Fatal intracerebral hemorrhage following endovascular Onyx embolization of an arteriovenous malformation: A case report.

INTRODUCTION: Patients with cerebral arteriovenous malformation (AVM) have a lifetime risk of hemorrhagic stroke. Although identified asymptomatic cases can be monitored with imaging follow-up, treatment is considered in cases of AVM rupture or hemodynamic instability. PATIENT CONCERNS: A 43-year-old man who had been taking antihypertensive drugs for the past 5 years visited our hospital 3 days after the abrupt onset of headache. The patient also complained of progressive ptosis in the left eye. DIAGNOSES: Brain computed tomography (CT) showed a small intraventricular hemorrhage with obstructive hydrocephalus. Subsequent brain CT angiography and magnetic resonance imaging confirmed the presence of an AVM in the cerebellar vermis. INTERVENTIONS: Endovascular embolization was performed directly through the right femoral artery. Near-total obliteration of the AVM nidus was achieved by using multiple Onyx castings. OUTCOMES: The patient developed an altered mental status and right hemiparesis after the procedure. CT performed after the procedure revealed intraventricular hemorrhage in all ventricles, with a left thalamic intracerebral hemorrhage. Despite emergency external ventricular drainage and aggressive treatment for intracranial pressure control, the patient expired on the 14th day after the embolization procedure. LESSONS: When treating AVMs, especially those with a large nidus of high flow, it is necessary to consider possible hemorrhagic complications and preventive measures.

Comparison of modified quick sequential organ failure assessment models as triage tools for febrile patients.

Object: Effective triage of febrile patients in the emergency department is crucial during times of overcrowding to prioritize care and allocate resources, especially during pandemics. However, available triage tools often require laboratory data and lack accuracy. We aimed to develop a simple and accurate triage tool for febrile patients by modifying the qSOFA score. Methods: We retrospectively analyzed data from 7,303 febrile patients and created modified versions of qSOFA using factors identified through multivariable analysis. The performance of these modified qSOFAs in predicting in hospital mortality and intensive care unit (ICU) admission was compared using the area under the receiver operating characteristic curve (AUROC). Results: Through multivariable analysis, the identified factors were age (A), male sex (M), SpO2 (S), and lactate levels (L). The AUROCs of ASqSOFA (for in-hospital mortality: 0.812; 95% CI: 0.789-0.835, for ICU admission: 0.794; 95% CI: 0.771-0.817), which included age and SpO2 with qSOFA, were simple and not inferior to other more complex models (e.g., ASMqSOFA, ASLqSOFA, and ASMLqSOFA). ASqSOFA also displayed significantly higher AUROC than other triage scales, such as the modified early warning score and Korean triage and acuity scale. The optimal cut-off score of ASqSOFA for the outcome was 2 and the score for redistribution to a lower-level emergency department was 0. Conclusion: We demonstrated that ASqSOFA can be employed as a simple and efficient triage tool for emergency febrile patients to aid in resource distribution during overcrowding. It may also be applicable in pre-hospital settings for febrile patient triage.

Enhancing Endosomal Escape and Gene Regulation Activity for Spherical Nucleic Acids.

The therapeutic potential of small interfering RNAs (siRNAs) is limited by their poor stability and low cellular uptake. When formulated as spherical nucleic acids (SNAs), siRNAs are resistant to nuclease degradation and enter cells without transfection agents with enhanced activity compared to their linear counterparts; however, the gene silencing activity of SNAs is limited by endosomal entrapment, a problem that impacts many siRNA-based nanoparticle constructs. To increase cytosolic delivery, SNAs are formulated using calcium chloride (CaCl2 ) instead of the conventionally used sodium chloride (NaCl). The divalent calcium (Ca2+ ) ions remain associated with the multivalent SNA and have a higher affinity for SNAs compared to their linear counterparts. Importantly, confocal microscopy studies show a 22% decrease in the accumulation of CaCl2 -salted SNAs within the late endosomes compared to NaCl-salted SNAs, indicating increased cytosolic delivery. Consistent with this finding, CaCl2 -salted SNAs comprised of siRNA and antisense DNA all exhibit enhanced gene silencing activity (up to 20-fold), compared to NaCl-salted SNAs regardless of sequence or cell line (U87-MG and SK-OV-3) studied. Moreover, CaCl2 -salted SNA-based forced intercalation probes show improved cytosolic mRNA detection.

Identifying the core microbiome of the sea star Pisaster ochraceus in the context of sea star wasting disease.

Sea stars are keystone species and their mass die-offs due to sea star wasting disease (SSWD) impact marine communities and have fueled recent interest in the microbiome of sea stars. We assessed the host specificity of the microbiome associated with three body regions of the sea star Pisaster ochraceus using 16S rRNA gene amplicon surveys of the bacterial communities living on and in Pisaster, their environment, and sympatric marine hosts across three populations in British Columbia, Canada. Overall, the bacterial communities on Pisaster are distinct from their environment and differ by both body region and geography. We identified core bacteria specifically associated with Pisaster across populations and nearly absent in other hosts and the environment. We then investigated the distribution of these core bacteria on SSWD-affected Pisaster from one BC site and by reanalyzing a study of SSWD on Pisaster from California. We find no differences in the distribution of core bacteria in early disease at either site and two core taxa differ in relative abundance in advanced disease in California. Using phylogenetic analyses, we find that most core bacteria have close relatives on other sea stars and marine animals, suggesting these clades have evolutionary adaptions to an animal-associated lifestyle.

Alternative approaches to identify core bacteria in Fucus distichus microbiome and assess their distribution and host-specificity.

BACKGROUND: Identifying meaningful ecological associations between host and components of the microbiome is challenging. This is especially true for hosts such as marine macroalgae where the taxonomic composition of the microbiome is highly diverse and variable in space and time. Identifying core taxa is one way forward but there are many methods and thresholds in use. This study leverages a large dataset of microbial communities associated with the widespread brown macroalga, Fucus distichus, across sites and years on one island in British Columbia, Canada. We compare three different methodological approaches to identify core taxa at the amplicon sequence variant (ASV) level from this dataset: (1) frequency analysis of taxa on F. distichus performed over the whole dataset, (2) indicator species analysis (IndVal) over the whole dataset that identifies frequent taxa that are enriched on F. distichus in comparison to the local environment, and (3) a two-step IndVal method that identifies taxa that are consistently enriched on F. distichus across sites and time points. We then investigated a F. distichus time-series dataset to see if those core taxa are seasonally consistent on another remote island in British Columbia, Canada. We then evaluate host-specificity of the identified F. distichus core ASVs using comparative data from 32 other macroalgal species sampled at one of the sites. RESULTS: We show that a handful of core ASVs are consistently identified by both frequency analysis and IndVal approaches with alternative definitions, although no ASVs were always present on F. distichus and IndVal identified a diverse array of F. distichus indicator taxa across sites on Calvert Island in multiple years. Frequency analysis captured a broader suit of taxa, while IndVal was better at identifying host-specific microbes. Finally, two-step IndVal identified hundreds of indicator ASVs for particular sites/timepoints but only 12 that were indicators in a majority (> 6 out of 11) of sites/timepoints. Ten of these ASVs were also indicators on Quadra Island, 250 km away. Many F. distichus-core ASVs are generally found on multiple macroalgal species, while a few ASVs are highly specific to F. distichus. CONCLUSIONS: Different methodological approaches with variable set thresholds influence core identification, but a handful of core taxa are apparently identifiable as they are widespread and temporally associated with F. distichus and enriched in comparison to the environment. Moreover, we show that many of these core ASVs of F. distichus are found on multiple macroalgal hosts, indicating that most occupy a macroalgal generalist niche rather than forming highly specialized associations with F. distichus. Further studies should test whether macroalgal generalists or specialists are more likely to engage in biologically important exchanges with host.

Endovascular treatment of a ruptured pseudoaneurysm of the internal carotid artery in a patient with nasopharyngeal cancer: A case report.

BACKGROUND: Radiation therapy (RT) for nasopharyngeal cancer can cause several complications. In rare cases, an internal carotid artery pseudoaneurysm can occur, which can be fatal. We report the experience of a nasopharyngeal cancer patient who underwent radiation therapy and subsequently developed a fatal pseudoaneurysm of the petrous internal carotid artery. CASE SUMMARY: A 39-year-old man was diagnosed with nasopharyngeal cancer 2 years ago (American Joint Committee on Cancer Stage T3N2M0) and received concurrent chemoradiation therapy. He subsequently relapsed and received chemotherapy. One week after the 4th cycle of chemotherapy, he was admitted to the emergency room of our hospital because of massive epistaxis accompanied by a headache. A pseudoaneurysm of the petrous internal carotid artery was confirmed by digital subtraction angiography (DSA). Stent-assisted endovascular coil embolization was performed and complete occlusion was achieved. No pseudoaneurysm was observed on DSA after coil embolization; however, intermittent epistaxis was maintained even after coil embolization. After seven days, a diagnostic laryngoscopy was performed. Massive bleeding occurred after aspiration of the blood clot during the laryngoscopy and the patient died of hypovolemic shock. In this case, epistaxis may have been a sign of pseudoaneurysm; therefore, treatment such as embolization should be performed promptly, and careful management should be undertaken after treatment. CONCLUSION: This case highlights a rare, serious complication of RT in nasopharyngeal cancer and how it should be recognized and treated.

Acquired dural arteriovenous fistula after cerebellopontine angle meningioma: A case report.

RATIONALE: Intracranial brain surgeries, including ventriculostomy, burr hole, craniotomy, and craniectomy, are the most common causes of acquired dural arteriovenous fistula (dAVF). Here we report a case of acquired dAVF after a cerebellopontine angle meningioma surgery. PATIENT CONCERNS: A 51-year-old woman was diagnosed with a 40-mm cerebellopontine angle meningioma. The patient underwent surgery via a retrosigmoid suboccipital approach. A small craniotomy and an additional craniectomy were performed. At 7 months after the surgery, she presented with pulsating tinnitus and headache. DIAGNOSIS: Magnetic resonance imaging and digital subtraction angiography showed a dAVF that was fed by the occipital artery and drained into transverse and sigmoid sinuses. INTERVENTIONS: We performed Onyx® (Irvine, CA) embolization. OUTCOMES: The patient's symptoms completely improved. LESSONS: Craniectomy defects, partially exposed sinuses, and incomplete cranioplasty might be risk factors for iatrogenic dAVF after a retrosigmoid suboccipital craniotomy or craniectomy. Complete reconstructive cranioplasty is an essential procedure to prevent a direct connection between the venous sinus and the external carotid artery.

The effect of periodontitis on recipient outcomes after kidney transplantation.

BACKGROUND: Recent several reports have demonstrated that periodontitis is prevalent and adversely affects the survival in patients with chronic kidney disease (CKD) or end-stage kidney disease. However, its impact on transplant outcomes remains uncertain. METHODS: This retrospective cohort study included 136 and 167 patients, respectively, who underwent living donor kidney transplantation (KT) at Seoul National University Hospital from July 2012 to August 2016 and Korea University Hospital from April 2008 to October 2018. We divided patients into three groups according to stages of periodontitis based on a new classification system. RESULTS: Patients with severe periodontitis were older, had a higher prevalence of diabetes, a higher body mass index and C-reactive protein level, a lower cardiac output, and were more likely to be smokers, indicating its association with chronic systemic inflammation. After KT, stage IV periodontitis was independently associated with a lower incidence of acute T cell-mediated rejection, suggesting the possible effect of periodontitis on immune function. However, 1-year and 3-year estimated glomerular filtration rates were not different. Among the KT recipients followed up more than 3 years, new-onset cardiovascular disease occurred in nine patients, and coronary artery disease occurred more frequently in patients with stage IV periodontitis. However, diabetes was the independent predictor of new-onset coronary artery disease in multivariate logistic regression analysis. CONCLUSION: Our findings showed that periodontitis might be an important player in determining posttransplant outcomes in recipients. Further interventional trials to test whether treating periodontitis could modify transplant outcome are needed.

Adrenocorticotropic hormone and ß-endorphin concentration as a prognostic factor in patients with subarachnoid hemorrhage due to aneurysmal rupture.

OBJECTIVE: Adrenocorticotropic hormone (ACTH) and ß-endorphin are pituitary neuro-peptides released by acute stress. We determined why the prognosis of patients with subarachnoid hemorrhages (SAH) due to aneurysmal rupture is not always dependent on the Hunt-Hess grading system (HHS) and delta-National Institutes of Health Stroke Scale (NIHSS), while studying endogenous neuropeptides, including ACTH and ß-endorphin. METHODS: We analyzed blood samples collected from patients with SAH (SAH group; n=37) and those with unruptured intracranial aneurysms (control group; n=37). Blood sampling was performed before any procedure or chemical agents administration. The results of ACTH and ß-endorphin measurements were compared using the delta-NIHSS and HHS. The data were analyzed using descriptive statistics, independent samples t-tests, and Pearson's correlations. RESULTS: Of the 18 patients with low-grade HHS, 13 had low delta-NIHSS and five showed high delta-NIHSS. Of the 19 patients with high-grade HHS, the delta-NIHSS was ≥14 in the other five patients. ACTH concentration was high (497.3 pg/mL) in five patients with high-grade HHS and high delta-NIHSS. ß-endorphin concentration was high (159.7 pg/mL) in 13 patients with low-grade HHS and low delta-NIHSS. CONCLUSIONS: High ACTH levels in patients with massive bleeding and poor neurological status suggests increasing ACTH secretion in response to bleeding stress, which may aggravate neurological status. Contrary to ACTH, high ß-endorphin levels in patients with low-grade HHS implied the involvement of additional factors in predicting fair outcomes related to low delta-NIHSS. These results may provide insight into the varying prognostic potential of HHS in SAH patients.

Lactate dehydrogenase to albumin ratio as a prognostic factor in lower respiratory tract infection patients.

PURPOSE: To verify the role of lactate dehydrogenase to albumin (LDH/ALB) ratio as an independent prognostic factor for mortality due to the lower respiratory tract infection (LRTI) in the emergency department (ED). METHODS: We reviewed the electronic medical records of patients who were admitted to the ED for the management of LRTI between January 2018 and December 2020. Initial vital signs, laboratory data, and patient severity scores in the ED were collected. The LDH/ALB ratio was compared to other albumin-based ratios (blood urea nitrogen to albumin ratio, C-reactive protein to albumin ratio, and lactate to albumin ratio) and severity scales (pneumonia severity index, modified early warning score, CURB-65 scores), which are being used as prognostic factors for in-hospital mortality. Multivariable logistic regression was performed to identify independent risk factors. RESULTS: The LDH/ALB ratio was higher in the non-survivor group than in the survivor group (median [interquartile range]: 217.6 [160.3;312.0] vs. 126.4 [100.3;165.1], p < 0.001). In the comparison of the area under the receiver operating characteristic curve (AUC) for predicting in-hospital mortality, the AUC of the LDH/ALB ratio (0.808, 95% confidence interval: 0.757-0.842, p < 0.001) was wider than other albumin-based ratios and severity scales, except the blood urea nitrogen to albumin ratio. In the multivariable logistic regression analysis, the LDH/ALB ratio independently affected in-hospital mortality. CONCLUSION: The LDH/ALB ratio may serve as an independent prognostic factor for in-hospital mortality in patients with LRTI.

Antegrade recanalization of parent artery in proximal occlusion of distal posterior inferior cerebellar artery ruptured aneurysm: A case report.

RATIONALE: Distal posterior inferior cerebellar artery (PICA) aneurysms are extremely rare. Herein, we describe a case of PICA pseudoaneurysm with proximal occlusion achieved using detachable coils, but antegrade recanalization, which showed a normal PICA configuration on follow-up angiography. Possible mechanisms of the recanalization and lesions are also discussed. PATIENT CONCERNS: The patient was an 80-year-old woman with a subarachnoid hemorrhage (SAH) resulting from a distal PICA-ruptured aneurysm, initially misdiagnosed as a non-aneurysmal traumatic SAH. DIAGNOSIS: On hospitalization day 10, the patient developed rebleeding, and brain computed tomography angiography confirmed a distal PICA pseudoaneurysm. INTERVENTION: Endovascular coil embolization was performed. Inevitably, the proximal PICA was occluded using detachable coils, and complete occlusion of the affected PICA was confirmed on the final angiogram. OUTCOME: Fortunately, the patient recovered fully without any neurological sequelae. One year after the procedure, a follow-up angiography was performed, which revealed recanalization of the previously occluded PICA, with normal configuration and no visible aneurysmal dilatation. CONCLUSION: Even if the SAH is scanty and predominantly in the perimesencephalic cistern, performing a catheter-based angiography is essential. In the case of proximal occlusion of the parent artery without internal trapping in endovascular treatment of PICA pseudoaneurysm, follow-up examination with a short-term angiography might be crucial.

Intracranial Pressure Patterns and Neurological Outcomes in Out-of-Hospital Cardiac Arrest Survivors after Targeted Temperature Management: A Retrospective Observational Study.

We aimed to investigate intracranial pressure (ICP) changes over time and the neurologic prognosis for out-of-hospital cardiac arrest (OHCA) survivors who received targeted temperature management (TTM). ICP was measured immediately after return of spontaneous circulation (ROSC) (day 1), then at 24 h (day 2), 48 h (day 3), and 72 h (day 4), through connecting a lumbar drain catheter to a manometer or a LiquoGuard machine. Neurological outcomes were determined at 3 months after ROSC, and a poor neurological outcome was defined as Cerebral Performance Category 3-5. Of the 91 patients in this study (males, n = 67, 74%), 51 (56%) had poor neurological outcomes. ICP was significantly higher in the poor outcome group at each time point except day 4. ICP elevation was highest between days 2 and 3 in the good outcome group, and between days 1 and 2 in the poor outcome group. However, there was no difference in total ICP elevation between the poor and good outcome groups (3.0 vs. 3.1; p = 0.476). All OHCA survivors who had received TTM had elevated ICP, regardless of neurologic prognosis. However, the changing pattern of ICP levels differed depending on the neurological outcome.

Lactate dehydrogenase to albumin ratio as a prognostic factor for patients with severe infection requiring intensive care.

ABSTRACT: This study was performed to verify whether lactate dehydrogenase to albumin (LDH/ALB) ratio could be used as an independent prognostic factor in patients with severe infection requiring intensive care.We reviewed electronic medical records of patients hospitalized to the intensive care unit via the emergency department with a diagnosis of infection between January 2014 and December 2019. From the collected data, ALB-based ratios (LDH/ALB, blood urea nitrogen to albumin, C-reactive protein to albumin, and lactate to albumin ratios) and some severity scores (modified early warning score, mortality in emergency department sepsis score [MEDS], and Acute Physiology And Chronic Health Evaluation II [APACHE II] score) were calculated. LDH/ALB ratio for predicting the in-hospital mortality was compared with other ALB-based ratios and severity scales by univariable and receiver-operating characteristics curve analysis. Modified severity scores by LDH/ALB ratio and multivariable logistic regression were used to verify the independence and usefulness of the LDH/ALB ratio.The median LDH/ALB ratio was higher in non-survivors than survivors (166.9 [interquartile range: 127.2-233.1] vs 214.7 [interquartile range: 160.2-309.7], P < .001). The area under the receiver-operating characteristics curve of the LDH/ALB ratio (0.642, 95% confidence interval: 0.602-0.681, P < .001) was not lower than that of other ALB-based ratios and severity scores. From multivariable logistic regression, LDH/ALB ratio was independently associated with in-hospital mortality (odds ratio = 1.001, 95% confidence interval: 1.000-1.002, P = .047). Area under the receiver-operating characteristics curves of MEDS and APACHE II scores were improved by modification with LDH/ALB ratio (MEDS: 0.643 vs 0.680, P < .001; APACHE II score: 0.675 vs 0.700, P = .003).LDH/ALB ratio may be useful as the prognostic factor in patients with severe infection requiring intensive care.

Lipid Nanoparticle Spherical Nucleic Acids for Intracellular DNA and RNA Delivery.

Lipid nanoparticle SNAs (LNP-SNAs) have been synthesized for the delivery of DNA and RNA to targets in the cytoplasm of cells. Both the composition of the LNP core and surface-presented DNA sequences contribute to LNP-SNA activity. G-rich sequences enhance the activity of LNP-SNAs compared to T-rich sequences. In the LNP core, increased cholesterol content leads to greater activity. Optimized LNP-SNA candidates reduce the siRNA concentration required to silence mRNA by 2 orders of magnitude compared to liposome-based SNAs. In addition, the LNP-SNA architectures alter biodistribution and efficacy profiles in mice. For example, mRNA within LNP-SNAs injected intravenously is primarily expressed in the spleen, while mRNA encapsulated by LNPs (no DNA on the surface) was expressed primarily in the liver with a relatively small amount in the spleen. These data show that the activity and biodistribution of LNP-SNA architectures are different from those of conventional liposomal SNAs and therefore potentially can be used to target tissues.

Three-Dimensional Reproducibility of the Soft Tissue Landmarks Taken by Structured-Light Facial Scanner in Accordance with the Head Position Change.

The aim of this study was to evaluate the three-dimensional reproducibility of the structured-light facial scanner according to the head position change. A mannequin head was used and angle of the mannequin's axis-orbital plane to the true horizontal plane was adjusted to +10, +5, 0, -5, and -10°. Facial scanning was conducted 30 times, respectively, and 150 3D images were obtained. Reoriented landmarks of each group were compared and analyzed. Reproducibility decreased as the distance from the facial center increased. Additionally, the landmarks below showed lower reproducibility and higher dispersion than landmarks above. These differences occurred mainly in the anteroposterior direction as opposed to other directions. Positive inclination of the head position showed superior reproducibility compared to a negative inclination. This study showed that reproducibility of a structured-light scanner could be varied depending on the head position. Inaccuracies of landmarks in the anteroposterior direction are greater than in other directions. This means that evaluations of the profile using a structured-light scanner should be made carefully. Therefore, the proper head position should be set to ensure the accuracy of the image.

Preventive effects of seat belts on traumatic brain injury in motor vehicle collisions classified by crash severities and collision directions.

PURPOSE: This study aimed to measure the preventive effect of seat belt on traumatic brain injury (TBI) and to compare the effect according to the crash severities and collision directions. METHODS: Korea In-Depth Accident Study (KIDAS) has collected vehicle and demographic data on injured occupants involved in motor vehicle collisions (MVCs) who visited three emergency medical centers for calendar years 2011-2016. Primary and secondary end points were TBI (abbreviated injury score 2+) and in-hospital mortality. Crush extent (CE) was classified into 1-2, 3-4, 5-6, and 7-9 according to the crash severity. We calculated adjusted odds ratios (ORs) of seat belts and CE for study outcomes and developed an interaction model in each collision direction using multivariate logistic regression analysis. RESULTS: Of the 2,245 occupants who were injured in MVCs, 295 (13.1%) occupants sustained TBI. In univariate analysis, old age, unbelted status, lateral collision, and higher CE were factors associated with TBI in MVCs. Occupants with belted status was less likely to have TBI and in-hospital mortality compared with those with unbelted status [AORs (95% CI) 0.48 (0.37-0.62) and 0.49 (0.30-0.81), respectively]. In interaction analysis, preventive effects of seat belts on TBI from MVCs were retained within CE 5-6 in frontal MVCs and within CE 1-2 in near side lateral MVCs, and those of seat belts on in-hospital mortality were reserved within CE 3-4 in frontal and rollover MVCs. CONCLUSIONS: The preventive effects of seat belts on TBI and in-hospital mortality are preserved within a limited crash severity in each collision direction.

Radiographic and Nasal Endoscopic Observation of Accidentally Perforated Anterior Nasal Cavity With Dental Implants: Case Reports with 5-23 Years of Follow-Up.

Severe atrophy of the maxillary anterior region may make implant placement difficult and, as a result, iatrogenic complications such as nasal floor perforation may occur. The purpose of the present case reports is to present radiographic and nasal endoscopic features in the anterior nasal floor when dental implants were inadvertently perforated into nasal cavities. Between 1996 and 2018, 4 patients recorded with anterior nasal floor perforation with dental implants were followed and reviewed with panoramic radiographs and cone-beam computerized tomography. Also, nasal endoscopic examinations were performed by one otolaryngologist. Four implants in 4 patients were included in this case report. All implants achieved osteointegration and survived for 5-23 years without clinical complications. Three implants did not show any mucosal thickening and only one had minor mucosal thickening as visible on the radiographs. Nasal endoscopy examinations revealed that 3 implants were covered with mucosa and one had threads exposed. Intraorally, only one had clinical signs of peri-implant mucositis. Dental implants that perforated into the anterior nasal floor did not show clinical, radiographic, and nasal endoscopic complications during the long-term follow-up period. Nasal endoscopy was a better diagnostic tool to evaluate the implants perforated into the nasal cavity than conventional panoramic or cone-beam computerized tomography.

Repeated Endovascular Thrombectomy in Patients with Acute Ischemic Stroke in a Single Center.

BACKGROUND: Patients with acute ischemic stroke treated with endovascular thrombectomy may be treated with repeat endovascular thrombectomy (rEVT) in case of recurrent large vessel occlusion (LVO). The purpose of this study is to report the frequency, timing, and outcomes of rEVT in a single center. MATERIALS AND METHODS: We retrospectively reviewed our databases for anterior or posterior circulation rEVT cases. Patient characteristics, procedural data, and functional outcomes (modified Rankin scale at 90 days) were analyzed. Early and late recurrence of stroke was divided at 30 days. RESULTS: Of 1025 patients treated between January 2011 and January 2020, 23 (2.2%) underwent rEVT. The median time between the first and second procedure was 185 days; 7 (30.4%) patients were re-treated within 30 days. Eleven patients (47.8%) had different occlusion sites between the two procedures. Good clinical outcome of patients with late ipsilateral recurrence was significantly higher than that of patients with late contralateral recurrence (83.3% vs. 16.7, p = 0.027). Overall good functional outcome after the second procedure was 43.5% (10/23). Overall good functional outcome of early and late recurrence groups were similar (57.1% vs. 37.5%, p = 0.650). One patient died due to an underlying cardiac problem. CONCLUSION: rEVT can be performed in patients with recurrent stroke of LVO. Ipsilateral recurrence of stroke was associated with good clinical outcome after rEVT.

Endovascular Approach in Patients with Acute Complete Occlusion Due to Middle Cerebral Artery Dissection.

OBJECTIVE: Dissection of the middle cerebral artery (MCA) is less common than dissection of vessels in the vertebrobasilar system or carotid artery. Acute complete occlusion related to MCA dissection is extremely rare. We report an endovascular approach in patients with acute complete occlusion due to MCA dissection. METHODS: We reviewed retrospectively the endovascular procedure and clinical results for acute-stroke patients who underwent recanalization from October 2014 through December 2018. Initial imaging findings and the endovascular procedure were analyzed for patients with acute complete occlusion due to MCA dissection. RESULTS: We undertook first-line aspiration thrombectomy using a Penumbra catheter in 294 patients with acute occlusion of the M1 segment. Of these patients, seven were confirmed to have acute complete occlusion due to MCA dissection. All patients had angiographic findings of an intimal flap at the proximal occlusion site of the MCA. One patient complained of severe headache during microcatheter passage through the occluded lesion and died due to massive bleeding caused by rupture of the false lumen. The remaining patients underwent initial contact aspiration thrombectomy without microcatheter passage. After aspiration thrombectomy, six patients had delayed flow through the MCA. One patient underwent stenting of the MCA because of progressive symptoms. CONCLUSION: An intimal flap at the proximal portion of an occluded MCA can suggest the possibility of MCA dissection. Contrast aspiration thrombectomy without microcatheter passage can reduce the risk of false lumen rupture in cases of MCA dissection.