Internal carotid artery agenesis disclosed by carotid ultrasonography.

(Upper panels) Ultrasonography showed caliber difference of common carotid arteries (right side: 0.39 cm; left side: 0.70 cm) for right internal carotid artery agenesis. (Lower panels) Bilateral ophthalmic arteries showed anterograde flow with 50% flow reduction over right side (right: peak systolic velocity, PSV [23.3 cm/s]; end diastolic velocity, EDV [7.0 cm/s]; left: PSV [47.0/s] EDV [14.2 cm/s]).

Idarucizumab for Intravenous Thrombolysis and Endovascular Thrombectomy in Acute Stroke: A Case Report.

BACKGROUND: Non-vitamin K antagonist oral anticoagulants (NOACs), such as dabigatran, are widely used to prevent ischemic stroke in patients with nonvalvular atrial fibrillation. Nonetheless, stroke occurs in 1-2% of patients, and the use of NOACs may increase the bleeding risk for patients who are receiving acute treatment of intravenous thrombolysis (IVT) or endovascular thrombectomy (EVT). Idarucizumab, a monoclonal antibody developed to bind dabigatran, has been proven safe and effective for patients with uncontrolled bleeding or for patients planning to receive emergent procedures. It is now accepted that patients taking dabigatran with recurrent stroke may benefit from IVT after idarucizumab. However, there are limited data regarding idarucizumab use in patients planning to have EVT. CASE REPORT: We present the case of a male patient taking dabigatran who had a stroke and who was treated with idarucizumab followed by combined IVT and EVT. The patient had immediate recanalization of the occluded vessel and near total recovery of function after 3 months. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our case report supports the evidence that patients presenting with acute ischemic stroke (AIS) despite being under dabigatran therapy should be evaluated for reversal by idarucizumab which can contribute to the eligibility for IVT as well as EVT. It has also been proved to provide better outcomes for patients with AIS. The availabilities of specific reversal agents for NOACs will probably alter the current management of patients with AIS.

Cognitive impairment in patients with end-stage renal disease: Accelerated brain aging?

BACKGROUND: Chronic kidney disease exhibits a prominent premature aging phenotype in many different organ systems, including the brain. Nevertheless, a comprehensive characterization of brain aging in non-demented patients with end-stage renal disease (ESRD) is lacking and it remains unclear if the collective changes of cognitive functions and brain structures in ESRD is compatible with aging. METHODS: We compared 56 non-demented, independently living dialysis patients (mean age 59.4 ± 11.0 years; mean dialysis vintage of 5.9 years) and 60 non-dialysis controls on a battery of neuropsychological tests, brain MRI T1 imaging and diffusion tensor imaging. Participants with diagnosis of dementia, Mini-Mental State Examination <24, medical history of stroke, or recent hospitalization within 1 month were excluded. RESULTS: Dialysis patients showed significantly worse performance in attention/information processing speed and executive function adjusted for age, sex, education, diabetes and depression. Reduced total brain volume and subcortical volume including hippocampus were found in dialysis patients. Vertex-wise analysis showed cortical thinning in middle frontal, lateral occipital and precuneus region. Furthermore, decreased white matter integrity was found primarily in bilateral anterior thalamic tract, fronto-occipital fasciculus, forceps minor and uncinate tract after correction for multiple comparisons. CONCLUSION: Overall, differences in cognitive functions, cortical volumes/thickness and white matter integrity associated with dialysis are also cognitive domains and brain structure changes associated with normal aging. In other words, non-demented, independently living dialysis patients present an accelerated brain aging phenotype even after taking into account effects of age, diabetes and depression.

Hyperdense Artery Sign, Clot Characteristics, and Response to Intravenous Thrombolysis in Han Chinese People with Acute Large Arterial Infarction.

BACKGROUND: Whether the presence of hyperdense artery sign (HAS) correlates with clot characteristics and response to intravenous thrombotic therapy (IVT) remains to be determined. Given that the existent literature was mainly from the Western nations, the current study aimed to examine the relationships among HAS, clot characteristics, and outcome of IVT in a Han Chinese sample in Taiwan. The specific objectives are (1) to correlate HAS with clot characteristics and (2) to explore relationships between HAS and effectiveness/complication of IVT. METHODS: We enrolled 75 patients treated with IVT following acute large arterial infarctions. All patients had a baseline brain computed tomography and a follow-up image at 24 hours after thrombolysis. Correlations were explored between HAS and clot characteristics. Multivariable logistic regressions were employed to examine the relationships between HAS and response to IVT at 24 hours, including early improvement and all forms of intracerebral hemorrhage (ICH). RESULTS: In this Han Chinese sample in Taiwan, 50.7% of the patients had HAS and 64% had early improvements following IVT. Those with HAS tended to have clots lodging at main trunks of cerebral arteries but no significant associations were found between HAS and stroke etiology. In multivariable logistic regressions, HAS predicted neither early improvement nor ICH complication. CONCLUSIONS: Instead of clot etiology, we found that it might be clot location that correlated with HAS. HAS was not associated with early improvement or ICH complication after IVT in this Han Chinese sample. We also showed that some other patient characteristics were likely to influence outcomes of IVT, which warrant clinical attention.

Yearly change in air pollution and brain aging among older adults: A community-based study in Taiwan.

BACKGROUND: Air pollution is recognized as a modifiable risk factor for dementia, and recent evidence suggests that improving air quality could attenuate cognitive decline and reduce dementia risk. However, studies have yet to explore the effects of improved air quality on brain structures. This study aims to investigate the impact of air pollution reduction on cognitive functions and structural brain differences among cognitively normal older adults. METHODS: Four hundred and thirty-one cognitively normal older adults were from the Epidemiology of Mild Cognitive Impairment study in Taiwan (EMCIT), a community-based cohort of adults aged 60 and older, between year 2017- 2021. Annual concentrations of PM2.5, NO2, O3, and PM10 at participants' residential addresses during the 10 years before enrollment were estimated using ensemble mixed spatial models. The yearly rate of change (slope) in air pollutants was estimated for each participant. Cognitive functions and structural brain images were collected during enrollment. The relationships between the rate of air pollution change and cognitive functions were examined using linear regression models. For air pollutants with significant findings in relation to cognitive function, we further explored the association with brain structure. RESULTS: Overall, all pollutant concentrations, except O3, decreased over the 10-year period. The yearly rates of change (slopes) in PM2.5 and NO2 were correlated with better attention (PM2.5: r = -0.1, p = 0.047; NO2: r = -0.1, p = 0.03) and higher white matter integrity in several brain regions. These regions included anterior thalamic radiation, superior longitudinal fasciculus, inferior longitudinal fasciculus, corticospinal tract, and inferior fronto-occipital fasciculus. CONCLUSIONS: Greater rate of reduction in air pollution was associated with better attention and attention-related white matter integrity. These results provide insight into the mechanism underlying the relationship between air pollution, brain health, and cognitive aging among older adults.

Clinical implications of U2AF1 mutation in patients with myelodysplastic syndrome and its stability during disease progression.

We aimed to analyze clinical impacts of the U2AF1 mutation on patients with myelodysplastic syndrome (MDS) and its stability during disease progression. We checked mutation status of the U2AF1 by direct sequencing in 478 de novo MDS patients and correlated with the clinical characteristics and outcomes. We also sequentially analyzed the U2AF1 mutation in 421 samples from 142 patients to determine its stability during the disease courses. Thirty-six patients (7.5%) were found to have U2AF1 mutations, which occurred more frequently in younger patients (P = 0.033). U2AF1 mutation was an independent poor-risk factor for overall survival (OS) in all patients (P = 0.030) and younger patients (P = 0.041). U2AF1 mutation could also predict shorter time-to-leukemia transformation (TTL) in younger patients (P = 0.020). In addition, U2AF1 mutation was associated with shorter TTL in lower-risk MDS patients. Sequential analyses showed all original U2AF1 mutations in U2AF1-mutated patients were retained during follow-ups unless complete remission was achieved, whereas none of the U2AF1-wild patients acquired a novel mutation during disease evolution. U2AF1 mutation is more prevalent in younger MDS patients and associated with inferior outcomes although it is stable during the clinical course. The mutation may be used as a biomarker for risk stratification.

Rare Condition of Aberrant Arterial Supply to a Normal Lung: A Cases Series and Literature Review.

Herein, we describe an aberrant artery to a normal lung, focusing on its classification, embryological hypotheses, diagnostic methods, and treatment modalities. We present three cases of aberrant arterial supply to a normal lung in various age groups (51 years, 5 months, and 29 years). The cases presented symptoms ranging from hemoptysis to respiratory distress. Successful transarterial embolization was performed in the 5-month-old infant. In addition, we collected case reports published from 1962 to the present from the literature to compare the trends in management and variations in manifestations.

Altered gut microbiota in older adults with mild cognitive impairment: a case-control study.

Introduction: The microbiota-gut-brain axis is implicated in Alzheimer's disease. Gut microbiota alterations in mild cognitive impairment (MCI) are inconsistent and remain to be understood. This study aims to investigate the gut microbial composition associated with MCI, cognitive functions, and structural brain differences. Methods: A nested case-control study was conducted in a community-based prospective cohort where detailed cognitive functions and structural brain images were collected. Thirty-one individuals with MCI were matched to sixty-five cognitively normal controls by age strata, gender, and urban/rural area. Fecal samples were examined using 16S ribosomal RNA (rRNA) V3-V4 sequencing. Compositional differences between the two groups were identified and correlated with the cognitive functions and volumes/thickness of brain structures. Results: There was no significant difference in alpha and beta diversity between MCIs and cognitively normal older adults. However, the abundance of the genus Ruminococcus, Butyricimonas, and Oxalobacter decreased in MCI patients, while an increased abundance of nine other genera, such as Flavonifractor, were found in MCIs. Altered genera discriminated MCI patients well from controls (AUC = 84.0%) and were associated with attention and executive function. Conclusion: This study provides insights into the role of gut microbiota in the neurodegenerative process.

Predictors of 30-day mortality after endovascular thrombectomy for large vessel occlusion in the elderly.

OBJECTIVES: Elderly acute ischemic stroke (AIS) patients (≥80 years) would have dismal clinical outcomes even after successful endovascular revascularization for large vessel occlusion (LVO) in the anterior circulation. We aimed to identify predictors of 30-day mortality after endovascular thrombectomy (EVT) in the elderly. MATERIALS AND METHODS: We included older patients who underwent EVT for AIS due to LVO within 6 h after stroke onset in the anterior circulation between 2017 and 2019. Patients due to posterior circulation stroke, with intracerebral hemorrhage (ICH) or pre-stroke modified Rankin Scale (mRS) score of 4 and 5 were excluded. The primary outcome was mortality within 30 days of EVT. The association between clinical, imaging, procedural, follow-up imaging and mortality were analyzed. Successful reperfusion was defined as modified Thrombolysis in Cerebral Infarction (mTICI) score of 2b or 3. Possible predictors of 30-day mortality were assessed by univariate and multivariable logistic regression. RESULTS: Total 238 AIS patients eligible for EVT were identified with 58 patients aged 80 years or more. 48 patients met inclusion criteria. Median age was 86 years (age range, 82-102 years). Successful reperfusion was achieved in 38 (79.2%) patients. The 30-day and 90-day mortality rate were 25% and 33.3%, respectively. The independent predictors of 30-day mortality were collateral scores <3 on mCTA (adjusted OR, 16.571; 95% CI, 1.041-263.868; p = 0.047) and number of passes (adjusted OR, 2.475; 95% CI, 1.047-5.847; p = 0.039). CONCLUSIONS: Lower collateral scores on mCTA and higher number of passes in thrombectomy were independently predictive of 30-day mortality in the elderly.

The 2023 Taiwan Stroke Society Guidelines for the management of patients with intracranial atherosclerotic disease.

Intracranial atherosclerotic disease (ICAD) is a major cause of ischemic stroke, especially in Asian populations, which has a high risk of recurrent stroke and cardiovascular comorbidities. The present guidelines aim to provide updated evidence-based recommendations for diagnosis and management of patients with ICAD. Taiwan Stroke Society guideline consensus group developed recommendations for management of patients with ICAD via consensus meetings based on updated evidences. Each proposed class of recommendation and level of evidence was approved by all members of the group. The guidelines cover six topics, including (1) epidemiology and diagnostic evaluation of ICAD, (2) nonpharmacological management of ICAD, (3) medical therapy for symptomatic ICAD, (4) endovascular thrombectomy and rescue therapy for acute ischemic stroke with underlying ICAD, (5) endovascular interventional therapy for postacute symptomatic intracranial arterial stenosis, and (6) surgical treatment of chronic symptomatic intracranial arterial stenosis. Intensive medical treatment including antiplatelet therapy, risk factor control, and life style modification are essential for patients with ICAD.

Flow diverter retreatment for intracranial aneurysms: A meta-analysis of efficacy and feasibility.

BACKGROUND: Recurrent intracranial aneurysm carries a risk of rupture and retreatment is often necessary. However, there is no consensus on the best retreatment modality of choice. Flow diverter has emerged as a promising option for this population in recent years. Given its high cost, patient selection to optimize outcomes is very important. PURPOSE: To identify patient factors predisposing to failure of flow diverter retreatment. METHOD: We conducted a systematic search on PubMed, Cochrane Library, Embase, Ovid/Medline, and ClinicalTrial.gov from 2000 to 2021. Studies regarding flow diverter retreatment of recurrent aneurysms were analyzed if they meet the inclusion criteria. RESULTS: A total of twenty-six studies were identified. Among 374 patients retreated with flow diverters, about 0.86 [0.81; 0.92] were successfully occluded and only 0.06 [0.02; 0.10] had unfavorable neurological outcomes. Major complications included intracranial hemorrhage (n = 7), ischemic stroke or thromboembolic event (n = 12), and death (n = 2). In-stent stenosis was reported in 10 of the cases. Saccular aneurysms are associated with a higher occlusion rate while aneurysm location, size, status, and prior treatment modality have no significant impact on retreatment efficacy. CONCLUSIONS: We demonstrated that flow diverter is an effective retreatment strategy except in patients with non-saccular aneurysms. It should be considered as a first-line option for patients with recurrent intracranial aneurysm.

Impact of smoking on one year functional outcomes after thrombectomy for young stroke patients.

BACKGROUND: The incidence of stroke in young patients (20-50 years old) has increased in recent decades. Unlike the use of good functional outcomes to evaluate prognosis, excellent functional outcomes are a better indicator of return to work among younger patients. The rate of return to work increases with time after stroke. This study investigated the short term (3 months) and long term (1 year) predictors of excellent functional outcomes in young patients after endovascular thrombectomy (EVT). METHODS: We included young patients who underwent EVT for acute ischemic stroke (AIS) due to large vessel occlusion within 6 hours after stroke onset between 2015 and 2021. Patients with intracerebral hemorrhage on pretreatment CT were excluded. The associations between clinical, imaging, and procedure variables, and excellent functional outcomes were analyzed using univariate and multivariable logistic regression analyses. An excellent functional outcome was defined as a modified Rankin Scale score of ≤1. RESULTS: Of the 361 patients with AIS eligible for EVT, 55 young patients (aged 24-50 years) were included. Of these, 36.4% and 41.8% achieved excellent functional outcomes at 3 and 12 months, respectively. Multivariate analysis revealed that smoking was the independent negative predictor of both 3 month (adjusted OR (aOR) 0.232, 95% CI 0.058 to 0.928; p=0.039) and 12 month (aOR 0.180, 95% CI 0.044 to 0.741; p=0.018) excellent functional outcomes. CONCLUSIONS: Current or former smoking habit was an independent negative predictor of both short term and long term excellent functional outcomes in young adults with AIS.

Autologous heparinized oxygenated blood reperfusion in acute ischemic stroke caused by infective endocarditis: a case report.

PURPOSE: Cerebral infarction secondary to septic embolism is a lethal complication of infective endocarditis. However, its effective treatment has not been well defined in the previous literature. CASE REPORT: We presented a patient suffering from right middle cerebral artery (MCA) embolism with left hemiplegia and infective endocarditis, who was once treated with intra-arterial thrombolysis with autologous heparinized arterial blood successfully. The patient recovered well with muscle power improvement significantly, but was attacked by another septic embolization with mycotic aneurysm rupture of left side MCA and intracranial hemorrhage. Despite of emergent decompressive craniectomy the patient died of this complication on the 25th day of his hospitalization. CONCLUSION: In this case, we demonstrated the safety and effectiveness of the autologous heparinized arterial blood in recanalization of the occluded vessel.

Quantitative CT angiography predicts large artery occlusion types and successful thrombectomy in acute ischemic stroke.

BACKGROUND: Clinical and radiological outcomes of endovascular thrombectomy (EVT) are related to etiologies of large vessel occlusion (LVO) in acute stroke. However, preprocedural computed tomography angiography (CTA) or CT perfusion imaging can hardly distinguish embolic occlusion from atherosclerotic occlusion. We hypothesized that quantitative multiphase CTA (mCTA) of LVO may predict occlusion types and thrombectomy outcome. METHODS: We retrospectively evaluated the consecutive stroke patients who had undergone mCTA and EVT <6 hours of onset at two independent medical centers. The intra-arterial radiodensities of Hounsfield unit (HU) were measured to examine the HUdistal/proximal ratio using receiver operating characteristic curve analysis. The derived cut-off value was re-examined in an independent cohort. RESULTS: In the derivation cohort (n = 102), 81 patients (79.4%) were embolic occlusion without severe residual intracranial atherosclerotic stenosis (ICAS[-]) and 21 patients were atherosclerosis-related occlusion (ICAS[+]) based on digital subtraction angiography (DSA). The optimal cut-off to predict embolic occlusion was HU ratio <0.6 measured at 2 mm from the occlusion site (maximum area under the curve = 0.87; sensitivity 96%; specificity 81%). This cut-off also independently predicted successful recanalization using stent-retrievers and/or contact aspiration (modified Treatment in Cerebral Ischemia score ≥2b; p = 0.002) after adjusting for age, atrial fibrillation, and collateral circulation score, but not predicted favorable outcome at 3 months post stroke. Importantly, in the validation cohort (n = 95, 80% embolic occlusion), this HU ratio cut-off similarly predicted occlusion types and recanalization outcome, respectively. CONCLUSION: The mCTA-based quantitative radiodensities of acute LVO provides preprocedural predictive values of DSA-determined occlusion types and thrombectomy outcomes.

Vertebral artery dissection presented as lateral medullary syndrome in a patient with migraine: a case report.

PURPOSE: Migraine and artery dissection are both rare causes of ischemic stroke. The mechanism of migraine-related intracranial artery dissection is still unknown. It is proposed that the repeated attack of migraine would make the involved artery more vulnerable to tearing and lead to dissection. CASE REPORT: We describe a 42-year-old female suffering from basilar-type migraine for more than 20 years. The patient complained severe dizziness with hyperventilation while watching television. Initially anxiety and migraine attack were impressed in the emergency room, but dizziness accompanied with dysarthria and dysphagia was noted later. After admission, lateral medullary syndrome was suspected after a detailed neurological examination, and a brain magnetic resonance image (MRI) revealed an acute infarction on the left lateral medulla oblongata, confirming the clinical diagnosis Furthermore, cerebral angiography revealed the left distal vertebral artery dissection. The patient was reluctant to use an anticoagulant; therefore aspirin was given for secondary stroke prevention and topiramate for migraine prophylaxis. CONCLUSION: The exact mechanism of migraine-related intracranial artery dissection has yet to be proven, we propose that this may be caused by vessel wall edematous changes with repeated migraine attacks resulting in sudden or unusual stretching.

Nonbifurcating Carotid Artery: A Case Report with a Review of Embryogenesis.

BACKGROUND Vascular anomalies of the carotid vessels can be attributed to false embryogenesis. A rare variant called a nonbifurcating carotid artery (NBCA) exists, where typical carotid bifurcation is not recognizable with its typical branches of the external carotid artery (ECA) and internal carotid artery (ICA). This paper describes a case of this anomaly and reviews the embryogenesis of the carotid arteries for explanation. CASE REPORT A 66-year-old man received a routine health examination at our hospital. Initial carotid ultrasound indicated an absence of bifurcation in the right cervical carotid artery, and magnetic resonance imaging of the brain indicated an absence of the proximal cervical segment of the right ICA, with a remnant arterial stump at the expected bifurcation level. No evidence of the carotid bulb was identified. The common carotid artery seemed to continue cranially in the trunk of the ECA, where it exhibited extracranial branches. After distributing these branches, the carotid artery coursed medially at the C2 level, where it ascended into the carotid canal to become the petrosal segment of the ICA. This carotid anomaly was labelled an NBCA. No aberrant intracranial arteries were derived from the NBCA in this case. CONCLUSIONS In this case, the arterial stump was considered a remnant from agenesis of the right ICA. We assumed that the NBCA most likely developed because of false regression of the third embryogenic aortic arch with persistence of the second aortic arch.