Risk of supranormal left ventricular ejection fraction in patients with aortic stenosis.

BACKGROUND: Cardiovascular events are increasing in patients with supranormal left ventricular ejection fraction (snLVEF). However, the effect of snLVEF in patients with aortic stenosis (AS) remains unclear, especially in patients with moderate AS. HYPOTHESIS: This study aimed to evaluate the prognosis of mortality and heart failure (HF) in patients with LVEF ≥ 50% and moderate or severe AS. METHODS: This retrospective study targeted patients with moderate or severe AS and LVEF > 50%. LVEF of 50%-65% was classified as normal LVEF (nLVEF, nEF group) and >65% as snLVEF (snEF group). AS severity was stratified based on the aortic valve area into moderate (1.0-1.5 cm²) and severe (<1.0 cm²). Primary outcomes included all-cause mortality and HF hospitalization. RESULTS: A total of 226 participants were included in this study. There were 67 and 65 participants with moderate AS in snEF (m-snEF) and nEF groups (m-nEF), respectively, and 41 and 53 participants with severe AS in the snEF (s-snEF) and nEF groups (s-nEF), respectively. During the observation period (median: 554 days), the primary composite outcome occurred in 108 individuals. Cox hazard analysis revealed no significant differences among the four groups in primary composite outcomes. With respect to HF hospitalization, the adjusted hazard ratios (95% confidence intervals) with m-snEF as the reference were as follows: m-nEF, 0.41 (0.19-0.89); s-nEF, 1.43 (0.76-2.67); and s-snEF, 1.83 (1.00-3.35). CONCLUSIONS: The risk of HF hospitalization for m-snLVEF was higher than m-nLVEF and not significantly different from s-nLVEF.

Development of Machine Learning Prediction Models for Self-Extubation After Delirium Using Emergency Department Data.

Delirium is common in the emergency department, and once it develops, there is a risk of self-extubation of drains and tubes, so it is critical to predict delirium before it occurs. Machine learning was used to create two prediction models in this study: one for predicting the occurrence of delirium and one for predicting self-extubation after delirium. Each model showed high discriminative performance, indicating the possibility of selecting high-risk cases. Visualization of predictors using Shapley additive explanation (SHAP), a machine learning interpretability method, showed that the predictors of delirium were different from those of self-extubation after delirium. Data-driven decisions, rather than empirical decisions, on whether or not to use physical restraints or other actions that cause patient suffering will result in improved value in medical care.

Temporal Generalizability of Machine Learning Models for Predicting Postoperative Delirium Using Electronic Health Record Data: Model Development and Validation Study.

BACKGROUND: Although machine learning models demonstrate significant potential in predicting postoperative delirium, the advantages of their implementation in real-world settings remain unclear and require a comparison with conventional models in practical applications. OBJECTIVE: The objective of this study was to validate the temporal generalizability of decision tree ensemble and sparse linear regression models for predicting delirium after surgery compared with that of the traditional logistic regression model. METHODS: The health record data of patients hospitalized at an advanced emergency and critical care medical center in Kumamoto, Japan, were collected electronically. We developed a decision tree ensemble model using extreme gradient boosting (XGBoost) and a sparse linear regression model using least absolute shrinkage and selection operator (LASSO) regression. To evaluate the predictive performance of the model, we used the area under the receiver operating characteristic curve (AUROC) and the Matthews correlation coefficient (MCC) to measure discrimination and the slope and intercept of the regression between predicted and observed probabilities to measure calibration. The Brier score was evaluated as an overall performance metric. We included 11,863 consecutive patients who underwent surgery with general anesthesia between December 2017 and February 2022. The patients were divided into a derivation cohort before the COVID-19 pandemic and a validation cohort during the COVID-19 pandemic. Postoperative delirium was diagnosed according to the confusion assessment method. RESULTS: A total of 6497 patients (68.5, SD 14.4 years, women n=2627, 40.4%) were included in the derivation cohort, and 5366 patients (67.8, SD 14.6 years, women n=2105, 39.2%) were included in the validation cohort. Regarding discrimination, the XGBoost model (AUROC 0.87-0.90 and MCC 0.34-0.44) did not significantly outperform the LASSO model (AUROC 0.86-0.89 and MCC 0.34-0.41). The logistic regression model (AUROC 0.84-0.88, MCC 0.33-0.40, slope 1.01-1.19, intercept -0.16 to 0.06, and Brier score 0.06-0.07), with 8 predictors (age, intensive care unit, neurosurgery, emergency admission, anesthesia time, BMI, blood loss during surgery, and use of an ambulance) achieved good predictive performance. CONCLUSIONS: The XGBoost model did not significantly outperform the LASSO model in predicting postoperative delirium. Furthermore, a parsimonious logistic model with a few important predictors achieved comparable performance to machine learning models in predicting postoperative delirium.

The impact of SAH finding on CT to the clinical outcome after mechanical thrombectomy for large vessel occlusion.

BACKGROUND AND PURPOSE: Whether subarachnoid haemorrhage (SAH) after mechanical thrombectomy affects the clinical outcomes of patients with acute large-vessel occlusion remains unclear. This study aimed to investigate the clinical impact of SAH on computed tomography (CT) after mechanical thrombectomy. METHODS: The SKIP study was an investigator-initiated, multicentre, randomised, open-label clinical trial. This study was performed in 23 hospital networks in Japan from January 1, 2017, to July 31, 2019. Among the 204 patients, seven were excluded because they did not undergo mechanical thrombectomy (MT) and had a modified Rankin scale (mRS) score > 2. The main outcome was the association between SAH within 36 h after mechanical thrombectomy and the clinical outcome at 90 days. RESULTS: Among 197 patients, the median age was 74 (67-79) years, 62.9% were male. Moreover, 26 (13.2%) patients had SAH (seven isolated SAH) on CT within 36 h. The SAH rate did not differ according to IV rt-PA administration (p = 0.4). The rate of favourable clinical outcomes tended to be lower in patients with SAH rather than patients without SAH (11 [42%] vs. 106 [62%], p = 0.08). Among the seven patients with isolated SAH, 6 showed favourable outcomes at 90 days. In the multivariate regression analysis, the presence of SAH within 36 h from onset was not associated with clinical outcome (Odd ratio, 0.59; 95% confidence interval, 0.18-1.95; p = 0.38). CONCLUSIONS: Among patients with acute stroke treated with MT, SAH, especially isolated SAH findings on CT, were not associated with poor clinical outcomes after 90 days. TRIAL REGISTRATION NUMBER: UMIN000021488.

Ultra-early rt-PA administration should improve patient outcome on mechanical thrombectomy: Post hoc analysis of SKIP.

BACKGROUND: To investigate whether ultra-early recombinant tissue-plasminogen activator (rt-PA) administration can improve patient outcomes on mechanical thrombectomy (MT) in patients with large vessel occlusion (LVO). METHODS: Participants comprised rt-PA-eligible 204 patients with internal carotid artery or middle cerebral artery occlusion in the SKIP trial, who were randomly assigned to receive mechanical thrombectomy alone or combined intravenous thrombolysis (rt-PA: alteplase at 0.6 mg/kg) plus mechanical thrombectomy. We assessed associations between onset-to-puncture time and onset-to-rt-PA administration time and frequency of favorable outcome at 90 days and any intracerebral hemorrhage (ICH) at 36 h after onset. RESULTS: As a cut-off onset-to-puncture time for favorable outcome, receiver operating characteristic curves defined 2.5 h (57% sensitivity, 62% specificity). For onset-to-puncture times ≤2.5 h and > 2.5 h, frequencies of favorable outcomes were 72% and 63% (p = 0.402) in patients with rt-PA therapy and 44% and 58% (p = 0.212) in patients without rt-PA therapy, respectively. In terms of onset-to-rt-PA administration time, frequencies of favorable outcomes among patients with ultra-early rt-PA administration at ≤100, >100 min after onset, and without rt-PA therapy with onset-to-puncture time ≤ 2.5 h, and with and without rt-PA therapy with onset-to-puncture time > 2.5 h were 84% and 64%, 63%, and 44% and 58%, respectively (p = 0.025). Frequencies of any ICH among those patients were 37% and 32%, 32%, and 63% and 40%, respectively (p = 0.006). CONCLUSION: Ultra-early rt-PA administration should improve patient outcomes on mechanical thrombectomy among patients with LVO. Relatively late rt-PA administration might increase the frequency of any ICH.

Systemic immune-inflammation index as a predictor of prognosis after carotid artery stenting compared with C-reactive protein.

BACKGROUND: Immune-inflammatory processes are highly associated with the progression of atherosclerosis. The systemic immune-inflammation index (SII) is a potential predictor for clinical outcomes in patients with stroke and ischemic heart disease. Therefore, this study aimed to investigate whether SII can accurately predict the short- and long-term prognoses in patients who underwent carotid artery stenting (CAS) compared to that with C-reactive protein (CRP). METHODS: This study was a single-center retrospective investigation. Overall, 129 patients who underwent CAS were categorized into tertiles based on their SII levels. We primarily investigated the long-term major adverse cardiac and cerebrovascular events (MACCE) and secondarily the in-hospital and long-term stroke incidence, as well as all-cause death. RESULTS: The in-hospital stroke rate tended to increase with a rise in SII (P = 0.13). Over the 5-year follow-up period, the Kaplan-Meier overall incidence of MACCE was 9.3%, 16.3%, and 39.5% in the lowest to highest tertiles, respectively (log-rank trend test, P<0.001). The rates of stroke and MACCE during the long-term follow-up were significantly higher with increasing SII. Cox regression analysis showed that the highest tertile of SII (>647) was a predictor of the incidence of long-term stroke (hazard ratio (HR), 21.3; 95% confidence interval (CI), 2.41-188; P = 0.006) and MACCE (HR, 3.98; 95% CI, 1.80-8.81; P<0.001). However, after adjusting for both SII and CRP, only SII remained a significant independent predictor, whereas CRP became less relevant. The receiver operating characteristic curve analysis of long-term MACCE showed that the area under the curve (AUC) for SII (AUC, 0.72; 95% CI, 0.60-0.84; P<0.001) was greater than that of CRP (AUC, 0.64; 95% CI, 0.51-0.77; P = 0.040). CONCLUSION: SII was shown to be an independent predictor of long-term prognosis in patients who underwent CAS and was suggested to be superior to CRP as an inflammatory prognosis predictor.

Investigation of effective invasive blood pressure control methods to prevent acute exacerbation of acute aortic dissection.

BACKGROUND: Acute aortic dissection is associated with high mortality and increased risk of complications. Acute exacerbations have a relatively high frequency; however, the contributing factors are unclear. Blood pressure (BP) and heart rate control are important factors, but the ideal BP control strategy to prevent acute exacerbations under invasive arterial pressure monitoring remains unclear. Therefore, in this study, we aimed to determine the relationship between invasive arterial BP and the effects of acute exacerbation of aortic dissection. METHODS AND RESULTS: This single-centre, retrospective, case-control study included 104 patients with a partial diagnosis of acute aortic dissection (Stanford type A or B) who were treated conservatively between September 2013 and September 2022. The patients were divided into exacerbation (acute exacerbation; n  = 26) and stable (no acute deterioration) groups. The SBP trend (122.5 ±â€…13.1 vs. 116.6 ±â€…10.6 mmHg, respectively; P  = 0.024) and mean BP trend (77.8 ±â€…5.8 vs. 74.4 ±â€…7.5 mmHg, respectively; P  = 0.038) significantly differed between the two groups. The time to target BP was significantly longer in the exacerbation group ( P  = 0.036). CONCLUSION: The exacerbation group did not achieve a mean SBP < 120 mmHg. Moreover, the importance of early BP reduction was demonstrated in the present study.

Comparison of the OPTIVUS-Complex PCI Multivessel Cohort With the Historical CREDO-Kyoto Registry Cohort-3.

BACKGROUND: There is a paucity of data on the effect of optimal intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) compared with standard PCI or coronary artery bypass grafting (CABG) in patients with multivessel disease.Methods and Results: The OPTIVUS-Complex PCI study multivessel cohort was a prospective multicenter single-arm study enrolling 1,021 patients undergoing multivessel PCI including the left anterior descending coronary artery using IVUS aiming to meet the prespecified criteria for optimal stent expansion. We conducted propensity score matching analyses between the OPTIVUS group and historical PCI or CABG control groups from the CREDO-Kyoto registry cohort-3 (1,565 and 899 patients) fulfilling the inclusion criteria for this study. The primary endpoint was a composite of death, myocardial infarction, stroke, or any coronary revascularization. In the propensity score-matched cohort (OPTIVUS vs. historical PCI control: 926 patients in each group; OPTIVUS vs. historical CABG control: 436 patients in each group), the cumulative 1-year incidence of the primary endpoint was significantly lower in the OPTIVUS group than in the historical PCI control group (10.4% vs. 23.3%; log-rank P<0.001) or the historical CABG control group (11.8% vs. 16.5%; log-rank P=0.02). CONCLUSIONS: IVUS-guided PCI targeting the OPTIVUS criteria combined with contemporary clinical practice was associated with superior clinical outcomes at 1 year compared with not only the historical PCI control, but also the historical CABG control.

National Institutes of Health Stroke Scale Score Less Than 10 at 24 hours After Stroke Onset Is a Strong Predictor of a Favorable Outcome After Mechanical Thrombectomy.

BACKGROUND: There are a few accurate predictors of patient outcomes after mechanical thrombectomy (MT). OBJECTIVE: To investigate whether the National Institutes of Health Stroke Scale (NIHSS) score 24 hours after stroke onset could predict favorable outcomes at 90 days in patients with acute stroke treated with MT. METHODS: Patients from the SKIP study were enrolled in this study. Using receiver operating characteristic curves, the optimal cut-off NIHSS score 24 hours after stroke onset was calculated to distinguish between favorable (modified Rankin Scale score 0-2) and unfavorable (modified Rankin Scale score 3-6) outcomes at 90 days. These receiver operating characteristic curves were compared with those of previously reported predictors of favorable outcomes, such as the ΔNIHSS score (baseline NIHSS score-NIHSS score at 24 h), percent delta (ΔNIHSS score × 100/baseline NIHSS score), and early neurological improvement indices. RESULTS: A total of 177 patients (median age, 72 years; female, 65 [37%]) were enrolled, and 109 (61.9%) had favorable outcomes. The respective sensitivity, specificity, and area under the curve values for an NIHSS of 10 were 92.6%, 80.7%, and .906; a ΔNIHSS score of 7 were 70.6%, 76.1%, and .797; and percent delta of 48.3% were 85.3%, 80.7%, and .890. CONCLUSION: NIHSS score <10 at 24 hours after stroke onset is a strong predictor of favorable outcomes at 90 days in patients treated with MT.

Intravenous Alteplase is Associated with First Pass Effect in Stent-retriever but not ADAPT Thrombectomy : Post Hoc Analysis of the SKIP Study.

PURPOSE: To investigate the effect of alteplase, either combined with stent-retriever thrombectomy or a direct aspiration first pass technique (ADAPT), in patients with large-vessel occlusion stroke. METHODS: This was a retrospective post hoc analysis of data from The Direct Mechanical Thrombectomy in Acute LVO Stroke (SKIP) study. Patients were divided into two groups according to the first-line thrombectomy technique: stent-retriever and ADAPT. Each group was further divided into two subgroups, namely MT and MT + alteplase. The procedural outcomes, such as first pass effect (FPE) ratio and number of passes, were evaluated. The clinical outcomes included mRS score at 3 months. RESULTS: A total of 180 patients were included (116 in the stent-retriever group and 64 in the ADAPT group). No interaction was detected between the first-line technique and alteplase administration. In the stent-retriever group, after adjusting for factors associated with FPE, the adjusted odds ratio (95% confidence interval) of FPE of the MT + alteplase subgroup versus the MT subgroup was 3.57 (1.5-8.48) and in the ADAPT group it was 1.35 (0.37-4.91). With alteplase, the number of passes decreased with adjusted odds ratios of 0.59 (0.37-0.93) in the stent-retriever group but not in the ADAPT group. In both first-line technique groups, clinical outcomes did not differ between subgroups. CONCLUSION: In the SKIP study, alteplase administration was associated with increased FPE when combined with stent-retriever thrombectomy, but not with ADAPT. We found no differences in the clinical outcomes.

A Resuscitated Adult With Left Main Coronary Artery Ostial Atresia and Graves' Disease: 10-Year Follow-up.

This is the first report of a resuscitated adult with left main coronary artery ostial atresia (LMCAOA), with long-term follow-up for 10 years. A 57-year-old woman with untreated Graves' disease presented with resuscitated cardiac arrest, and her computed tomography coronary angiography showed a string-like left main without significant atherosclerosis, which led to the diagnosis of LMCAOA. Noninvasive and invasive testing revealed extensive myocardial ischemia because of LMCAOA with concomitant coronary spasm. After successful revascularization with coronary artery bypass grafting, the patient has remained stable for 10 years, which highlights this treatment as being highly effective and durable in patients with LMCAOA and cardiac arrest.

Il s'agit du premier rapport d'un adulte réanimé présentant une atrésie ostiale de l'artère coronaire principale gauche (atrésie ostiale de l'ACPG), comportant un suivi à long terme sur une période de 10 ans. Une femme de 57 ans atteinte de la maladie de Basedow non traitée a subi un arrêt cardiaque en réanimation. La coronarographie par tomodensitométrie a montré une artère principale gauche en forme de cordon sans athérosclérose importante, ce qui a conduit au diagnostic d'atrésie ostiale de l'ACPG. Des tests non invasifs et invasifs ont révélé une ischémie myocardique étendue due à l'atrésie ostiale de l'ACPG avec spasme coronaire concomitant. Après une revascularisation réussie par pontage aorto-coronarien, la patiente est restée stable pendant 10 ans, ce qui montre que ce traitement est très efficace et durable chez les patients atteints d'atrésie ostiale de l'ACPG et d'arrêt cardiaque.

Effect of Mechanical Thrombectomy Without vs With Intravenous Thrombolysis on Functional Outcome Among Patients With Acute Ischemic Stroke: The SKIP Randomized Clinical Trial.

IMPORTANCE: Whether intravenous thrombolysis is needed in combination with mechanical thrombectomy in patients with acute large vessel occlusion stroke is unclear. OBJECTIVE: To examine whether mechanical thrombectomy alone is noninferior to combined intravenous thrombolysis plus mechanical thrombectomy for favorable poststroke outcome. DESIGN, SETTING, AND PARTICIPANTS: Investigator-initiated, multicenter, randomized, open-label, noninferiority clinical trial in 204 patients with acute ischemic stroke due to large vessel occlusion enrolled at 23 hospital networks in Japan from January 1, 2017, to July 31, 2019, with final follow-up on October 31, 2019. INTERVENTIONS: Patients were randomly assigned to mechanical thrombectomy alone (n = 101) or combined intravenous thrombolysis (alteplase at a 0.6-mg/kg dose) plus mechanical thrombectomy (n = 103). MAIN OUTCOMES AND MEASURES: The primary efficacy end point was a favorable outcome defined as a modified Rankin Scale score (range, 0 [no symptoms] to 6 [death]) of 0 to 2 at 90 days, with a noninferiority margin odds ratio of 0.74, assessed using a 1-sided significance threshold of .025 (97.5% CI). There were 7 prespecified secondary efficacy end points, including mortality by day 90. There were 4 prespecified safety end points, including any intracerebral hemorrhage and symptomatic intracerebral hemorrhage within 36 hours. RESULTS: Among 204 patients (median age, 74 years; 62.7% men; median National Institutes of Health Stroke Scale score, 18), all patients completed the trial. Favorable outcome occurred in 60 patients (59.4%) in the mechanical thrombectomy alone group and 59 patients (57.3%) in the combined intravenous thrombolysis plus mechanical thrombectomy group, with no significant between-group difference (difference, 2.1% [1-sided 97.5% CI, -11.4% to ∞]; odds ratio, 1.09 [1-sided 97.5% CI, 0.63 to ∞]; P = .18 for noninferiority). Among the 7 secondary efficacy end points and 4 safety end points, 10 were not significantly different, including mortality at 90 days (8 [7.9%] vs 9 [8.7%]; difference, -0.8% [95% CI, -9.5% to 7.8%]; odds ratio, 0.90 [95% CI, 0.33 to 2.43]; P > .99). Any intracerebral hemorrhage was observed less frequently in the mechanical thrombectomy alone group than in the combined group (34 [33.7%] vs 52 [50.5%]; difference, -16.8% [95% CI, -32.1% to -1.6%]; odds ratio, 0.50 [95% CI, 0.28 to 0.88]; P = .02). Symptomatic intracerebral hemorrhage was not significantly different between groups (6 [5.9%] vs 8 [7.7%]; difference, -1.8% [95% CI, -9.7% to 6.1%]; odds ratio, 0.75 [95% CI, 0.25 to 2.24]; P = .78). CONCLUSIONS AND RELEVANCE: Among patients with acute large vessel occlusion stroke, mechanical thrombectomy alone, compared with combined intravenous thrombolysis plus mechanical thrombectomy, failed to demonstrate noninferiority regarding favorable functional outcome. However, the wide confidence intervals around the effect estimate also did not allow a conclusion of inferiority. TRIAL REGISTRATION: umin.ac.jp/ctr Identifier: UMIN000021488.

Reducing door-to-reperfusion time in acute stroke endovascular therapy using magnetic resonance imaging as a screening modality.

BACKGROUND: The feasibility of performing MRI first for patients with suspected hyperacute stroke in real-world practice has not been fully examined. Moreover, most past studies of reducing door-to-reperfusion time (DRT) in endovascular treatment (EVT) were conducted using CT. The aim of this study was to evaluate the feasibility of an MRI-first policy and to examine the effects of a quality improvement (QI) process for reducing DRT using MRI. METHODS: From January 2013 to December 2018, consecutive patients with acute stroke who came to hospital directly and were treated with emergent EVT were prospectively enrolled into the present study. In principle, MRI was performed first for patients with suspected acute stroke. A step-by-step QI process for decreasing DRT was adopted during this period. Time metrics for EVT were compared between specific time periods. RESULTS: A total of 180 patients (71 women; median age 76 years (range 69-64); National Institutes of Health Stroke Scale score 17 (range 10-23)) were included in the present study. More patients in the late phase were managed with the MRI-first policy (p<0.001). DRT (199 min in Phase 1, 135 min in Phase 2, 129 min in Phase 3, and 121 min in Phase 4, p<0.001) was significantly reduced across the phases. The percentage of patients with DRT <120 min increased significantly across time periods (p<0.001). Symptomatic intracerebral hemorrhage did not increase across phases (p=0.575). CONCLUSION: An MRI-first policy was feasible, and DRT decreased considerably with a step-by-step QI process. This process may be applicable to other hospitals.

Association between initial NIHSS score and recanalization rate after endovascular thrombectomy.

BACKGROUND: National institutes of Health Stroke Scale (NIHSS) score and the presence of successful recanalization are crucial determinants of clinical outcome in patients with major artery occlusion. However, it is unknown whether successful recanalization rate after endovascular therapy (EVT) depends on NIHSS score. METHODS: From our prospective EVT registry, data on patients with an occlusion at the internal carotid artery or middle cerebral artery were analyzed. Successful recanalization was judged as positive when reperfusion of the thrombolysis in cerebral infarction (TICI) scale ≥2b was observed. Successful recanalization rate was also evaluated based on the NIHSS score subgroups: 0-8, 9-16, 17-24, and >24. Multivariate regression analysis was used to evaluate the impact of NIHSS score on successful recanalization. RESULTS: We studied 183 patients (age 76 [68-83], male 110 [60%], NIHSS score 19 [14-24]). One hundred and forty-six (80%) patients had the successful recanalization. Patients achieved the recanalization had lower NIHSS score as 18 (12-23), contrary those failed it had higher NIHSS score as 24 (20-27) (p < .001). Successful recanalization rate was correlated to the NIHSS score grade; 100% in the NIHSS 0-8 group, 88% in 9-16, 81% in 17-24, and only 60% in >24 (p < .001). Multivariate regression analysis showed NIHSS score was an independent parameter of recanalization (odds ratio 0.905 [95%CI 0.837-0.979], p = .013). CONCLUSION: NIHSS score may serve as a predictor of successful recanalization. Recanalization is relatively easier in mild stroke than in those with severe stroke.

The randomized study of endovascular therapy with versus without intravenous tissue plasminogen activator in acute stroke with ICA and M1 occlusion (SKIP study).

RATIONALE: Bridging therapy with endovascular therapy (EVT) and intravenous thrombolysis (IVT) has been reported to improve outcomes for acute stroke patients with large-vessel occlusion in the anterior circulation. While the IVT may increase the reperfusion rate, the risk of hemorrhagic complications increases. Whether EVT without IVT (direct EVT) is equally effective as bridging therapy in acute stroke remains unclear. AIM: This randomized study of endovascular therapy with versus without intravenous tissue plasminogen activator for acute stroke with ICA and M1 occlusion aims to clarify the efficacy and safety of direct EVT compared with bridging therapy. METHODS AND DESIGN: This is an investigator-initiated, multicenter, prospective, randomized, open-treatment, blinded-endpoint clinical trial. The target patient number is 200, comprising 100 patients receiving direct EVT and 100 receiving bridging therapy. STUDY OUTCOME: The primary efficacy endpoint is a modified Rankin Scale score of 0-2 at 90 days. Safety outcome measures are any intracranial hemorrhage at 24 h. DISCUSSION: This trial may help determine whether direct EVT should be recommended as a routine clinical strategy for ischemic stroke patients within 4.5 h from onset. Direct EVT would then become the choice of therapy in stroke centers with endovascular facilities. TRIAL REGISTRATION: UMIN000021488.

Cerebral Embolism Caused by Thrombus in the Pulmonary Vein Stump after Left Lower Lobectomy: A Case Report and Literature Review.

Cerebral embolism after left upper lobectomy caused by a thrombus in the pulmonary vein stump (PVS) is a serious complication. However, it is unclear if cerebral embolism can develop after other types of lobectomy. We present a case of a 68-year-old man with cerebral embolism after left lower lobectomy with a longer PVS than normal. There were no clinically suspected sources for the thrombus except for the PVS. This thrombus seemed to have formed in the PVS. The endovascularly removed thrombus contained scattered nuclear debris around neutrophils, suggesting a physiological response caused by tissue injury.

[To optimize the initial assessment for stroke patients transferred from general hospital may improve the clinical outcome after endovascular thrombectomy].

Rapid adaption of endovascular thrombectomy (EVT) is essential for patients with large arterial occlusion (LAO). Although patients transferred need longer transportation, they have an advantage of preadmission diagnosis regarding arterial occlusion. The aim of the present study is to evaluate whether optimizing the assessment at comprehensive center for patients transferred may improve the clinical outcome after EVT. Data on consecutive patients treated with EVT between September 2014 and May 2017 were studied. Generally, we have two distinct protocols for EVT candidates: 1) the transfer group, patients are directly taken to the CT and escorted to the angiography room; and 2) the direct group, patients receive the routine emergent evaluation and examined with MRI/MRA. Good outcome was defined as modified Rankin Scale score ≤1 at 3 months. Thirty-one (29%) patients were classified into the transfer group and the 77 (71%) were into the direct group. Although the onset to door time was longer in the transfer group (175 [137-275] min. vs. 76 [51-260] min, P = 0.001), the rate of good outcome was similar between the 2 groups (41% vs. 25%, P = 0.205). By multivariate regression analysis, the onset to reperfusion time was the independent factor (odds ratio 0.982, 95%CI: 0.967-0.998, P = 0.026) associated with good outcome, while transfer itself was not the independent parameter (odds ratio 0.732, 95%CI: 0.125-4.291, P = 0.730). Regarding time parameters, door to picture time (11 [7-24] min vs. 27 [21-39] min., P < 0.001) and picture to puncture time (27 [18-60] min. vs. 54 [39-78] min, P < 0.001) were shorter in the transfer group. Thus, the onset to puncture time (234 [177-299] min. vs. 170 [125-367] min, P = 0.063) and the onset to reperfusion time (271 [208-352] min. vs. 237 [159-382] min., P = 0.183) were similar between the 2 groups. Shortening the initial evaluation at comprehensive stroke center can provide a good outcome for patients transferred.

A Report of a Case Involving Body Lateropulsion with Numbness of the Ipsilesional Fingers Caused by a Small Infarction in the Dorsal Part of the Middle Medulla.

Based on the complexity of functional anatomy, a small infarction in the medulla can produce various types of clinical symptoms or signs depending on the location of this infarction. We describe the case of a 46-year-old man who presented with sudden onset of body lateropulsion to the left side and numbness of the ipsilateral fingers. 3-tesla diffusion-weighted magnetic resonance imaging with a section thickness of 2 mm revealed a small infarction in the dorsal part of the left middle medulla. To our knowledge, this is the first case report describing vestibular dysfunction apparent upon otoelectrophysiological examination but without vestibular symptoms or signs except for body lateropulsion.

Impact of Paradoxical Decrease in High-density Lipoprotein Cholesterol Levels After Statin Therapy on Major Adverse Cardiovascular Events in Patients with Stable Angina Pectoris.

PURPOSE: Statin therapy usually increases HDL-C levels. However, a paradoxical decrease in HDL-C levels after statin therapy is often seen in clinical settings. The relationship between a paradoxical decrease in HDL-C levels after statin therapy and adverse cardiovascular events in patients with stable angina pectoris (SAP) is not well understood. The purpose of this study was to analyze the relationship between paradoxical HDL-C decreases after statin therapy and major adverse cardiovascular events (MACEs) in patients undergoing percutaneous coronary intervention (PCI) for SAP. METHODS: Between January 2006 and March 2015, 867 patients underwent PCI for SAP. Of them, we enrolled 209 patients who were newly started on statin therapy before PCI. We excluded patients who had started statin therapy earlier than 6 months before PCI, patients who had not started statin therapy after PCI, and patients who were diagnosed with acute coronary syndrome. They were divided into 2 groups according to the change in their HDL-C levels between baseline and 6 to 9 months after the index PCI: decreased HDL group after statin treatment (80 patients) and increased HDL group (129 patients). The primary end points were MACEs defined as a composite of all-cause death, nonfatal acute myocardial infarction, and target vessel revascularization (TVR). FINDINGS: Using Kaplan-Meier analysis, the 7-year event rate for composite MACEs in the decreased HDL group was found to be higher than that for the increased HDL group (38% versus 24%, log-rank P = 0.02). TVR occurred more frequently in the decreased HDL group than in the increased HDL group (32% versus 12%, log-rank P = 0.01). With the use of multivariate analysis, changes in HDL-C levels after statin therapy indicated a significant inverse association with the increased risk of MACEs, (hazard ratio [HR] = 0.94; 95% CI, 0.92-0.97; P < 0.01). The incidence of MACEs was more strongly associated with ΔHDL than with ΔLDL. Moreover, BMS usage also independently predicted MACEs (HR = 2.18; 95% CI, 1.14-4.17; P < 0.01). IMPLICATIONS: A paradoxical decrease in HDL-C levels after statin therapy might be a risk factor for MACEs, especially TVR, in patients with SAP.

Correlations between geriatric nutritional risk index and peripheral artery disease in elderly coronary artery disease patients.

AIM: Malnutrition is associated with the development of atherosclerosis and an increased risk of cardiovascular mortality in elderly patients. The present study aimed to investigate the association between the Geriatric Nutritional Risk Index (GNRI), a simple nutritional assessment tool, and the prevalence of peripheral artery disease (PAD) in elderly coronary artery disease patients. METHODS: We evaluated 228 elderly coronary artery disease patients (mean age 74.0 ± 5.7 years). Ankle-brachial index (ABI) measurements were routinely carried out to investigate the prevalence of lower extremity PAD. Patients showing ABI <0.9 were defined as having PAD. RESULTS: Based on our findings, 20.6% of the study patients had PAD. The median GNRI values were significantly lower in patients with PAD than those in patients without PAD (93.8 vs 100.0, P < 0.001). Even after multivariate adjustment, GNRI values were independently associated with PAD (odds ratio 0.94; 95% confidence interval 0.89-0.99; P = 0.024). Furthermore, patients with low GNRI and high C-reactive protein levels had a 5.5-fold higher risk of having PAD than those with high GNRI and low C-reactive protein levels. CONCLUSIONS: GNRI values showed a strong relationship with PAD in elderly coronary artery disease patients. These data reinforce the utility of GNRI as a screening tool in clinical practice. Geriatr Gerontol Int 2017; 17: 1057-1062.