reports consecutive mechanical thrombectomy procedures for ACIS at our hospital over 4 years. Hemodynamics were explored using transcranial Doppler ultrasound. The functional outcome was assessed using the modified Rankin scale. A total of 121 eligible cases were included: 61 (50.4%) exhibited good outcomes (modified Rankin scale score ≤2) by day 90. The logistic regression analysis showed that ipsilateral middle cerebral artery (iMCA) systolic blood flow (SBF) (OR = 0.983, 95% CI: 0.969-0.997, P = 0.014), preoperative National Institutes of Health Stroke Scale (NIHSS)score (OR = 1.160, 95% CI: 1.067-1.261, P < 0.001), intracranial hemorrhage after therapy (OR = 19.514, 95% CI: 4.364-87.265, P < 0.001), and Alberta Stroke Program Early Computed Tomography Score (OR = 0.639, 95% CI: 0.416-0.981, P = 0.040) were independently associated with prognosis. The iMCA SBF and preoperative NIHSS score were significantly predictive of a good outcome in the receiver operating characteristic analysis. In conclusion, elevated iMCA SBF might be a prognostic indicator of a good 90-day outcome following endovascular treatment in ACIS patients treated with mechanical thrombectomy, but large prospective studies are mandatory to validate the findings of our study.

Novel Imaging Biomarker Prediction of Parenchymal Hemorrhage after Mechanical Thrombectomy in Patients with Large Ischemic Core.

BACKGROUND: Recently studies have shown that select acute ischemic stroke (AIS) patients with large ischemic core could be deemed as reasonable candidates to receive mechanical thrombectomy (MT) with low risk of developing parenchymal hemorrhage (PH) or symptomatic intracerebral hemorrhage (sICH); however, the selection criterion remains lacking. Our study aims to investigate the relationship between a novel imaging biomarker of largest core mass volume (LCMV) and development of PH in stroke patients with large ischemic core who have undergone MT. METHODS: A total of 26 AIS patients with large ischemic core (defined as ischemic core volume ≧ 50 ml) were enrolled in the study. Volume of ischemic core and the LCMV measured with Mistar software were measured in all patients. Fourteen patients with AIS developed PH while 12 patients showed no signs of PH based on CT imaging obtained between 24 h and 3 day after MT. We compared the volume of ischemic core and LCMV between two groups. RESULTS: Volume of ischemic core showed no significant difference between the PH and no PH group [105.5 (62.4-131.5) vs 75.0 (56.3-102.2), p = 0.105], whereas LCMV was significantly higher in the PH (14.80 ± 5.23) vs. no PH group (8.40 ± 2.61, p = 0.001). ROC analysis revealed that LCMV was positively correlated with PH (area under the curve = 0.905). The optimal LCMV associated with PH was ≧ 9.67 ml. CONCLUSION: LCMV is an effective and easy-to-use imaging biomarker to predict PH after MT in AIS patients with large ischemic core.

Rescue stenting after the failure of mechanical thrombectomy to treat acute intracranial atherosclerotic occlusion.

Background: Acute ischemic stroke (AIS) with intracranial large vessel occlusion (LVO) is refractory to reperfusion because of the underlying intracranial atherosclerosis (ICAS), and this condition often requires salvage methods such as balloon angioplasty and rescue stenting (RS). In this study, we investigated the short-term outcomes of RS after failed mechanical thrombectomy (MT) for the treatment of acute intracranial atherosclerotic occlusion. Methods: We retrospectively evaluated the clinical data of 127 patients who underwent MT for acute intracranial atherosclerotic occlusion in our hospital between August 2018 and January 2022. The degree of recanalization was evaluated immediately after the treatment by Modified Thrombolysis in Cerebral Infarction (mTICI). The modified Rankin Scale (mRS) was used 90 days after treatment to evaluate the neurological functions. In addition, the incidence of symptomatic intracranial hemorrhage (sICH) and postoperative mortality within 90 days of treatment were calculated. Results: Among the 127 patients, 86 patients (67.7%) had revascularization (mTICI 2b-3) immediately after MT (non-RS group), and RS was performed in 41 patients (32.3%) after MT failure (RS group). No difference in the sICH rate was observed between the two groups (17.1 vs. 16.3%, p = 0.91). There was a slightly higher mortality rate in the RS group (14.6 vs. 12.8%, p = 0.71); however, the difference was not significant. There was no difference in the proportion of patients in the RS and non-RS groups who had a 90-day mRS score of 0-2 (48.8 vs. 52.3%, p = 0.76). Conclusions: Rescue stenting after MT failure might be a feasible rescue modality for treating acute intracranial atherosclerotic occlusion.

Increased Postoperative Fasting Glucose Is Associated With Unfavorable Outcomes in Patients Treated With Mechanical Thrombectomy Treatment.

Background and objective: Hyperglycemia on admission was associated with worse clinical outcomes after mechanical thrombectomy (MT) of acute ischemic stroke (AIS). We evaluated whether increased postoperative fasting glucose (PFG) was also related to poor clinical outcomes in patients who underwent MT treatment. Methods: Consecutive patients with large vessel occlusion underwent MT in our center were included. Admission glucose and fasting glucose levels after MT treatment were evaluated. Primary outcome was 90-day unfavorable outcomes (modified Rankin Scale score of 3-6). Secondary outcome was the rate of symptomatic intracranial hemorrhage (sICH) after MT treatment. The association of PFG and 90-day clinical outcome after MT treatment was determined using logistic regression analyses. Results: One hundred twenty seven patients were collected. The median postoperative fasting glucose level was 6.27 mmol/L (IQR 5.59-7.62). Fourteen patients (11.02%) had sICH, and fifty-eight patients (45.67%) had unfavorable outcomes at 90-day after MT. After adjustment for potential confounding factors, PFG level was an independent predictor of 90-day unfavorable outcome (OR 1.265; 95% CI 1.017-1.575; p = 0.035) and sICH (OR 1.523; 95% CI 1.056-2.195; p = 0.024) after MT. In addition, older age, higher baseline NIHSS score, and higher postoperative NLR were also associated with unfavorable outcomes at 90-day after MT treatment. Conclusions: Increased PFG is associated with unfavorable outcomes at 90-day and an increased risk of sICH in patients underwent MT treatment.

Prolonged Duration of Blood Pressure Drops During General Anesthesia Is Associated With Worse Outcomes After Mechanical Thrombectomy.

Background and Purpose: Optimal periprocedural management of blood pressure during mechanical thrombectomy (MT) remains controversial. This study aimed to investigate the relationship between the duration of blood pressure drops during general anesthesia and the outcomes in large vessel occlusion (LVO) patients treated with MT. Methods: We retrospectively reviewed our prospectively collected data for LVO patients treated with MT between January 2018 and July 2020. Intraprocedural mean arterial pressure (MAP) was recorded every 5 min throughout the procedure. Baseline MAP minus each MAP value recorded during general anesthesia was defined ΔMAP. Cumulated time (in min) and longest continuous episode (in min) with ΔMAP more than 10, 15, 20, 25, and 30 mmHg were calculated, respectively. Poor outcome was defined as 90-day modified Rankin score (mRS) 3-6. Associations between cumulated time of different ΔMAP thresholds and poor outcome were determined using binary logistic regression models. Results: A total of 131 patients were finally included in the study. After controlling for age, atrial fibrillation, baseline NIHSS, baseline ASPECTS, procedure duration of MT, and times of retrieval attempts, the results indicated that cumulated time of MAP drop more than 10 mmHg (OR 1.013; 95% CI 1.004-1.023; P = 0.007) and 15 mmHg (OR 1.011; 95% CI 1.002-1.020; P = 0.017) were independently associated with poor outcomes. Conclusion: Prolonged episodes of intraprocedural MAP lowering were more likely to have poor outcomes in LVO patients following MT with general anesthesia, which might be helpful in guiding intraprocedural hemodynamic management of patients under general anesthesia.

Absent filling of the superficial middle cerebral vein is associated with reperfusion but not parenchymal hematoma in stroke patients undergoing thrombectomy: an observational study.

BACKGROUND: Parenchymal hematoma (PH) is the most feared complication of reperfusion therapy after stroke. The opacification of the superficial middle cerebral vein (SMCV) on computed tomography perfusion (CTP) has been associated with poor functional outcomes after stroke, while its association with PH has not been verified for acute stroke patients undergoing thrombectomy. METHODS: Consecutive patients with acute anterior large artery occlusion (LAO) who received thrombectomy were retrospectively enrolled between May 2018 and May 2019. Absent filing of the SMCV (SMCV-) on CTP-derived CT angiography was defined as no contrast filling of the SMCV across the whole venous phase in the ischemic hemisphere, while SMCV+ was defined as the presence of contrast filling of the SMCV at any time point of the venous phase. RESULTS: A total of 52 patients were enrolled in the study, and 15 patients (28.8%) developed a PH within 48 hours after thrombectomy. SMCV- was not associated with PH in both the univariate and multivariate logistic regression analyses (all P>0.05), but was an independent risk factor for reperfusion [modified thrombolysis in cerebral infarction score of 2b-3; odds ratio (OR) =0.172, 95% confidence interval (CI): 0.031-0.960, P=0.045]. Reperfusion was associated with a reduced risk of PH (OR =0.110, 95% CI: 0.013-0.913, P=0.041). However, in a subgroup analysis of patients who had reperfusion, the SMCV- group had a higher rate of PH than the SMCV+ group (40.0% vs. 13.8%, P=0.049). CONCLUSIONS: In patients who received thrombectomy, SMCV- did not predict PH, but was a risk factor for reperfusion. Although reperfusion was a protective factor for PH, the SMCV- group was still at a higher risk of PH compared with the SMCV+ group when reperfusion was successfully achieved.

Absent Contrast Filling of Ipsilateral Superficial Middle Cerebral Vein Predicts Midline Shift in Acute Middle Cerebral Artery Occlusion.

Background and purpose: Midline shift is a life-threatening complication of acute large artery occlusion (LAO). The value of superficial middle cerebral vein (SMCV) for predicting midline shift is currently unclear for patients with acute LAO. Methods: Consecutive acute LAO (middle cerebral artery M1 ± intracranial internal carotid artery) patients between March 2018 and May 2019 were included. Absent filling of ipsilateral cortical vein (marked as SMCV-) was defined as no contrast filling into the vein across the whole venous phase of four-dimensional computed tomography (CT) angiography derived from CT perfusion in the ischemic hemisphere. Results: In the total of 81 patients, 31 (38.4%) were identified as SMCV-. SMCV- independently predicted midline shift, with sensitivity of 87.5% and specificity of 82.5%. Receiver operating characteristic analysis showed that including SMCV- as a predictor in addition to baseline ischemic core volume significantly increased the area under the curve in predicting midline shift (SMCV- with baseline ischemic core volume vs. baseline ischemic core volume: AUC = 0.903 vs. 0.841, Z = 2.451, P = 0.014). Conclusion: In acute LAO patients, the presence of SMCV- was a sensitive and specific imaging marker for midline shift. SMCV- had supplementary value to baseline ischemic core volume in predicting midline shift.

Number of Stent Retriever Passes Associated with Clinical Outcome After Mechanical Thrombectomy in Acute Ischemic Stroke.

OBJECTIVE: To evaluate the association between the number of stent retriever (SR) passes and clinical outcome after mechanical thrombectomy (MT) in patients with acute ischemic stroke(AIS). METHODS: We retrospectively analyze data collected from consecutive patients with large vessel occlusion (LVO) in anterior circulation treated with MT. Baseline characteristics, number of SR passes, symptomatic intracranial hemorrhage (sICH), clinical outcome measured by modified Rankin Scale (mRS) at 90 days after MT were collected. Multivariate logistic regression analysis was performed to assess the association between number of SR passes and patients' clinical outcome. RESULTS: 134 patients with LVO achieved successful reperfusion (mTICI 2B/3) were enrolled. Univariate analysis showed that patients with favorable outcomes were less likely to need more than three passes of SR (9.8%vs39.7%, p = 0.001). In a multivariable analysis, baseline NIHSS score (OR 0.922, 95%CI 0.859∼0.990, p = 0.025), more than three passes of SR (OR 0.284, 95%CI0.091∼0.882, p = 0.030) and symptomatic intracranial hemorrhage (OR 0.116,95%CI0.021∼0.650, p = 0.014) each independently predicted poor outcome after MT at 90 days. CONCLUSION: The need for more than three passes of SR may be used as an independent predictor of poor outcome after MT in patients with acute ischemic stroke at 90 days.

Tremor Caused by Dandy-Walker Syndrome Concomitant with Syringomyelia: Case Report and Review of the Literature Review.

BACKGROUND: Dandy-Walker Syndrome (DWS) is a rare congenital brain malformation characterized by underdevelopment of cerebellar vermis and cystic enlargement of the fourth ventricle and enlargement of the posterior fossa. The cooccurrence of DWS and syringomyelia in adults is very rare. CASE DESCRIPTION: We report a man aged 19 years who presented with a 2-year history of tremor. Magnetic resonance imaging showed cystic dilation of the fourth ventricle, hypoplasia of the cerebellar vermis, and syringomyelia. Posterior fossa decompression and spinal cord ostomy were performed. Tremor was markedly improved and the fourth ventricular and the syringomyelia were reduced in size postoperatively. CONCLUSIONS: Tremor can be a clinical manifestation in patients of DWS concomitant with syringomyelia in adults. Spinal cord ostomy combined with posterior fossa decompression may be an effective approach for alleviation of symptoms and syringomyelia.

The effective clinical outcomes of the Gufoni maneuver used to treat 91 vertigo patients with apogeotropic direction-changing positional nystagmus (apo-DCPN).

This study aimed to observe and analyze the effects and outcomes of patients with apogeotropic direction-changing positional nystagmus (apo-DCPN) who received Gufoni maneuver.A total of 91 patients with positional vertigo admitted to the specialized dizziness clinic in Zhejiang Provincial People's Hospital from February 2014 to August 2017 were included. The immediate treatment responses to the Gufoni maneuver were observed and recorded. The patients in whom the treatment was ineffective were followed up for 4 weeks to observe the outcome of apo-DCPN.In 21 patients, the apo-DCPN was transformed after Gufoni maneuver, and 7 patients developed transformation within 4 weeks of follow-up. Spontaneous remission of apo-DCPN within the follow-up period was observed in 55 patients who were unresponsive to the Gufoni maneuver. The prevalence of migraine was significantly higher in the early remission group (P < .05) and the period between the initial visit and nystagmus remission was significantly shorter in the group of patients with migraine history (P < .05).This study demonstrates that the immediate treatment efficacy of the Gufoni maneuver is poor in positional vertigo patients with apo-DCPN. We believe that the reason for the low efficacy is that the Gufoni maneuver is only effective for some patients with apo-DCPN type HSC-BPPV. In patients with early spontaneous remission and a history of migraine, central positional nystagmus of probable vestibular migraine (VM) or benign recurrent vertigo should be considered for the mechanisms of apo-DCPN generation.

Tirofiban facilitates the reperfusion process during endovascular thrombectomy in ICAS.

The aim of the present study was to assess the use of tirofiban injections for rescue therapy following artery reocclusion due to intra-luminal thrombosis during endovascular thrombectomy in patients with acute ischemic stroke (AIS). A total of seven cases of patients treated with adjunctive tirofiban injections following failed endovascular thrombectomy due to instant intra-luminal thrombosis were retrospectively assessed. A Solitaire stent was used as the primary thrombectomy device in all patients. Tirofiban was injected intra-arterially via a temporarily deployed Solitaire stent with continuous intravenous infusion for the subsequent 24 h; half of the conventionally recommended dose was employed. Outcome measures included angiographic reperfusion (mTICI), symptomatic intracranial hemorrhage, mortality and functional independence at 90 days (modified Rankin Scale, 0-2). Six patients had occlusions in the middle cerebral artery and one patient had occlusions in the basilar artery. Of the seven patients, five exhibited successful reperfusion (mTICI 2b-3) and achieved functional independence following 90 days. Reperfusion failed in the remaining two patients, who succumbed within 90 days of therapy. No intracranial or extracranial hemorrhage cases were identified. The results of the present study suggest that tirofiban facilitates reperfusion and ameliorates long-term prognosis in patients with AIS undergoing endovascular thrombectomy, and may be safe for those receiving intravenous tissue plasminogen activator therapy.

Good recovery of subarachnoid hemorrhage concomitant with ischemia due to anterior cerebral artery dissection by conservative treatment: A case report.

The present report describes the case of a 57-year-old woman presenting with subarachnoid hemorrhage (SAH) and acute ischemic stroke (AIS) due to anterior cerebral artery (ACA) dissection, which exhibited severe stenosis at the origin with distal dilatation of the A2 segment and occlusion of the A3 segment. In this case, computed tomography (CT) revealed SAH in right superior frontal sulcus and the interhemispheric fissure. Magnetic resonance imaging demonstrated acute infarct in the territory of the right ACA. Brain digital subtraction angiography showed severe stenosis at the origin of the A2 segment with distal dilatation and occlusion at the origin of the A3 segment of the right ACA, suggesting a diagnosis of dissection. Only treatment with atorvastatin, her clinical condition subsequently improved. The stenosis and dilatation of A2 segment were ameliorated as demonstrated by a follow-up CT angiography 5 months after onset. SAH concomitant with ischemia caused by ACA dissection is rare. Conservative treatment may be a safe and effective choice for patients with SAH concomitant with AIS due to ACA dissection.