Stent-retriever characteristics and strategies associated with recanalization in thrombectomy for acute ischemic stroke.

INTRODUCTION: Predictive factors for successful reperfusion in mechanical thrombectomy for acute ischemic stroke, and especially technical factors, remain controversial. We investigated various techniques for better angiographic outcomes. METHODS: In this retrospective study, acute ischemic stroke patients with large vessel occlusion treated with mechanical thrombectomy with combined technique were included. Scoring of the reperfusion grade for each attempt was conducted, and each attempt was divided into two groups based on successful reperfusion, which was defined using the presence or absence of modified thrombolysis in cerebral infarction 2b-3. The following characteristics were evaluated: the choice of stent-retriever, its length, occlusion site, thrombus position relative to deployed stent-retriever, methods of thrombectomy, and successful advancement of the distal access catheter to the proximal end of the thrombus. RESULTS: Among 251 patients who underwent mechanical thrombectomy, 154 patients (255 attempts: mTICI 0-2a group, n = 119; mTICI 2b-3 group, n = 136) were included in the analysis. The thrombus position relative to the deployed stent-retriever was likely associated with successful reperfusion, although it was not statistically significant (proximal two-thirds 56.8 %; distal one-third 44.3 %, p = 0.09). Successful advancement of the distal access catheter was related to successful reperfusion both in univariate analysis (success 57.9 %; fail 35.8 %, p < 0.01) and in multivariate regression analysis (odds ratio 2.45; 95 % confidence interval: 1.30-4.61, p < 0.01). CONCLUSIONS: Successful advancement of the distal access catheter to the proximal end of thrombus might be a key component for successful reperfusion in mechanical thrombectomy.

Carotid Free-Floating Thrombus Treated With a Combined Technique Using Embotrap III for Distal Protection.

Carotid free-floating thrombus (FFT) is a rare condition in patients with acute ischemic stroke. Recently, endovascular therapy for carotid FFT has been increasingly reported, but the strategy has not yet been established. We report a case of an acute stroke patient with a carotid FFT, who was successfully treated with a combination of the direct aspiration first-pass technique (ADAPT) and the Embotrap III (Cerenovus, Irvine, CA), specifically designed to prevent distal embolization. We propose the utility of distal embolic protection with Embotrap III for the treatment of patients with carotid FFT. A 71-year-old man who presented with sudden left hemiparesis was admitted to our hospital. Ultrasonography on admission revealed severe stenosis and an FFT at the origin of the right internal carotid artery. Thrombectomy with an aspiration catheter, accompanied by a stent retriever with distal basket Embotrap III for distal protection, was performed. After the FFT was safely aspirated, a carotid Wallstent (Boston Scientific, Marlborough, MA) was deployed in the stenosis. Follow-up ultrasonography showed neither FFT nor in-stent protrusion. The patient did not experience recurrence, as per clinical or radiological findings, and was discharged on day 11 without any neurological deficits. Embotrap III may be useful for a patient with a carotid FFT as distal protection during mechanical thrombectomies.

[Yips in Kyudo (Japanese archery): prevalence, classification, and aggravating factors].

In Kyudo (Japanese archery), there are four disorders that hinder an archer's performance: Hayake (releasing the bow too early), Motare (unable to release the bow when intended), Biku (jerking when aiming), and Yusuri (shaking when drawing the bow, or aiming). These disorders are similar to Yips, a psycho-neuromuscular movement disorder, recognized in various sports, but few studies have examined yips in Kyudo. This study examined the frequency, classification, and risk factors of yips in Kyudo among medical students. The results showed that 41 of 65 students (63.1%) experienced at least one disorder. The frequency of Hayake was the highest (35 patients; 85.3%). An experience of playing was associated with the increased risk of yips in Kyudo. Motare was the only disorder that appeared on its own, and without complications from other disorders. Based on its characteristics, it was suspected that task-specific focal dystonia involved in Motare.

Wall Redness of Enlarged Unruptured Cerebral Aneurysm.

OBJECTIVES: The wall of enlarged unruptured cerebral aneurysm (EUCA) is thought to be reddish, thin, and fragile. This study aimed to evaluate the EUCA wall redness based on quantitative signal intensity method and to compare the clinical and radiological characteristics between EUCA and non-EUCA. MATERIALS & METHODS: In this retrospective analysis, red (R), green (G), blue (B), and RGB signal intensities of aneurysm were quantitatively measured using an intraoperative digital picture in 150 cases. Color intensities were measured by two independent investigators. Aneurysm redness was defined as an R/RGB ratio since the brightness of the operative field differed by each surgery or angle of the microscope. RESULTS: The median aneurysm size was 4.9 mm (IQR 3.9-5.9 mm). Median color intensity of R, G, B, RGB, and R/RGB ratio were 206 (185-215), 129 (107-150), 136 (115-157), 157 (140-174), and 1.26 (1.20-1.38), respectively. The intraclass correlation coefficient for R/RGB ratio was 0.73 (P<0.0001). The proportion of female sex was significantly higher for EUCA (p = 0.019). Median R/RGB ratio in GUCA was significantly larger than that of non-EUCA (OR 1.25, 95% CI 1.19-1.35) (p = 0.035). Even after adjustment of female sex, a R/RGB ratio ≧1.36 was related to EUCA (OR 3.02, 95% CI 1.30-7.02). CONCLUSIONS: The present study showed that a R/RGB ratio could be calculated easily and a larger R/RGB ratio was related to EUCA. When EUCA is managed by surgical treatment, more careful manipulation should be needed compared to non-EUCA due to a "red" wall of EUCA.

Mechanical Thrombectomy via the Transfemoral Approach for Acute Middle Cerebral Artery M1 Occlusion That Occurred during Intra-Aortic Balloon Pumping Application.

Objective: We report a case of cardioembolic stroke treated by mechanical thrombectomy (MT) via the transfemoral approach under the assistance of intra-aortic balloon pumping (IABP). Case Presentation: A 64-year-old man suddenly developed consciousness disturbance, aphasia, and left hemiparesis during intensive care for acute myocardial infarction (AMI) with IABP. The patient was transferred to our hospital and diagnosed with acute right middle cerebral artery (MCA) occlusion. We performed MT using a balloon-guiding catheter via the transfemoral approach and achieved complete recanalization. Conclusion: Endovascular therapy for acute MCA M1 occlusion via the transfemoral route was safe even when the patient was treated using IABP.

Pre-hospital Diagnosis of Large Vessel Occlusion in Patients Being Transported by Helicopter.

BACKGROUND: During the helicopter transportation of patients suspected of large vessel occlusion (LVO), an accurate and rapid decision-making process is required. AIMS: We attempted to create an algorithm for the pre-hospital diagnosis of the presence of LVO in patients suspected of stroke using data from patients transported urgently by helicopter. METHODS: One hundred and sixty-five patients transported by helicopter were divided into two subgroups: a training dataset and a validation dataset. We extracted clinical information obtained on site, the unadjusted score of the National Institutes of Health Stroke Scale, and previously reported pre-hospital scales as an LVO screen. On the basis of the analyses of these factors, an algorithm was devised to predict the presence of LVO and its predictive accuracy was evaluated using the validation dataset. RESULTS: Ischemic stroke with LVO was diagnosed in 36 out of 121 cases (29.8%) in the training dataset and in 10 out of 44 cases (22.7%) in the validation dataset. Combining five factors (conjugate deviation, upper limb paresis, atrial fibrillation, Japan Coma Scale ≥ 200, and systolic blood pressure ≥ 180), an algorithm was created to classify cases into six groups with different likelihoods of LVO presence. The algorithm predicted correctly 6 out of 10 cases in the validation dataset. Furthermore, it definitively ruled out 17 out of 34 cases in the validation dataset. CONCLUSIONS: Using the newly created algorithm, emergency staff could easily and accurately distinguish patients suitable for urgent endovascular thrombectomy from patients with non-LVO or stroke mimics.

Pre-Hospital Delay in Patients with Acute Ischemic Stroke in a Multicenter Stroke Registry: K-PLUS.

PURPOSE: There is scant data related to prehospital delay in cases of acute ischemic stroke from multicenter studies conducted after change of the therapeutic window of intravenous tissue plasminogen activator (iv-tPA) administration to within 4.5 h of onset. We investigated factors causing prehospital delay and their associations with clinical outcomes using data from a regional multicenter stroke registry. METHODS: Data from the multicenter regional stroke registry were analyzed. Patients admitted within 24 h of the last known well time were categorized according to whether their admission was early (≤ 4 h; n = 2350) or delayed (> 4 h; n = 2752). We then compared patients' backgrounds and outcomes between the two groups. RESULTS: Five-thousand, one-hundred two patients presented at hospitals within 24 h of onset. On multivariate analysis, atrial fibrillation, higher NIHSS score on admission, anterior circulation stroke, detection of symptoms immediately after onset, and emergency system use were positively associated with early admission, whereas modified Rankin Scale (mRS) score before onset, onset at home, diabetes, current smoking, dementia and symptom detection between 00:00 and 06:00 h were negatively associated. Early admission was associated with mRS scores of 0-2 at discharge independent of backgrounds, stroke severity, and thrombolytic therapy (odds ratio, 1.56; 95% confidence interval, 1.32-1.84). CONCLUSIONS: Certain patient factors relating to prehospital delay, such as lack of awareness of onset or non-cardioembolic etiology, are crucial but often inevitable. However, earlier admission was associated mRS scores of 0-2 independent of other factors. This study may help to plan educational activities to general population or public awareness campaigns.

Stent Retriever-Assisted Continuous Aspiration for Distal Intracranial Vessel Embolectomy: The Distal Combined Technique.

OBJECTIVE: We investigated the efficacy of a combined approach with stent retriever-assisted aspiration catheter for distal intracranial vessel occlusion (distal combined technique [DCT]). METHODS: We evaluated consecutive patients with acute ischemic stroke with distal occlusion in anterior circulation, including occlusions of the M2/M3 or A2/A3 segments, who received endovascular therapy (EVT) in a single center. Modified Thrombolysis in Cerebral Infraction (mTICI) score including TICI 2C category, processing time from puncture to reperfusion, proportion of a favorable clinical outcome at discharge (modified Rankin Scale [mRS] score ≤2), and incidence of symptomatic intracranial hemorrhage (sICH) were compared between the DCT and single device approach technique (non-DCT) groups. RESULTS: Of 65 patients, 28 were treated with EVT using the DCT and 37 were treated with EVT with a single device approach (non-DCT). In the DCT group, a higher reperfusion rate at the first pass (mTICI score ≥2B, 92% vs. 54%; P = 0.0008; mTICI score ≥2C, 71% vs. 16%; P < 0.0001; mTICI score 3, 57% vs. 14%; P = 0.0004) and shorter time from puncture to successful reperfusion (median, 31 vs. 43 minutes; P = 0.0006) were achieved, respectively. The final successful reperfusion rate was also higher in the DCT group than in the non-DCT group (mTICI score ≥2C, 85% vs. 51%; P = 0.004; mTICI score 3, 75% vs. 43%; P = 0.012), respectively. sICH occurred in 2 patients in the non-DCT group. Patients with mRS score ≤2 at discharge were more prevalent in the DCT than in the non-DCT group (57% vs. 27%, respectively; P = 0.021). CONCLUSIONS: This retrospective analysis indicated that the DCT is a useful and safe strategy for patients with distal anterior intracranial vessel occlusion.

Endovascular therapy for middle cerebral artery M2 segment occlusion: subanalyses of RESCUE-Japan Registry 2.

OBJECTIVE: To compare the efficacy of endovascular therapy (EVT) with that of medical treatment in 'real-world 'patients with M2 occlusion. METHODS: This was a post hoc analysis of the Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism Japan Registry 2. Among 2420 patients in the registry, we evaluated patients with isolated M2 occlusion and those with functional independence before the stroke. Multivariable logistic regression analysis was used to evaluate and compare clinical outcomes between EVT and medical treatment. Additional propensity score-matched (PSM) analyses were performed. We performed subgroup analyses of the primary outcome (modified Rankin Scale score 0-2 at 90 days) using forest plots of treatment effects. RESULTS: Overall, 372 patients with M2 occlusion (n=184 EVT; n=188, medical treatment) were evaluated. The EVT group had a higher baseline National Institutes of Health Stroke Scale score (median (IQR), 15 [9-19] vs 10 [5-16]) and earlier onset to hospital door time (110 [50-258] vs 150 [60-343] min) than the medical treatment group. After adjustment, EVT was significantly associated with higher odds of primary outcome (adjusted OR=2.09; 95% CI 1.26 to 3.47) and lower odds of mortality at 90 days (adjusted OR= 0.27; 95% CI 0.08 to 0.93). After PSM analyses (184 patients were 1:1 matched with each group), EVT was effective and safe relative to medical treatment. Effects favoring EVT were present in several subgroups of interest. CONCLUSION: In patients with M2 occlusion, our registry suggests that EVT is effective and safe.

Calcified Cerebral Embolism Due to a Calcified Amorphous Tumor.

A 59-year-old man developed brain embolism in the frontal and parietal cortex. Brain CT showed a high-density spot in the upper branch of the left middle cerebral artery, indicating calcified cerebral embolism. Calcified amorphous tumor attached to the mitral valve was identified as the cause of embolism. After surgical resection, anticoagulation was started and recurrent stroke did not occur.