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Objectives: This study aimed to examine nationwide trends in acute stroke endovascular thrombectomy (EVT) following five pivotal trials in 2015 that established it as the 'standard of care'., Methods: The Japanese Registry of NeuroEndovascular Therapy 4 was a nationwide retrospective study registering consecutive patients who underwent neurointervention by specialists certified by the Japanese Society for Neuroendovascular Therapy at 166 centers from January 2015 to December 2019. We extracted patients who underwent EVT, and analyzed the annual trends in baseline characteristics, revascularization procedures and outcomes., Results: A total of 13,090 patients (75.3 ± 12.2 years, 5637 women) were included. Analyses revealed an annual increase in patient age and treatments beyond 6 h after onset. However, there was an annual decline in premorbidly independent patients and those with large vessel occlusion. The frequency of stent-aspiration techniques and rate of successful reperfusions significantly increased from 19.9 % to 51.0 % and from 81.4 % to 83.9 %, respectively through the study period. Trends in patients achieving a favorable (modified Rankin Scale score of 0-2 at 30 days) or fatal outcome, or experiencing intracranial hemorrhagic complications remained unchanged. However, calendar time was associated with favorable outcomes after adjusting for clinical and treatment characteristics (odds ratio, 1.040; P = 0.015)., Conclusions: During the study period, EVT indications expanded for patients with characteristics linked to worse outcomes. However, factors such as advancements in techniques, have led to modest but significant improvements in reperfusion status, leading to maintenance of the post-EVT clinical outcomes., Registration: URL: https://www.umin.ac.jp/ctr/; Unique identifier: UMIN000038869., Competing Interests: Declaration of competing interest Nobuyuki Sakai reports a research grant from Biomedical Solutions, Medtronic, Terumo and TG Medical; lecturer fees from Asahi-Intec, Biomedical Solutions, Daiichi-Sankyo, Kaneka, Medtronic, and Terumo; membership on the advisory boards of Johnson & Johnson, Medtronic and Terumo outside the submitted work. Yuji Matsumaru reports a research grant from Allum and lecture fees from Medtronic, Stryker, Terumo, Johnson & Johnson, Kaneka, Medico's Hirata, Biomedical solution outside the submitted work. Hiroshi Yamagami reports a research grant from Bristol-Myers Squibb; lecturer's fees from Stryker, Medtronic, Johson & Johnson, Medico's Hirata, Bristol-Myers Squibb, Diichi-Sankyo, Boston Scientific, and Otsuka Pharmaceutical outside the submitted work. Tetsu Satow reports a research grant from CANON medical systems; a lecturer's fee from Medtronic; a consulting fee from Kaneka outside the submitted work. Hirotoshi Imamura reports lecturer fees from Medtronic, Daiichi Sankyo, Terumo, Stryker, Johnson & Johnson and Asahi-Intec outside the submitted work. The other co-authors have no conflict of interest related to this manuscript., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Uncertainty remains on the optimal management of basilar artery occlusion (BAO). Two large randomized controlled trials (RCTs) in 2019 and 2021 demonstrated neutral results with respect to the use of endovascular therapy (EVT) for BAO. This study aimed to understand regional variation in physicians' perceptions towards the treatment of BAO as stratified by physician respondents from China versus outside China, prior to the publication of studies demonstrating a benefit of EVT for BAO., Methods: An international online survey was conducted of stroke neurologists and neurointerventionalists from January to March 2022. Survey questions evaluated physician opinions toward the use of EVT in BAO, as well as the clinical and imaging features underlying treatment decisions. Respondents were dichotomized as either from China or from other countries and differences between groups were analyzed., Results: There were 1245 physician respondents across 73 countries of which 295 (23.7%) were from China. Compared to respondents from the rest of the world, respondents from China were more likely to be interventionalists (71.5% vs 35.0%; p < 0.0001). Overall, more than 95% of respondents believed that EVT was superior to medical therapy under certain circumstances. Chinese respondents were more likely to believe that further RCTs were necessary than respondents from other countries (93.6% vs 76.2%; p < 0.0001). Chinese respondents were more likely to use advanced imaging in later time windows and use a premorbid mRS threshold of ≤2 for BAO selection to EVT., Conclusion: Most stroke physicians believe EVT is beneficial in selected patients with BAO. Clinical and imaging modality differences were observed in the selection criteria used for EVT. There was greater inclination to enroll all trial eligible patients in a BAO RCT by respondents from China as compared to other parts of the world., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: Endovascular therapy (EVT) is safe and effective for acute ischemic stroke (AIS) due to large-vessel occlusion (LVO). However, the influence of the AIS subtype (large-artery atherosclerosis [LAA] or cardioembolism [CE]) on clinical outcome in patients treated with EVT remains unclear. This study aimed to evaluate the differences in clinical results between the two subtypes using data from a multicenter prospective registry (RESCUE-Japan Registry 2)., Materials and Methods: Among 2420 patients in RESCUE-Japan Registry, 682 patients who were diagnosed with LAA or CE were enrolled. The primary outcome was a modified Rankin Scale (mRS) score of 0-2 at 90 days. The secondary outcomes were 90-day mRS 0-1, 0-3, and 6. The relationship between time from onset and clinical outcome was also analyzed., Results: Among the 682 patients, 124 were classified into the LAA group and 558 into the CE group. The baseline National Institutes of Health Stroke Scale score was significantly lower (median 15 vs. 18, p < 0.001). At 90 days, mRS 0-2 was observed in 54 of 124 patients (44%) in the LAA group and 232 of 558 patients (42%) in the CE group (p = 0.69). The proportion of patients with mRS 0-2 tended to decrease according to onset-to-puncture time in the CE group but not in the LAA group (p trend =0.0007)., Conclusions: The rate of good outcome was similar between LVO due to LAA and CE. However, the rate of favorable outcome did not decrease according to onset-to-puncture time in the LAA group., Competing Interests: Declaration of Competing Interest Dr. Shirakawa has no conflict of interest. Dr. Matsukawa has no conflict of interest. Dr. Sakai received research grants from Biomedical Solutions, Daiichi-Sankyo, NeuroVasc, and Terumo, and lecturer fees from Biomedical Solutions, Johnson & Johnson, Medtronic, Microvention, Penumbra, and Stryker. Dr. Yamagami received a research grant from Bristol-Myers Squibb; lecturer fees from Bayer, Daiichi-Sankyo, Bristol-Myers Squibb, Boehringer-Ingelheim, and Stryker; and membership in the advisory boards of Daiichi-Sankyo. Dr. Imamura received lecturer fees from Medtronic and Stryker. Dr. Matsumoto received lecturer fees from Medtronic, Stryker, Sumitomo Bakelite, Kaneka Medix, and Fuji Systems. Dr. Tanaka received lecturer fees from Daiichi-Sankyo. Dr. Takeuchi received lecturer fees from Daiichi Sankyo and Stryker. Dr. Uchida received lecturer fees from Daiichi Sankyo. Dr. Morimoto received lecturer fees from Bayer, Daiichi Sankyo, Japan Lifeline, Kyocera, Mitsubishi Tanabe, Novartis, and Toray; received manuscript fees from Bristol-Myers Squibb and Kowa; and served in the advisory boards of Asahi Kasei, Bristol-Myers Squibb, and Boston Scientific. Dr Yoshimura received research grants from Medtronic, Medicos Hirata, Terumo, Bristol-Myers Squibb, and Otsuka, and lecturer fees from Daiichi Sankyo, Pfizer, Boehringer-Ingelheim, Otsuka, Bayer, Pfizer, Bristol-Myers Squibb, Stryker, Medtronic, and Mitsubishi Tanabe., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Serum potassium levels are considered as a marker of cerebrovascular emergencies but there is less clarity on the association between initial serum potassium levels recorded on patient's arrival at the emergency department with the type of stroke. This is a case-control study using data of a tertiary care hospital in Japan from April 2018 to September 2019. We identified adult patients with hemorrhagic stroke including subarachnoid hemorrhage (cases) and those with ischemic stroke (controls). Data on age, sex, chief complaints, vital signs, and initial blood tests were collected. We analyzed the association between serum potassium levels and the type of stroke by drawing a LOWESS curve. Additionally, we fitted a logistic regression model to examine the association of interest. There were 416 stroke patients (158 hemorrhagic and 258 ischemic). The median age was 77 years (IQR: 68, 84), and 54% were male. The mean potassium level was 3.69 ± 0.55 mEq/L for hemorrhagic stroke and 4.08 ± 0.65 mEq/L for ischemic stroke. The LOWESS curve showed that the lower initial potassium level was linearly associated with a greater likelihood of hemorrhagic stroke. In the logistic regression model, the odds ratio for the risk of hemorrhagic stroke per 1 mEq/L lower potassium level was 3.31 (95% confidence interval [CI]: 2.24-5.04). This association remained significant in a multivariable model adjusting for other covariates (OR: 2.62 [95% CI: 1.70-4.16]). Initial potassium level was lower in patients with hemorrhagic stroke compared to those with ischemic stroke., Competing Interests: Declaration of Competing Interest Dr. Fukaguchi, Dr. Soeno, Dr. Hara, Dr. Shirakawa are contracted researchers of TXP Medical Co. Ltd. Dr. Goto is the Chief Scientific Officer of TXP Medical Co. Ltd. Dr. Sonoo is the Chief Executive Officer of TXP Medical Co. Ltd., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objectives: Cardioembolic stroke has a poor prognosis. We evaluated the region-dependent efficacy of endovascular therapy (EVT) based on diffusion-weighted imaging-Alberta Stroke Program Early CT Score (DWI-ASPECTS)., Methods: This post-hoc analysis of the RELAXED study, which investigated the optimal timing of rivaroxaban to prevent nonvalvular atrial fibrillation (NVAF) recurrence in patients with acute ischemic stroke (AIS), included NVAF patients admitted with AIS or transient ischemic attack in the middle cerebral artery (MCA), with internal carotid artery (ICA), M1, or M2-MCA occlusion. Relationships between DWI-ASPECTS region and functional outcome (modified Rankin Scale [mRS]), mortality, recurrence, and hemorrhagic stroke were compared between patients with and without EVT, and adjusted odds ratios for age, pre-stroke mRS, National Institutes of Health Stroke Scale (NIHSS), ICA occlusion, infarct size, recombinant tissue plasminogen activator (rt-PA) use, and onset-to-hospitalization time were estimated., Results: EVT patients had significantly lower hemoglobin levels, higher median NIHSS scores, more lentiform nucleus infarcts, ICA or M1-MCA occlusions, treatment with rt-PA, and fewer M3, M5, or M6 infarcts and M2-MCA occlusions than no-EVT patients. EVT patients had shorter onset-to-hospitalization times and more frequent favorable functional outcomes (p=0.007). Mortality, recurrent ischemic stroke, and hemorrhagic infarction were similar in both groups. EVT was associated with significantly better functional outcomes among patients with insular ribbon (p=0.043) and M3 (p=0.0008) infarcts. M3 patients had significantly fewer rt-PA and EVT, and longer onset-to-hospitalization times., Conclusions: An occlusion in the insular ribbon or M3 region was associated with favorable functional outcomes in patients treated with EVT after cardioembolic stroke., Competing Interests: Declaration of Competing Interest K.U. received lecture fees from Daiichi-Sankyo. M.Y. received lecture fees from Boehringer Ingelheim, Bayer, Daiichi-Sankyo, Pfizer, BMS, Takeda, Sumitomo Dainippon, Sanofi, Otsuka, CSL Behring, Eisai, Tanabe-Mitsubishi, Medtronic, Boston Scientific, and Sekisui Medical and research support from Sanofi, Boehringer Ingelheim, and Daiichi-Sankyo. K.T. received lecture fees from Nippon Boehringer Ingelheim, Bayer Yakuhin, Daiichi-Sankyo, and BMS. E.M. received lecture fees from Johnson & Johnson, Otsuka, Novartis, Daiichi-Sankyo, Sumitomo Dainippon Pharma, Sosei, Kyowahakko-Kirin, Toshiba, Medtronic, and Nihon Medi-Physics and research support from Eisai, Daiichi-Sankyo, Novartis, Fuji Film RI, General Electric, MHWL, MEXT, and JSPS. T. Hirano received lecture fees from Astellas, Bayer, Boehringer Ingelheim, BMS, CSL Behring, Daiichi-Sankyo, Eisai, Medtronic, Otsuka, Pfizer, Sumitomo Dainippon, Sanofi, Takeda, and Tanabe-Mitsubishi and research support from Astellas, Bayer, Boehringer Ingelheim, Daiichi-Sankyo, Eisai, MSD, Otsuka, Tanabe-Mitsubishi, and JSPS KAKENHI (grant number 25461320, PI, 2014-2016; grant number 16K09731, PI, 2016-2017). H.Y. received lecture fees from Bayer, Boehringer Ingelheim, Daiichi-Sankyo, BMS, Takeda, Otsuka, Tanabe-Mitsubishi, Medtronic, Stryker, Termo, Johnson and Johnson, and Medico's Hirata and research support from BMS. T.N. received lecture fees from Astellas, AstraZeneca, Bayer, Bristol-Myers Squibb, Daiichi, Sankyo, Sumitomo Dainippon, Eisai, FP, Kyowa Hakko Kirin, Medtronic, Mochida, Nippon Boehringer Ingelheim, Novartis, Otsuka, Pfizer, Sanofi, Takeda, and Mitsubishi Tanabe. S.U. received lecture fees from Boehringer Ingelheim, Bayer, Daiichi-Sankyo, Takeda, Sumitomo Dainippon, Sanofi, Otsuka, Mitsubishi Tanabe, AstraZeneca, Shionogi, and Astellas Amgen and research support from the Japan Cardiovascular Research Foundation. K.M. received lecture fees from Bayer Healthcare, Otsuka Pharmaceutical, Boehringer Ingelheim, AstraZeneca, Pfizer, Mitsubishi Tanabe Pharma Cooperation, Japan Stryker, Kowa, Nihon Medi-Physics Co, BMS, Sawai Pharmaceutical Co., Sumitomo Dainippon Pharma Co Ltd, Medico's Hirata, Daiichi-Sankyo, Astellas Pharma, Kyowa Hakko Kirin Pharma, Inc, Sanofi, MSD, Eisai Co., Nippon Chemiphar, and Towa Pharmaceutical Co. S.Y. received lecture fees from Boehringer Ingelheim, Bayer, Daiichi-Sankyo, Pfizer, BMS, Takeda, Sanofi, Otsuka, Tanabe-Mitsubishi, Medtronic, Stryker, and Medico's Hirata and research support from BMS and Takeda. Y.O., F.S., H.K., and T. Hamasaki have no disclosures to report., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Experimental models have clearly demonstrated sex differences in the pathophysiology of stroke and prognosis, however clinical evidence remains elusive. In this study, we examined sex differences as a post hoc analysis of RELAXED (Recurrent Embolism Lessened by rivaroxaban, an anti-X agent, of Early Dosing for acute IS and TIA with atrial fibrillation) Study., Methods: We stratified study participants by sex and compared baseline and clinical characteristics as well as clinical outcomes. The primary outcome measure was a good outcome defined as a modified Rankin Scale score of 0-2 at 90 days after stroke. Secondary outcomes were mortality at 90 days, intracranial hemorrhage within 90 days, and recurrence of stroke or transient ischemic attack within 90 days. We constructed a logistic regression model to estimate the adjusted odds ratio of female patients compared with male patients for the primary and secondary outcomes., Results: Of 1303 patients, most were male (57.7%) with a mean age of 74.5 years. Female patients were older with a mean age of 80.6 ± 8.9 years and had significantly less frequent anticoagulation therapy before onset of stroke and more severe NIHSS scores. Good outcome was observed in 51.2% and 63.3% of the females and males (p < 0.0001). The adjusted odds ratio of a good outcome in females was 1.12 (95% confidence interval, 0.44-2.87) (p = 0.81). There were no sex differences in secondary outcomes., Conclusion: Adjusted regression analysis found no sex difference in the treatment outcomes at 90 days after stroke with non-valvular atrial fibrillation., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: To clarify the relationship between early neurological symptoms and long-term functional outcomes of acute ischemic stroke, which would be beneficial for patient management and determining clinical study criteria of novel therapeutic interventions., Materials and Methods: We retrieved data from the Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism Japan Registry 2 (RESCUE-Japan Registry 2) and investigated the association between 24- and 72-hour National Institutes of Health Stroke Scale (NIHSS) and 90-day modified Rankin Scale (mRS) scores, stratified by the site of occlusion (carotid or vertebrobasilar circulatory large arterial occlusion [ACO or PCO, respectively]) and endovascular recanalization therapy (EVT) performance. We examined the correlation using Spearman's rank correlation coefficient (rho). Predictive accuracies of 24- and 72-hour NIHSS scores for good outcomes at 90 days (defined as mRS score of 0-2) were evaluated by receiver operating characteristic (ROC) analyses and the corresponding areas under the curves (AUCs)., Results: Among the 2420 patients, 1745 had ACO (971 with EVT, 774 without EVT) and 263 had PCO (127 with EVT, 136 without EVT). The 24- and 72-hour NIHSS scores were significantly associated with 90-day mRS scores and accurately predicted good outcomes (all rhos ≥0.76, all AUCs ≥0.86). In the ACO group, there were differences in rho and AUC depending on EVT performance and the time from onset to NIHSS acquisition, but no differences were observed in the PCO group., Conclusions: EVT performance and time frame should be considered when determining the criteria of novel therapeutic interventions, especially for patients with ACO., Competing Interests: Declaration of Competing Interest Dr. Tatebayashi had no disclosures to report. Dr. Yoshimura reported research grants from Medtronic, Medicos Hirata, Termo, Bristol-Myers Squibb, and Otsuka; lecturer's fees from Daiichi Sankyo, Pfizer, Boehringer-Ingelheim, Otsuka, Bayer, Pfizer, Bristol-Myers Squibb, Stryker, Medtronic, and Mitsubishi Tanabe. Dr. Sakai reported a research grants from Biomedical Solutions, Daiichi-Sankyo, NeuroVasc and Terumo; lecturer's fees from Biomedical Solutions, Johnson&Johnson, Medtronic, Microvention, Penumbra and Stryker. Dr. Uchida reported the lecturer's fee from Daiichi Sankyo. Dr. Kageyama had no disclosures to report. Dr. Yamagami reported research grant from Bristol-Myers Squibb, the lecturer's fees from Bayer, Daiichi-Sankyo, Bristol-Myers Squibb, Boehringer-Ingelheim, Medtronic, Medicos Hirata, Termo, Johnson & Johnson and Stryker; and membership of the advisory boards for Daiichi-Sankyo. Dr. Morimoto reported lecturer's fees from Bayer, Daiichi Sankyo, Japan Lifeline, Kyocera, Mitsubishi Tanabe, Novartis, and Toray; the manuscript fees from Bristol-Myers Squibb and Kowa; served advisory boards for Asahi Kasei, Bristol-Myers Squibb, and Boston Scientific., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: In all of randomized controlled trials of mechanical thrombectomy, the target vessels were proximal. Herein we report a clinical trial of the Tron FX stent retriever, including the smallest size of 2/15 mm for distal intracranial large vessel occlusion (LVO)., Objective: Eligible patients presented within 8 h of onset with proximal or distal LVOs, and the Tron FX 4/20 mm or 2/15 mm were used as the first-line device., Methods: The primary endpoints were rate of modified Thrombolysis in Cerebral Infarction (mTICI) grade 2a-3 immediately after using Tron FX only, and mortality rate 90 d. We compared the outcomes between sizes 4/20 and 2/15 mm., Results: The clinical trial was conducted in 50 cases, of which 44% presented with distal LVO and 15 cases were treated using only Tron FX 2/15 mm. The overall rate of mTICI grade 2a-3 was 80.0% (75.8% with Tron FX 4/20 mm, and 86.7% with 2/15 mm), and a 90-day modified Rankin Scale ≤ 2 or improvement of National Institute of Health Stroke Scale after thrombectomy ≥ 10 was achieved in 66.7% of cases (61.3% with Tron FX 4/20 mm, and 80.0% with 2/15 mm). The overall 90-day mortality rate was 8.0%, and symptomatic intracranial hemorrhage within 24 h occurred in 2.0% of cases., Conclusion: In this clinical trial using the Tron FX, which included the size of 2/15 mm for distal LVO, its efficacy was similar and its safety was superior compared with previous studies., Competing Interests: Declaration of Competing Interest All authors who are members of the Japan Neurosurgical Society (JNS) have registered online self-reported conflicts of interest disclosure statement forms through the website for JNS members. H. Imamura received Speakers’ Bureau/Honoraria from Medtronic Co. N. Sakai received Speakers’ Bureau/Honoraria from JIMRO Co., Johnson & Johnson K.K., Medtronic Co,. Penumbra Co., and Stryker Japan K.K., and research funding from Japanese Ministry of Health, Labour and Welfare and Terumo Co. H. Yamagami received Speakers’ Bureau/Honoraria from Terumo Co., Biomedical Solutions Co., and Otsuka Pharmaceutical Co., and research funding from JIMRO Co. Y. Matsumoto received Speakers’ Bureau/Honoraria from Medtronic Co., Takeda Pharmaceutical Co., Otsuka Pharmaceutical Co., GE Health care Japan Co., Stryker Co., Century Medical Co., Medico's Hirata Co., and Fuji systems Co. S. Yoshimura received Speakers’ Bureau/Honoraria from Boehringer-Ingelheim Co., Daiichi Sankyo Co., Bayer Co., and Bristol-Meyers Squibb Co., and research funding from Otsuka Pharmaceutical Co. and Medtronic Co. Y. Matsumaru received Speakers’ Bureau/Honoraria from Medtronic Co., Stryker Co., Terumo Co., Johnson & Johnson Co., Kaneka Co., JIMRO Co., and Biomedical Solutions Co. Other authors have no conflict of interest related to this manuscript., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Our previous trial acute dual study (ADS) reported that dual antiplatelet therapy (DAPT) using cilostazol and aspirin did not reduce the rate of short-term neurological worsening in non-cardioembolic stroke patients. Present post-hoc analysis investigated whether the impact of combined cilostazol and aspirin differed among stroke subtypes and factors associated with neurological deterioration and/or stroke recurrence., Methods: Using the ADS registry, the rate of neurological deterioration, defined as clinical worsening and/or recurrent stroke, including transient ischemic attack was calculated. Stroke subtypes included large-artery atherosclerosis (LAA), small vessel occlusion (SVO), other determined etiology (Others), and undetermined etiology of stroke (Undetermined)., Results: Data of 1022 patients were analyzed. Deterioration was seen in 104 (10%) patients, and the rates were not markedly different between patients treated with DAPT vs. aspirin in any stroke subtypes: LAA, 19% vs. 11%, (p=0.192); SVO, 10% vs. 10% (p=1.000); Others, 6% vs. 6% (p=1.000); Undetermined, 11% vs. 8% (p=0.590). Diabetes mellitus was the independent factor associated with deterioration (odds ratio 4.360, 95% confidence interval 1.139-16.691, p=0.032) in the LAA group. Age (1.030 [1.004-1.057], p=0.026), systolic blood pressure (1.012 [1.003-1.022], p=0.010), and infarct size (2.550 [1.488-4.371], p=0.001) were associated with deterioration in SVO group, and intracranial stenosis/occlusion was associated with it in the Undetermined group (3.744 [1.138-12.318], p=0.030)., Conclusions: Combined cilostazol and aspirin did not reduce the rate of short-term neurological deterioration in any clinical stroke subtype. The characteristics of patients whose condition deteriorates in the acute period may differ based on the stroke subtypes., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest or funding sources to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background and Purpose: We hypothesized that the relationships between treatments and outcomes in acute basilar artery occlusion (BAO) are different, depending on the severity of initial neurological deficits., Methods: Of 2420 ischemic stroke patients with large vessel occlusion in a prospective, multicenter registry in Japan, patients with acute BAO were enrolled. Subjects were divided into two severity groups according to the baseline NIH Stroke Scale score: severe (≥10) and mild (<10) groups. The primary effectiveness outcome was favorable outcome, defined as modified Rankin Scale score 0-3 at 3 months. Safety outcomes included any intracranial hemorrhage (ICH) within 72 h. Outcomes in each group were compared between patients who received endovascular therapy (EVT) and those with standard medical treatment (SMT)., Results: In this study, 167 patients (52 female; median age 75 years) were analyzed. The favorable outcome was seen in 93 patients (56%) overall. In the severe group (n = 128), the proportion of favorable outcome was higher in patients who received EVT (60/111, 54%) than those with SMT (2/17, 12%, P < 0.01). In the mild group (n = 39), the rates of favorable outcome were comparable between the EVT (13/18, 72%) and SMT patients (18/21, 86%, P = 0.43). No significant differences in the rates of any ICH were seen among any groups., Conclusions: In acute BAO stroke with severe neurological deficit, independent ambulation was more frequently seen in patients who received EVT than those with SMT. Patients with mild neurological deficits showed similar rates of independent ambulation between the two treatment selections., (Copyright © 2020. Published by Elsevier Inc.)

Background: Detection and treatment of atrial fibrillation (AF) is a major goal in preventing secondary stroke. Insertable cardiac monitors (ICMs) are available for diagnosis of arrhythmia monitoring in patients with cryptogenic stroke. Magnetic resonance imaging (MRI)-based diagnostic evaluation for acute ischemic stroke subtype classification is common in Japan and can be useful for specific diagnosis of cryptogenic stroke., Purpose: We aimed to investigate the detection rate of AF with an ICM in patients with cryptogenic stroke who were diagnosed by MRI., Methods: We performed a retrospective, multicenter, observational study. AF monitoring data of an ICM (Reveal LINQ) in patients with cryptogenic stroke were registered from 5 stroke centers in Japan between October 2016 and March 2018. ICM candidates in cryptogenic stroke were diagnosed by MRI-based evaluation and selected according to the criteria proposed by the Japan Stroke Society. Detection of AF was defined as AF for longer than 120 seconds., Results: Eighty-four consecutive patients (64 men; aged 38-90 years) underwent ICM implantation after diagnosis of cryptogenic stroke. AF was detected in 22 of 84 (26.2%) patients with an ICM during a median follow-up of 221.5 days (range: 93-365 days). The detection rate of AF within 3 months after ICM implantation was 21.4%., Conclusions: The AF detection rate with an ICM is approximately one fifth within 3 months in patients with cryptogenic stroke as diagnosed by MRI. Our data suggest that the Japanese criteria based on MRI may be useful for selecting adequate candidates for ICM implantation., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: TIAregistry.org is an international cohort of patients with transient ischemic attack (TIA) or minor stroke within 7 days before enrollment in the registry. Main analyses of 1-year follow-up data have been reported. 5 We conducted subanalysis on the baseline and 1-year follow-up data of Japanese patients., Methods: The patients were classified into 2 groups based on Japanese ethnicity, Japanese (345) and non-Japanese (3238), and their baseline data and 1-year event rates were compared. We also determined risk factors and predictors of 1-year stroke., Results: Current smoking, regular alcohol drinking, intracranial arterial stenosis, and small vessel occlusion; and hypertension, dyslipidemia, coronary artery disease, and extracranial arterial stenosis were more and less common among Japanese patients, respectively. Stroke risk was higher and TIA risk was lower at 1-year follow-up among Japanese patients. The baseline risk factors for recurrent stroke were diabetes, alcohol drinking, and large artery atherosclerosis. Independent predictors of 1-year stroke risk were prior congestive heart failure and alcohol consumption., Conclusions: The two populations of patients featured differences in risk factors, stroke subtypes, and outcome events. Predictors of recurrent stroke among Japanese patients included congestive heart failure and regular alcohol drinking. Strategies to attenuate residual risk of stroke aside from adherence to current guidelines should take our Japanese-patient specific findings into account., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Clinical outcomes after successful endovascular therapy in patients with acute ischemic stroke are associated with several factors including onset-to-reperfusion time (ORT), the National Institute of Health Stroke Scale (NIHSS) score, and the Alberta Stroke Program Early CT Score (ASPECTS). The NIHSS-time score, calculated as follows: [NIHSS score] × [onset-to-treatment time (h)] or [NIHSS score] × [ORT (h)], has been reported to predict clinical outcomes after intravenous recombinant tissue plasminogen activator therapy and endovascular therapy for acute stroke. The objective of the current study was to assess whether the combination of the ASPECTS and the ORT can predict the outcomes after endovascular therapy., Methods: The charts of 117 consecutive ischemic stroke patients with successful reperfusion after endovascular therapy were retrospectively reviewed. We analyzed the association of ORT, ASPECTS, and ASPECTS-time score with clinical outcome. ASPECTS-time score was calculated as follows: [11 - ASPECTS] × [ORT (h)]., Results: Rates of good outcome for patients with ASPECTS-time scores of tertile values, scores 5.67 or less, scores greater than 5.67 to 10.40 or less, and scores greater than 10.40, were 66.7%, 56.4%, and 33.3%, respectively (P < .05). Ordinal logistic regression analysis showed that the ASPECTS-time score (per category increase) was an independent predictor for better outcome (common odds ratio: .374; 95% confidence interval: .150-0.930; P < .05)., Conclusions: A lower ASPECTS-time score may predict better clinical outcomes after endovascular treatment., (Copyright © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: The symptomatic intracranial hemorrhage (SICH) is a serious complication of endovascular therapy (EVT) in acute ischemic stroke (AIS) with large vessel occlusion. We aimed to clarify the predictors of SICH after EVT in patients with internal carotid artery (ICA) or proximal M1 segment of middle cerebral artery occlusions., Methods: Among 1442 AIS patients with large vessel occlusion admitted within 24 hours after onset between July 2010 and June 2011, 226 patients with ICA or proximal M1 occlusions were treated with EVT. SICH was defined as any type of intracranial hemorrhage with a decline in the National Institutes of Health Stroke Scale (NIHSS) score ≥4., Results: Of the 226 patients, 204 with sufficient data were analyzed. SICH was observed in 10 patients (4.9%). Baseline NIHSS score (22 versus 17), serum glucose level (206 mg/dL versus 140 mg/dL), and prior antiplatelet therapy (60.0% versus 21.7%) were significantly higher in patients with SICH than in those without (all P < .01). With receiver operating characteristic analyses, the optimal cutoff values for predicting SICH were NIHSS score ≥19 and serum glucose ≥160 mg/dL. In multivariate analysis, glucose level ≥160 mg/dL (odds ratio: 11.89; 95% confidence interval [CI]: 2.79-65.08), prior antiplatelet therapy (odds ratio: 8.03; 95% CI: 1.83-41.70), and NIHSS score ≥19 (odds ratio: 7.78; 95% CI: 1.63-59.44) were independent predictors of SICH., Conclusion: Hyperglycemia, prior antiplatelet therapy, and high baseline NIHSS score were associated with SICH after EVT in AIS patients with ICA or proximal M1 occlusions., (Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: In the acute phase of cardioembolic stroke in patients with nonvalvular atrial fibrillation (NVAF), the recurrence rate is high. Nonvitamin K antagonist oral anticoagulants may be appropriate for prevention of early recurrence because they have a much lower risk of hemorrhagic stroke than warfarin., Methods: RELAXED (Recurrent Embolism Lessened by rivaroxaban, an Anti-Xa agent, of Early Dosing for acute ischemic stroke and transient ischemic attack with atrial fibrillation) study is an observational study designed to investigate the optimal timing to start administration of rivaroxaban for prevention of recurrence in NVAF patients in the acute phase of cardioembolic stroke (ClinicalTrials.gov: NCT02129920 and UMIN-clinical trials registry: UMIN000013932). It will evaluate the efficacy and safety of rivaroxaban with regard to infarct size, timing of initiation of rivaroxaban medication, and other patient characteristics. A total of 2000 consecutive patients with acute ischemic stroke in the territory of the middle cerebral artery and NVAF will be enrolled in 100 institutes throughout Japan, and they will receive rivaroxaban within 30 days of the index stroke for secondary prevention of stroke. The infarct size within 48 hours after stroke onset will be measured by diffusion-weighted magnetic resonance imaging. The primary efficacy endpoint is recurrent ischemic stroke, and the primary safety endpoint is major bleeding during the observational period of 3 months after stroke onset. The optimal timing to start treatment with rivaroxaban during the acute stage of ischemic stroke will be determined by analysis of the correlation between primary endpoints and the size of cerebral infarct., Conclusions: The RELAXED observational registry study will elucidate the optimal timing of the initiation of rivaroxaban in acute cardioembolic stroke associated with NVAF., (Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: Recanalization therapies such as intravenous thrombolysis (IVT) or endovascular treatment (EVT) improve acute ischemic stroke outcomes; however, they carry the risk of intracranial hemorrhage (ICH). The present study assessed the frequency and predictive factor of ICH in Japanese patients with acute large vessel occlusion., Methods: The Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism-Japan Registry prospectively registered 1442 stroke patients with major vessel occlusion who were admitted to 84 Japanese stroke centers within 24 hours after onset, from July 2010 to June 2011. Among these 1442 patients, 1357 were included to evaluate the incidence rate and predictive factors of ICH within 24 hours after onset., Results: ICH was observed in 284 (20.9%) patients. Among these patients, 46 (3.4%) had symptomatic ICH, and its incidence was higher in the recanalization therapy (IVT and/or EVT) group than in the conservative therapy group (4.5% versus 2.1%, P = .013). On multivariate analyses, symptomatic ICH was related to pretreatment antiplatelet agent use and systemic heparinization, and was related to neither IVT nor EVT., Conclusions: Symptomatic ICH was not affected by recanalization therapy or EVT itself in Japanese patients with acute large vessel occlusion., (Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: The effect of renal dysfunction on intracerebral hemorrhage (ICH) remains unclear. We investigated associations of renal dysfunction assessed by estimated glomerular filtration rate (eGFR) with clinical courses and outcomes in ICH patients., Methods: From a prospective, multicenter, observational study, 203 patients who had supratentorial ICH within 3 hours of onset were included. Patients were classified into 3 groups based on eGFR: Group 1 (eGFR < 60 mL/minute/m(2)), Group 2 (60-89), and Group 3 (≥ 90). Outcomes included neurologic deterioration within 72 hours, hematoma expansion (> 33% in volume) at 24 hours, and favorable (modified Rankin Scale [mRS] ≤ 2) or unfavorable (mRS ≥ 5) outcome at 3 months., Results: Thirty-seven patients (16 women, 74.6 ± 13.2 years) were assigned to Group 1, 99 (34 women, 65.2 ± 11.4 years) to Group 2, and 67 (30 women, 61.3 ± 9.4 years) to Group 3. Significant differences were found in age (P < .001) and initial systolic blood pressure among the groups (208.4 ± 18.0, 201.9 ± 15.1, and 198.1 ± 14.2 mm Hg for Group 1, 2, and 3, respectively; P = .006). Similar rates of neurologic deterioration (14%, 6%, and 6%) and hematoma expansion (16%, 14%, and 18%) were observed among the groups. However, in Group 1, favorable outcome was less frequent (17%, 48%, and 42%; P = .002) and unfavorable outcome was more frequent (24%, 7%, and 6%; P = .013) than in the other groups. After adjustment for confounders, eGFR < 60 mL/minute/m(2) was independently associated with both favorable outcome (odds ratio [OR], .21; 95% CI, .07-.54) and unfavorable outcome (OR, 5.64; 95% CI, 1.80-18.58)., Conclusions: Renal dysfunction (eGFR < 60 mL/minute/m(2)) was associated with poor clinical outcome after ICH., (Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: Intravenous nicardipine is commonly used to reduce elevated blood pressure in acute intracerebral hemorrhage (ICH). We determined factors associated with nicardipine dosing and the association of dose with clinical outcomes in hyperacute ICH., Methods: Hyperacute (<3 hours from onset) ICH patients with initial systolic blood pressure (SBP) greater than 180 mm Hg were included. All patients initially received 5 mg/hour of intravenous nicardipine. The dose was adjusted to maintain SBP between 120 and 160 mm Hg. Associations of maximum hourly and total doses with early neurologic deterioration (END), hematoma expansion (>33%), and modified Rankin Scale score 4-6 at 3 months were assessed., Results: Two hundred six patients (81 women, 65.8 ± 11.8 years) were studied. Initial SBP was 201.9 ± 15.9 mm Hg. Maximum and total nicardipine doses were 9.1 ± 4.2 mg/hour and 123.7 ± 100.2 mg/day, respectively. Multivariate analyses revealed that men (standardized regression coefficient [β] = .20, P = .0030 for maximum dose; β = .25, P = .0002 for total dose), age (β = -.28, P = .0002; β = -.25, P = .0005), and initial SBP (β = .19, P = .0018; β = .18, P = .0021) were independently associated with both maximum and total doses. Body weight (β = .20, P = .0084) was independently associated with total dose. After multivariate adjustment, maximum dose (per 1 mg/hour; odds ratio [OR], 1.25; 95% confidence interval [CI], 1.09-1.45) was independently, and total dose (per 10 mg/day; OR, 1.06; 95% CI, .998-1.132) tended to be independently, associated with END. Nicardipine dose was not associated with hematoma expansion or 3-month outcome., Conclusions: Nicardipine dose is roughly predictable with sex, age, body weight, and initial SBP in acute ICH. The maximum dose was associated with neurologic deterioration., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: The presence or absence of the penumbra area is important when performing reperfusion therapy in patients with acute ischemic stroke. As a predictor of this penumbra area, magnetic resonance angiography (MRA)-diffusion-weighted imaging (DWI) mismatch is attracting attention. The usefulness of MRA-DWI mismatch (MDM) using the DWI-Alberta Stroke Program Early Computed Tomography Score (ASPECTS) in endovascular treatment (EVT) of patients with cerebral large vessel occlusion was evaluated., Methods: Of 1442 patients registered in the Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism-Japan Registry between July 1, 2010 and June 30, 2011 who presented to the hospital within 24 hours of the onset of acute cerebral infarction because of cerebral large vessel occlusion, 188 patients who had internal carotid artery or middle cerebral artery occlusion and achieved recanalization with EVT were included. Of these, 71 patients underwent intracranial EVT because intravenous recombinant tissue plasminogen activator therapy was ineffective. The associations between the presence or absence of MDM (MDM-positive [MDM-P], DWI-ASPECTS≥6; MDM-negative [MDM-N], DWI-ASPECTS<6) and 90-day prognosis (modified Rankin Scale [mRS]) and symptomatic intracranial hemorrhage (sICH) were examined., Results: Of the 188 patients analyzed, the time from symptom onset to admission was within 3 hours in 143 patients, 3-8 hours in 36 patients, and 8 hours or more in 9 patients. The time from the onset was within 3 hours in 118 patients in the MDM-P and 25 patients in the MDM-N cases. Favorable outcomes (mRS score≤2 at 90 days) were seen in 63 patients (53.4%) in the MDM-P group and 7 patients (28.0%) in the MDM-N group, showing a significantly more favorable clinical outcome in the MDM-P group (P=.027). The incidence of sICH was significantly lower in the MDM-P group (MDM-P group 3.4%, MDM-P group 20.0%; P=.009). The time from the onset was 3-8 hours in 29 patients in the MDM-P group and in 7 patients in the MDM-N group. Favorable outcomes were seen in 12 patients (41.4%) in the MDM-P group and 2 patients (28.6%) in the MDM-N group, with no significant difference between the 2 groups. No patients had sICH. The patients admitted 8 hours or more after the onset were all MDM-P. Five patients (55.6%) had a favorable outcome., Conclusions: This study demonstrated the safety and efficacy of EVT in MDM-P patients within 3 hours of symptom onset. Although the ratio of patients who had a favorable outcome was high in the MDM-P patients admitted 3-8 hours after the onset, the difference was not significant., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: Carotid artery stenting (CAS) is minimally invasive but may cause perioperative cerebral infarction associated with distal embolization. We conducted a multicenter prospective observational study on the onset of vascular events after CAS to find out the efficacy and safety of CAS in Japan and to investigate the effects of antiplatelet drugs administered before and after CAS on efficacy and safety of CAS., Methods: A total of 949 patients with cervical carotid artery stenosis were enrolled at 43 institutions in Japan; 934 who had undergone CAS with antiplatelet drugs and followed for 1 year were analyzed. Primary end point was the incidence of the first event of death, ischemic stroke, hemorrhagic stroke, transient ischemic attack, myocardial infarction, or serious hemorrhage within 1 year after enrollment. Comparison of the incidences of events according to antiplatelet drugs was also conducted., Results: The primary end point was observed in 69 patients (7.4%) within 30 days of enrollment and in 40 patients (4.3%) between 31 days and 1 year after enrollment. The incidence of the first event for aspirin+cilostazol was significantly lower than that for aspirin+clopidogrel (P=.01), aspirin+clopidogrel+cilostazol (P=.01), and antiplatelet monotherapy (P<.01). Patient age (P=.01), presence of ischemic cerebrovascular disease (P=.02), presence of antidiabetic drugs (P<.01), femoral artery puncture (P=.02), guiding catheter used (P=.02), and Angioguard XP used (P=.01) were also correlated with the primary end point., Conclusion: Incidences of the primary end point within 30 days and 1 year of enrollment were comparable with previous reports, suggesting that CAS is a useful alternative for carotid endarterectomy in carotid stenosis patients with high risk for carotid endarterectomy. Further randomized controlled studies are needed to determine whether differences in mechanism of action of antiplatelet drugs might have contributed to the results of the present study., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this nationwide, prospective registry of acute cerebral large-vessel occlusion was to assess the efficacy of endovascular treatment (EVT) on outcome in the "real-world" settings., Methods: Medical information of the patients was anonymized and registered prospectively through a Web site from 84 medical centers in Japan. Reperfusion of the affected arteries was evaluated by the Thrombolysis in Cerebral Infarction grade on cerebral angiography or by the modified Mori grade on magnetic resonance angiography. Clinical outcome was evaluated by modified Rankin Scale (mRS) at 90 days after onset. Symptomatic intracranial hemorrhage and procedure-related complications were also analyzed., Results: Among intravenous tissue plasminogen activator (IV t-PA)-failed patients, no significant difference in favorable outcome was seen with or without EVT overall (41.7% versus 36.8%, P = .55). However, EVT significantly increased favorable outcomes (mRS score 0-2) in patients with internal carotid artery (ICA)/middle cerebral artery M1/basilar artery (BA) occlusion (41.3% versus 20.5%, P = .019). In contrast, among t-PA-ineligible patients, EVT significantly increased favorable outcomes overall (29.1% versus 19.5%; odds ratio, 1.70; P = .007). Furthermore, favorable outcomes were more common in patients with ICA/M1/BA occlusion (29.0% versus 10.3%; odds ratio, 3.56; P < .0001). Multivariate analysis also confirmed the efficacy of IV t-PA, EVT, and their combination for favorable outcome., Conclusions: EVT significantly improved clinical outcomes in IV t-PA-failed and t-PA-ineligible patients with ICA/M1/BA occlusion. These findings support the introduction of EVT for acute proximal artery occlusion., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

This study aimed to characterize the flow patterns using ultrasound (US) in the external carotid artery (ECA) in patients with total occlusion of internal carotid artery (ICA) and characterize collateral retrograde flow through the ophthalmic artery (OA, secondary collateral, internalization). This study was performed on 45 patients who were retrospectively selected with total occlusion of the ICA, who underwent digital subtraction angiography (DSA), magnetic resonance angiography (MRA), and US (43 men; mean age 68.1 ± 7.9 years). Collateral retrograde flow and collateral flow through the circle of Willis (primary collateral) were determined by DSA and MRA. We compared several US parameters such as ECA peak systolic velocity, mean velocity, end-diastolic (ED) velocity, pulsatility index (PI), and pulsatility transmission index (PTI). PTI was defined as the ratio of ipsilateral ECA PI to the ipsilateral common carotid artery (CCA). In this patient group, 27 patients showed retrograde flow through OA as assessed by DSA. The presence of primary collateral flow was significantly lower in patients with retrograde flow than without (P < .05). ECA ED velocity was significantly higher, and PI and PTI were significantly lower with retrograde flow through OA than without (P < .05). According to receiver operating characteristic analysis, PTI was the most highly correlated ultrasonologic parameter with internalization (cutoff value, .94; sensitivity, 92.6%; specificity, 94.5%). Using PTI was discriminative to determine internalization of ECA because a collateral pathway through OA in cases of ICA occlusion had less primary collateral pathways., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: The therapeutic efficacy of low-dose intravenous alteplase (0.6 mg/kg) for basilar artery occlusion (BAO) remains unknown., Methods: BAO patients enrolled from the Japanese multicenter registry involving 600 stroke patients treated with the low-dose intravenous alteplase were studied., Results: Twenty-five patients had BAO (8 women ranging from 32-92 years of age; mean baseline National Institutes of Health Stroke Scale [NIHSS] score 16). The stroke subtype was cardioembolic in 15 patients and atherothrombotic in 4 patients. BAO was recanalized during hospitalization in 18 (78%) of 23 patients undergoing follow-up angiography. Within the initial 24 hours, 14 patients (56%) had a ≥ 8-point decrease in the NIHSS score, being more common than 267 patients with middle cerebral artery occlusion (MCO) from the same registry (odds ratio [OR] 2.50; 95% confidence interval [CI] 1.06-5.97) after adjustment by sex, age, and baseline NIHSS score. In addition, 4 patients (16%) had a ≥ 4-point increase in the score, being marginally more common than MCO patients (OR 3.13; 95% CI 0.81-10.25). Symptomatic intracranial hemorrhage within the initial 36 hours (8% v 5%), independence at 3 months (modified Rankin Scale score ≤ 2, 48% v 52%), and mortality at 3 months (4% v 6%) were similar when comparing BAO and MCO patients. When compared with previous studies of BAO, vital and functional outcomes at 3 months were relatively better in our study., Conclusions: The use of low-dose alteplase resulted in similar outcomes when comparing acute BAO and MCO patients., (Copyright © 2013 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

This study examined outcomes of patients with acute ischemic stroke (AIS) with major cerebral artery occlusion after the approval of intravenous recombinant tissue-type plasminogen activator (IV rt-PA) but before approval of the MERCI retriever. We retrospectively enrolled 1170 consecutive patients with AIS and major cerebral artery occlusion (496 women; mean age, 73.9 ± 12.3 years) who were admitted within 24 hours after the onset of symptoms to 12 Japanese stroke centers between October 2005 and June 2009. Cardioembolism was a leading cause of AIS in this group (68.2%). The occlusion sites of the major cerebral arteries included the common carotid artery and internal carotid artery (ICA; 29.6%), middle cerebral artery (52.2%), and basilar artery (7.6%). Recanalization therapy (RT) was performed in 32.0% of patients (IV rt-PA, 20.0%; neuroendovascular therapy, 9.4%; combined, 2.5%). Symptomatic intracerebral hemorrhage within 36 hours with a ≥ 1-point increase in the National Institutes of Health Stroke Scale score occurred in 5.3% of the patients. At 3 months (or at hospital discharge), 29.3% of the patients had a favorable outcome (based on a modified Rankin scale score of 0-2), 23.8% were bedridden, and 15.6% died. After multivariate adjustment, RT was positively associated with a favorable outcome and negatively associated with death, whereas age, baseline National Institutes of Health Stroke Scale score, and ICA occlusion were negatively associated with a favorable outcome and positively associated with death. One-third of the patients with AIS and major cerebral artery occlusion were treated with RT, which was independently associated with favorable outcomes and death. However, 40% of the patients became bedridden or died during the post-alteplase, pre-MERCI era in Japan., (Copyright © 2013 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Restenosis after carotid artery stenting (CAS) is a critical issue. Cilostazol can reduce restenosis after interventions in coronary or femoropopliteal arteries. We investigated whether periprocedural cilostazol treatment was related to the incidence of in-stent restenosis (ISR) or target vessel revascularization (TVR) after CAS. The study group comprised 553 of 580 patients who underwent CAS between April 2003 and August 2006 and were followed for 30 months after the procedure. ISR was defined as stenosis of at least 50% detected on angiography or ultrasonography. TVR was defined as revascularization of the treated carotid artery. During CAS, 207 patients (37.4%) were treated with cilostazol. Over 30 months, ISR occurred in 23 patients (4.2%), TVR occurred in 16 patients (2.9%), and either ISR or TVR occurred in 25 patients (4.5%). The incidence of ISR or TVR was significantly lower in the cilostazol-treated group than in the untreated group (1.4% vs 6.4%; log-rank P = .006). In a multivariate analysis, cilostazol treatment (hazard ratio [HR], 0.28; 95% confidence interval [CI], 0.08-0.95; P = .041) and stent diameter (HR, 0.73/1-mm increase; 95% CI, 0.54-0.99; P = .044) were independent factors for the occurrence of ISR or TVR. The incidence of a composite of events, including thromboembolism, hemorrhage, death, and TVR, tended to be lower in the cilostazol-treated group than in the untreated group (15.0% vs 19.9%; log-rank P = .17). Periprocedural cilostazol treatment was associated with lower rates of ISR and retreatment after CAS. A prospective randomized controlled trial is needed to clarify the effect of cilostazol on ISR after CAS., (Copyright © 2012 National Stroke Association. Published by Elsevier Inc. All rights reserved.)