The Role of Mechanical Thrombectomy for Acute Massive Pulmonary Embolism in a Patient With Unilateral Lung Transplant and Atrial Septal Defect.

PURPOSE: The risk of thromboembolic disease is high in patients with lung transplantation and is associated with significant morbidity and mortality with single healthy transplanted lung. We present a case involving successful endovascular management of life-threatening acute massive pulmonary embolism (PE) in a patient with single lung transplant and atrial septal defect (ASD). CASE REPORT: A 65-year-old man with a history of interstitial lung disease status post single left orthotopic lung transplant in 2012 presented with acute massive PE and clot burden in the pulmonary arteries of the transplanted left lung. Severe right heart dysfunction, hemodynamic instability, and requirement for vasopressors persisted post systemic thrombolytic therapy. As a result, the patient underwent successful endovascular mechanical thrombectomy with immediate improvement in oxygen saturation and hemodynamic status. The procedure was performed without adverse outcomes or paradoxical embolization despite the presence of ASD. The right heart dysfunction resolved, the patient was extubated the next day, and was discharged to home 2 days post procedure. CONCLUSIONS: Endovascular mechanical thrombectomy was safely used to treat acute massive PE in a single transplanted lung in the presence of ASD. CLINICAL IMPACT: Endovascular mechanical thrombectomy could be safely utilized to treat patients with lung transplant and acute massive or submassive pulmonary embolism. However, safely of mechanical thrombectomy should be determined in case-based scenarios and based on time interval from transplantation to when the thrombectomy is required.

Semi-automated measurement of vascular tortuosity and its implications for mechanical thrombectomy performance.

PURPOSE: Few studies have examined the geometry of endovascular mechanical thrombectomy pathways. Here we examine the tortuosity and angulations of catheter pathways from the aortic arch to the termination of the internal carotid artery (ICA) and its association with thrombectomy performance. METHODS: We included 100 consecutive anterior circulation large vessel occlusion thrombectomy patients over 12 months. Computed tomography angiograms (CTA) were used for 3D segmentation of catheter pathway from the aortic arch to ICA termination. Tortuosity index (TI) and angulations of the catheter pathway were measured in a semi-automated fashion. TI and angulation degree were compared between sides and correlated with age and procedural measures. RESULTS: We analyzed 188 catheter pathways in 100 patients. Severe angulation (≤ 30°) was present in 5.8% and 39.4% of common carotid artery (CCA) and extracranial ICA segments, respectively. Five pathways (2.6%) had 360° loop. CCA and extracranial ICA tortuosity had a weak but significant correlation with age (r = 0.17, 0.21, p value = 0.05, 0.02 respectively), time from groin puncture to the site of occlusion (r = 0.29, 0.25, p values = 0.008, 0.026 respectively), and fluoroscopy time (r = 0.022, 0.31, p values = 0.016, 0.001 respectively). There was a significant difference in the pattern of angulation (p value = 0.04) and tortuosity between right and left side in CCA segment (TI = 0.20 ± 0.086 vs. 0.15 ± 0.82, p value < 0.001). CONCLUSIONS: There was a significant difference in CCA angulation between right and left sides. TI of extracranial CCA and ICA correlated with age and influenced time from groin puncture to the occlusion site and total fluoroscopy time.

Is Endovascular Therapy for Stroke Cost-Effective Globally? A Systematic Review of the Literature.

OBJECTIVES: Cost-effectiveness of endovascular therapy (EVT) is a key consideration for broad use of this approach for emergent large vessel occlusion stroke. We evaluated the evidence on cost-effectiveness of EVT in comparison with best medical management from a global perspective. MATERIALS AND METHODS: This systematic review of studies published between January 2010 and May 2020 evaluated the cost effectiveness of EVT for patients with large vessel occlusion acute ischemic stroke. The gain in quality adjusted life year (QALY) and incremental cost-effectiveness ratio (ICER), expressed as cost per QALY resulting from EVT, were recorded. The study setting (country, economic perspective), decision model, and data sources used in economic models of EVT cost-effectiveness were recorded. RESULTS: Twenty-five original studies from 12 different countries were included in our review. Five of these studies were reported from a societal perspective; 18 were reported from a healthcare system perspective. Two studies used real-world data. The time horizon varied from 1 year to a lifetime; however, 18 studies reported a time horizon of >10 years. Twenty studies reported using outcome data from randomized, controlled clinical trials for their models. Nineteen studies reported using a Markov model. Incremental QALYs ranged from 0.09-3.5. All studies but 1 reported that EVT was cost-effective. CONCLUSIONS: Evidence from different countries and economic perspectives suggests that EVT for stroke treatment is cost-effective. Most cost-effectiveness studies are based on outcome data from randomized clinical trials. However, there is a need to study the cost-effectiveness of EVT based solely on real-world outcome data.

Multimodal Regional Brain Monitoring of Tissue Ischemia in Severe Cerebral Venous Sinus Thrombosis.

BACKGROUND: Comatose critically ill patients with severe diffuse cerebral venous thrombosis (CVT) are at high risk of secondary hypoxic/ischemic insults, which may considerably worsen neurological recovery. Multimodal brain monitoring (MBM) may therefore improve patient care in this setting, yet no data are available in the literature. METHODS: We report two patients with coma following severe diffuse CVT who underwent emergent invasive MBM with intracranial pressure (ICP), brain tissue oximetry (PbtO2), and cerebral microdialysis (CMD). Therapy of CVT consisted of intravenous unfractionated heparin (UFH), followed by endovascular mechanical thrombectomy (EMT). EMT efficacy was assessed continuously at the bedside using MBM. RESULTS: Despite effective therapeutic UFH (aPTT two times baseline levels in the two subjects), average CMD levels of lactate and glucose in the 6 h prior to EMT displayed evidence of regional brain ischemia. The EMT procedure was associated with a rapid (within 6 h) improvement in both CMD lactate (6.42 ± 0.61 4.89 ± 0.55 mmol/L, p = 0.02) and glucose (0.49 ± 0.17 vs. 0.96 ± 0.32 mmol/L, p = 0.0005). EMT was also associated with a significant increase in PbtO2 (22.9 ± 7.5 vs. 30.1 ± 3.6 mmHg, p = 0.0003) and a decrease in CMD glutamate (12.69 ± 1.06 vs. 5.73 ± 1.76 µmol/L, p = 0.017) and intracranial pressure (ICP) (13 ± 4 vs. 11 ± 4 mmHg (p = 004). Patients did not require surgical decompression, regained consciousness, and were discharged from the hospital with a good neurological outcome (modified Rankin score 3 and 4). CONCLUSIONS: This study illustrates the potential utility of continuous bedside MBM in patients with coma after severe brain injury, irrespective of the primary acute cerebral condition. Despite adequate ICP and PbtO2 control, the presence of CMD signs of regional brain cell ischemia triggered emergent EMT to treat CVT, which was associated with a significant and clinically relevant improvement of intracerebral physiology.

Magnetic resonance-guided, high-intensity focused ultrasound sonolysis: potential applications for stroke.

Stroke is one of the leading causes of death worldwide and a significant source of long-term morbidity. Unfortunately, a substantial number of stroke patients either are ineligible or do not significantly benefit from contemporary medical and interventional therapies. To address this void, investigators recently made technological advances to render transcranial MR-guided, high-intensity focused ultrasound (MRg-HIFU) sonolysis a potential therapeutic option for both acute ischemic stroke (AIS)-as an alternative for patients with emergent large-vessel occlusion (ELVO) who are ineligible for endovascular mechanical thrombectomy (EMT) or as salvage therapy for patients in whom EMT fails-and intracerebral hemorrhage (ICH)-as a neoadjuvant means of clot lysis prior to surgical evacuation. Herein, the authors review the technological principles behind MRg-HIFU sonolysis, its results in in vitro and in vivo stroke models, and its potential clinical applications. As a noninvasive transcranial technique that affords rapid clot lysis, MRg-HIFU thrombolysis may develop into a therapeutic option for patients with AIS or ICH. However, additional studies of transcranial MRg-HIFU are necessary to ascertain the merit of this treatment approach for thrombolysis in both AIS and ICH, as well as its technical limitations and risks.

Streamlining Workflow for Endovascular Mechanical Thrombectomy: Lessons Learned from a Comprehensive Stroke Center.

BACKGROUND: Recently, 5 randomized controlled trials confirmed the superiority of endovascular mechanical thrombectomy (EMT) to intravenous thrombolysis in acute ischemic stroke with large-vessel occlusion. The implication is that our health systems would witness an increasing number of patients treated with EMT. However, in-hospital delays, leading to increased time to reperfusion, are associated with poor clinical outcomes. This review outlines the in-hospital workflow of the treatment of acute ischemic stroke at a comprehensive stroke center and the lessons learned in reduction of in-hospital delays. METHODS: The in-hospital workflow for acute ischemic stroke was described from prehospital notification to femoral arterial puncture in preparation for EMT. Systematic review of literature was also performed with PubMed. RESULTS: The implementation of workflow streamlining could result in reduction of in-hospital time delays for patients who were eligible for EMT. In particular, time-critical measures, including prehospital notification, the transfer of patients from door to computed tomography (CT) room, initiation of intravenous thrombolysis in the CT room, and the mobilization of neurointervention team in parallel with thrombolysis, all contributed to reduction in time delays. CONCLUSIONS: We have identified issues resulting in in-hospital time delays and have reported possible solutions to improve workflow efficiencies. We believe that these measures may help stroke centers initiate an EMT service for eligible patients.

Direct Common Carotid Artery Puncture for Endovascular Treatment of Acute Large Vessel Ischemic Stroke in a Patient with Aortic Coarctation.

Coarctation of the aorta is a condition that typically presents in childhood as a congenital malformation. This report describes a case of acute right middle cerebral artery ischemic stroke, which occurred in a patient with aortic coarctation that remained undiagnosed until her eighth decade. Complex anatomical variant presented a significant technical challenge in establishing endovascular access for mechanical thrombectomy using standard femoral, brachial, or radial artery approaches. Direct right common carotid puncture was performed successfully with subsequent reperfusion and full neurological recovery. Direct carotid artery puncture represents an alternative to standard transfemoral access in the event of stroke in a patient with difficult anatomy.

Evaluation of recanalisation treatment on posterior circulation ischemic stroke by Solitaire device-A multicenter retrospective study.

OBJECTIVES: Posterior circulation ischemic stroke (PCIS), accounting for approximately 20% of total ischemic stroke, is a sever disease that associated with high rate of morbidity and mortality. Though the effectiveness of endovascular mechanical thrombectomy has been well demonstrated in many types of ischemic stroke, it is still unclear what the outcome is in posterior circulation ischemic stroke. METHODS AND MATERIALS: In current study, data was collected from 139 Chinese patients who received endovascular mechanical thrombectomy treatment with Solitaire device after acute posterior circulation ischemic stroke. We measured the mortality, symptomatic intracranial hemorrhage (SICH) and National Institutes of Health Stroke Scale (NIHSS) to evaluate the safety of endovascular mechanical thrombectomy. Meanwhile, the clinical outcome of endovascular mechanical thrombectomy was also evaluated based on recanalisation rate, HIHSS, and the modified Rankin Scale (mRS). RESULTS: Recanalisation was successful in 124 (89.3%) patients after surgery. Herniation was the second fatal stroke complication, out of the 6 patients suffered from herniation, 3 patients (50%) died during surgery and 2 (33%) died after surgery. As for other stroke complications such as pulmonary infection, 1 patient (4.3%) died during surgery and 1 patient (4.3%) died 3 days after surgery. CONCLUSION: Our findings indicate that endovascular mechanical treatment is a safe treatment which brings clear benefit to patients suffered from posterior circulation ischemic stroke, in both the recanalisation rate and functional outcomes.

Predicting Occluded Middle Cerebral Artery Morphology for Endovascular Mechanical Thrombectomy: A Contralateral Shape Analysis Approach.

Introduction Predicting the shape of the occluded middle cerebral artery (MCA) from the contralateral MCA might help catheterization in endovascular mechanical thrombectomy (EMT). Materials and Methods We analyzed magnetic resonance (MR) angiography in 100 consecutive patients who had MR imaging for diseases other than acute ischemic stroke. To assess the symmetricity of MCA, the shape of M1, length of M1, number of M2, number of early branches (EBs), and distance from the top of the internal carotid artery to EB were investigated. Results The shape of M1 was upward in 42%, horizontal in 47%, and downward in 11%. The M1 shape was the same on both sides in 64%, which exceeded the probability assumed to be left-right independent. The number of M2 trunks and EBs matched left and right in 86 and 55% of patients, respectively; however, these agreement rates were not higher than those with independent left and right sides. No left-right correlation was found between the M1 length and the distance from the internal carotid artery to EB. Conclusion Based on our data, the symmetry of MCA was observed only in the shape of the M1 segment. This finding could be beneficial for EMT targeting MCA embolisms.

Relationship between thrombus vWF and NETs with clinical severity and peripheral blood immunocytes' indicators in patients with acute ischemic stroke.

OBJECTIVE: To investigate the association between von Willebrand factor (vWF) and neutrophil extracellular traps (NETs) in thrombus with clinical severity and peripheral blood immunocytes' indicators in patients with early-stage acute ischemic stroke (AIS). METHODS: A retrospective study was conducted using the clinical data of 66 patients with AIS who underwent endovascular mechanical thrombectomy and had their thrombus samples collected. The concentrations of vWF and NETs in the thrombus samples were quantitatively assessed. Peripheral blood samples taken in the early stages of the disease were analyzed for total white blood cell counts (WBC), ratios of neutrophils (NEU%), lymphocytes (LYM%), eosinophils (EOS%), and monocytes (MONO%). The severity of clinical symptoms in these patients was evaluated using the modified Rankin Scale (mRS), Essen Stroke Risk Score (ESRS), Barthel Index (BI), and National Institute of Health Stroke Scale (NIHSS). RESULTS: Higher vWF levels in thrombus were associated with lower NIHSS scores, while higher NETs levels were associated with higher initial NIHSS scores. In the early stages of AIS, WBC count and vWF levels were negatively correlated, as well as NEU%. LYM% was positively correlated with vWF level; however, it was negatively correlated with NETs. EOS% was positively correlated with vWF levels. CONCLUSION: In the early stages of AIS, a higher peripheral WBC count and NEU%, combined with decreased EOS% and LYM%, were significantly correlated with a lower vWF level in the thrombus, potentially indicating more severe symptoms. Consequently, the timely administration of vWF-targeted medications is recommended for such patients. Reduced LYM% is indicative of elevated NETs levels and correlated with more severe clinical symptoms. Therefore, the prompt initiation of NETs-targeted medication is warranted for these patients.

Predictive value of intracranial high-density areas in neurological function.

BACKGROUND: Intracranial high-density areas (HDAs) have attracted considerable attention for predicting clinical outcomes; however, whether HDAs predict worse neurological function and mental health remains controversial and unclear, which requires further investigation. AIM: To investigate the predictive value of intracranial HDAs for neurological function and mental health after endovascular treatment. METHODS: In this prospective study, 96 patients with acute ischemic stroke (AIS) who accepted endovascular mechanical thrombectomy (EMT) were included. The enrolled patients underwent cranial computed tomography (CT) examination within 24 hours after EMT. Clinical data in terms of National Institutes of Health Stroke Scale (NIHSS), the 3-month modified Rankin Scale (mRS), self-rating depression scale (SDS), and self-rating anxiety scale (SAS) scores were collected and compared between patients with HDAs and non-HDAs and between patients with good and poor clinical prognosis. RESULTS: Compared to patients without HDAs, patients with HDAs presented severe neurological deficits (admission NIHSS score: 18 ± 3 vs 19 ± 4), were more likely to have post-stroke disabilities (mRS < 3: 35% vs 62%), and suffered more severe depression (SDS score: 58 ± 16 vs 64 ± 13) and anxiety disorder (SAS score: 52 ± 8 vs 59 ± 10). Compared to patients with a good prognosis, patients with a poor prognosis presented severe neurological deficits (admission NIHSS score: 17 ± 4 vs 20 ± 3), were more likely to have HDAs on CT images (64% vs 33%), and suffered more severe depression (SDS score: 55 ± 19 vs 65 ± 11) and anxiety (SAS score: 50 ± 8 vs 58 ± 12). Multivariate analysis revealed that HDAs were independent negative prognostic factors. CONCLUSION: In conclusion, HDAs on CT images predicted poor prognosis and severe depressive and anxiety symptoms in patients with AIS who underwent EMT.

Endovascular Mechanical Thrombectomy with a Large-Bore Aspiration Catheter and Stent Retriever for Cerebral Venous Sinus Thrombosis in Pregnancy: A Case Report.

Objective: A case of cerebral venous sinus thrombosis (CVST) during pregnancy effectively recanalized by endovascular mechanical thrombectomy with the combined use of an aspiration catheter and a stent retriever is reported. Case Presentation: A 27-year-old woman at eight weeks' gestation developed sudden onset of right hemiparalysis and seizures and was referred to our hospital. Her National Institutes of Health Stroke Scale score on admission was 23. On MRI, diffusion-weighted imaging showed a hyperintensity area in the left frontal lobe, and T2* imaging showed hemorrhagic infarction in the same area. MR venography showed obstruction of the anterior two-thirds of the superior sagittal sinus (SSS). Anticoagulant therapy with heparin was started, but since the venous return was expected to be severely impaired, mechanical thrombectomy by endovascular surgery was selected, hoping to resolve symptoms early. Using a large-bore aspiration catheter in combination with a stent retriever, it was possible to safely guide the aspiration catheter into the anterior half of the SSS. The use of a large-bore aspiration catheter enabled retrieval of a large amount of thrombus in a short time, and complete recanalization was achieved. The patient's hemiplegia and aphasia improved significantly within a week after the procedure, and she was discharged without sequelae. Conclusion: Mechanical endovascular therapy of CVST performed with a combination of a large-bore aspiration catheter and a stent retriever should be considered particularly for patients with severe neurological symptoms or intracranial hemorrhage and for those who do not respond to anticoagulation therapy.

Endovascular mechanical thrombectomy for cerebral venous sinus thrombosis after mRNA-based SIRS-CoV-2 vaccination.

Background: As vaccinations against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continue worldwide, increased rates of venous thrombotic events, mainly as cerebral venous sinus thrombosis (CVST), have been reported following adenovirus vector-based SARS-CoV-2 vaccination. However, few reports have described the occurrence of venous thrombosis after messenger RNA (mRNA)-based vaccination. Here, we describe a case of CVST after a first dose of mRNA-based vaccination that was treated with emergent endovascular mechanical thrombectomy and systemic heparinization.Case Description.A 43-year-old, previously healthy man suffered severe headache and partial seizures affecting the left arm 4 days after receiving the first dose of an mRNA-based SARS-CoV-2 vaccination (FC3661; Pfizer/BioNTech). Computed tomography showed intraparenchymal hemorrhage. Seven days after vaccination, symptoms worsened and he was transferred to our tertiary hospital. Magnetic resonance venography revealed CVST with occlusion of the superior sagittal sinus (SSS) and right transverse sinus (TS). Since no findings suggested thrombosis with thrombocytopenia syndrome, the patient underwent systemic heparinization and emergent mechanical thrombectomy with balloon transluminal angioplasty, a stent retriever and an aspiration catheter. Complete SSS and right TS recanalization were achieved and the patient was discharged without neurological deficits. Conclusion: Clinicians should be aware that apparently healthy individuals with no risk factors can develop CVST after receiving an mRNA-based vaccine and appropriate treatment including EMT need to be performed immediately.(228 words).

Assessment of Primary Collateral Grades Based on the Integrity of Willis' Circle: Predicting the Prognosis of Acute Intracranial Internal Carotid Artery Occlusion Before Thrombectomy.

OBJECTIVE: Endovascular mechanical thrombectomy (EVMT) has shown significant efficacy in improving neurological functions in patients with intracranial internal carotid artery occlusion (IICAO), but its clinical outcomes are variable. We examined the relationship between favorable clinical outcomes after EVMT in IICAO and a set of predictors. METHODS: In this retrospective study, 189 patients with IICAO treated by EVMT at 3 centers from November 2015 to December 2020 were included and analyzed. Non-contrast computed tomography and computed tomography angiography were evaluated on admission. The morphology of IICAO was categorized into Ia, Ib, L, or T types, depending on the involvement of the posterior communicating artery origin, proximal anterior cerebral artery, and middle cerebral artery. The Willis' circle was categorized as integrated or compromised Willis' circle. In combination with the involvement of the IICAO and the integrity of Willis' circle, we used the primary collateral grade (PCG) to describe the presence of functional Willisian collaterals. Baseline data including demographics, characteristics, vascular risk factors, and initial National Institutes of Health Stroke Scale scores were collected. Hemorrhagic transformation was evaluated using the 24-hour non-contrast computed tomography after EVMT. Favorable outcomes based on modified Rankin scale, were defined as 0-2 at 90 days. RESULTS: A total of 189 patients were included (median age, 69 years; 126 male [66.7%]). 104 patients [55.0%] showed reperfusion after EVMT, but 72 patients [38.1%] achieved favorable outcomes at 90 days. The mortality rate of type Ib was significantly higher than that with type Ia (χ2 = 14.21, P = 0.001). The outcome with different structure of Willis' circle was not statistically different between the 2 groups. A multivariate logistic regression analysis showed that IICAO T-type (odds ratio, 0.028 [95% confidence interval: 0.323-3.829], P = 0.042) and PCG 2 (odds ratio 9.427[95% confidence interval:1.863-47.698], P = 0.007) were predictors of favorable outcomes. CONCLUSIONS: Evaluation of PCG by determining the type of IICAO and the integrity of Willis' circle may serve as a valuable indicator for the prognosis and as an essential reference for screening patients before EVMT.

Indian College of Radiology and Imaging (ICRI) Consensus Guidelines for the Early Management of Patients with Acute Ischemic Stroke: Imaging and Intervention.

The medical science has witnessed significant change in the management of acute stroke patients as a result of recent advances in the field of stroke imaging and endovascular mechanical thrombectomy in addition to intravenous thrombolysis and optimization of stroke services in balance with available resources. Despite initial negative trials, we witnessed the publication of five multicenter randomized clinical trials showing superiority of the endovascular approach over standard medical management in patients with large vessel occlusion. The aim of this study is to provide comprehensive set of evidence-based recommendations regarding imaging and endovascular interventions in acute ischemic stroke patients.

Endovascular Mechanical Thrombectomy for Basilar Artery Occlusion Caused by Thrombosis as an Initial Manifestation of Acute Myelogenous Leukemia: A Case Report.

We report a rare case of a basilar artery occlusion (BAO) caused by thrombosis as an initial magnification of acute myelogenous leukemia (AML) and performed mechanical thrombectomy (MT) to treat it. A 67-year-old female presented left hemiparalysis of her arm and right-sided blindness. Magnetic resonance imaging (MRI) and magnetic resonance angiography revealed acute infarction in the left occipital and anterior lobes of the cerebellum and incomplete BAO. Her blood test showed hyperleukocytosis with precursor cells and high levels of C-reactive protein, and we diagnosed AML and disseminated intravascular coagulation (DIC). We decided to treat conservatively with rapid rehydration and heparin, but three hours after admission, she suddenly lost consciousness. We performed acute MT with a direct aspiration first-pass technique (ADAPT). A white elastic embolus was aspirated, and DSA showed successful recanalization of the basilar artery. The next day, MRI revealed acute infarction in the midbrain and bilateral thalamus. The patient remained unconscious after MT and so chemotherapy to treat the acute leukemia could not be performed. The patient died of the primary disease 14 days after BAO. Thrombosis in association with AML is very rare disease and could occur in arterial vessels because of hypercoagulation, and this tendency may not respond to anticoagulation therapy. Although ADAPT might be performed safety without complications even in cases of DIC, indications for treatment with MT should be carefully considered in patients in whom hemorrhage is a possibility.

Ilio-Femoral Deep Vein Thrombosis Secondary to May-Thurner Syndrome With Ipsilateral Lower Limb Arterio-Venous Graft In-Situ.

Ilio-femoral deep vein thrombosis (DVT) is rare in patients with lower limb arterio-venous grafts due to a state of high blood flow. May-Thurner syndrome (MTS) is an anomaly where the left common iliac vein is compressed by the right common iliac artery. We present a rare case of ilio-femoral deep vein thrombosis in a patient with May-Thurner Syndrome and an underlying arteriovenous graft in-situ who presented with acute lower limb swelling. The patient underwent catheter-directed thrombolysis, pharmaco-mechanical thrombectomy, venoplasty and iliac vein stenting. Follow-up surveillance duplex ultrasound showed patency of the iliac vein stent and arteriovenous graft at 1-year postoperatively.

Successful Emergent Endovascular Mechanical Thrombectomy for Pediatric and Young Adult Cerebral Venous Sinus Thrombosis in Coma.

BACKGROUND: Cerebral venous sinus thrombosis (CVST) is a relatively uncommon cause of stroke in pediatric patients and young adults. The clinical course of CVST is also highly variable. In particular, coma has been noted as a predictor of poor outcome. The standard treatment for CVST in adults is systemic anticoagulation, which can lead to recanalization. Endovascular mechanical thrombectomy (EMT) is considered as possibly indicated in the event of failure to respond to anticoagulation or a comatose state. However, the role of endovascular therapy in the management of pediatric and young adult CVST is unclear. Here, we describe 3 cases of successful emergent EMT for pediatric and young adult CVST presenting in a comatose state. CASE DESCRIPTION: A 17-year-old boy presented with rapid deterioration and a comatose state despite anticoagulation using heparin. Emergent EMT was performed for CVST. Balloon percutaneous transmural angioplasty and catheter aspiration were repeatedly performed, and partial recanalization of the superior sagittal sinus was achieved by the end of the procedure. The child was discharged without neurologic deficits. Another 2 comatose cases with CVST underwent emergent EMT with balloon percutaneous transmural angioplasty and catheter aspiration, and partial recanalization was again achieved. These patients finally showed complete superior sagittal sinus recanalization and were discharged without neurologic deficits. CONCLUSION: Pediatric and young comatose CVST warrants endovascular mechanical thrombectomy as soon as possible.

Cutting Edge Acute Ischemic Stroke Management.

Acute ischemic stroke (AIS) is a medical emergency that requires prompt recognition and streamlined work-up to ensure that time-dependent therapies are initiated to achieve the best outcomes. This article discusses frequently missed AIS in the emergency department, the role of various imagining modalities in the work-up of AIS, updates on the use of intravenous thrombolytics and endovascular therapy for AIS, pearls on supportive care management of AIS, and prehospital and hospital process improvements to shorten door-to-needle time.

A nomogram model predicting futile recanalization in patients with acute anterior circulation large vessel occlusion after endovascular mechanical thrombectomy / 中华神经医学杂志

Objective:To investigate the risk factors for futile recanalization in patients with acute anterior circulation large vessel occlusion after endovascular mechanical thrombectomy (EMT), and establish a nomogram model predicting futile recanalization in these patients.Methods:One hundred and eighty-eight patients with acute anterior circulation large vessel occlusion after EMT were enrolled from Department of Neurology, Zhongshan Hospital of Chinese Medicine, Guangzhou University of Chinese Medicine from January 2018 to December 2021. Patients were divided into futile recanalization group and effective recanalization group according to whether futile recanalization occurred; futile recanalization was defined as successful recanalization showed by immediate postoperative DSA (modified thrombolysis in cerebral infarction [mTICI] ≥2b), but poor functional outcome (modified Rankin Scale [mRS] scores>2 90 d after surgery). The clinical data were compared between futile recanalization group and effective recanalization group. Multivariate Logistic regression analysis was used to screen the risk factors for futile recanalization. R software was used to establish a nomogram model for futile recanalization. C-index was used to evaluate the differentiation of the model, and correction curve was used to evaluate the accuracy of the line graph model prediction. Receiver operating characteristic (ROC) curve was used to evaluate the predictive efficiency of the nomogram model.Results:Ninety-two patients had futile recanalization. Compared with the effective recanalization group, futile recanalization group had significantly older age, significantly higher hemoglobin A1c on admission, significantly longer time from puncture to vascular recanalization, significantly higher proportions of patients with hypertension history and poor collateral circulation, and significantly different severities of stroke and white matter hyperintensities (WMHs) and distribution of occlusive sites ( P<0.05). Multivariate Logistic regression analysis showed that age, history of hypertension, time from puncture to vascular recanalization, poor collateral circulation, severe WMHs, and moderate-severe stroke were independent risk factors for futile recanalization after EMT in patients with acute anterior circulation large vessel occlusion ( P<0.05). A nomogram model of futile recanalization was established according to the above 6 factors, with C-index of 0.862 ( 95%CI: 0.809-0.914); the calibration curve of the model was highly coordinated to the ideal model curve; area under the ROC curve of futile recanalization was 0.862 ( 95%CI: 0.809-0.914, P<0.001). Conclusions:Acute anterior circulation large vessel occlusion patients with older age, history of hypertension, longer time from puncture to vascular recanalization, poor collateral circulation, severe WMHs, and moderate-severe stroke trend to have futile recanalization after EMT. This nomogram can predict futile recanalization after EMT.