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Background: The underlying etiology of intracranial non-occlusive intraluminal thrombus (iNOT) remains unknown. This study aimed to investigate whether the presence of iNOT can indicate the underlying etiology of large vessel occlusion (LVO) in patients undergoing endovascular therapy (EVT)., Methods: Among patients who underwent EVT at three comprehensive stroke centers, we included those with intracranial LVO in the anterior circulation. The presence of iNOT was determined by pretreatment DSA. We investigated the association between iNOT and intracranial atherosclerotic stenosis (ICAS) related LVO., Results: Of 546 patients, 44 (8.1%) had iNOT. Patients with iNOT were younger, had less hypertension, atrial fibrillation, and a history of antiplatelet use. In addition, the involvement of the M1 segment of the middle cerebral artery (MCA) was more frequent. However, they had a lower National Institutes of Health Stroke Scale (NIHSS) score on admission and longer onset to recanalization time compared with patients with no iNOT. In a logistic regression model adjusting for age, sex, atrial fibrillation, smoking, prior antiplatelet and anticoagulant use, intravenous tissue plasminogen activator, NIHSS on admission, number of technical trials, intraprocedural re-occlusion, and the location of LVO (p<0.10 in the univariate analysis), the presence of iNOT was significantly associated with ICAS related LVO (adjusted OR 3.04; 95% CI 1.33 to 6.90; p=0.007)., Conclusions: The presence of iNOT may reflect an underlying ICAS related LVO in patients undergoing EVT., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

In ischemic stroke patients undergoing endovascular treatment (EVT), we aimed to test the hypothesis that cerebral microbleeds (CMBs) are associated with clinical outcomes, while estimating the mediating effects of hemorrhagic transformation (HT), small-vessel disease burden (white matter hyperintensities, WMH), and procedural success. From a multicenter EVT registry, patients who underwent pretreatment MR imaging were analyzed. They were trichotomized according to presence of CMBs (none vs. 1-4 vs. ≥ 5). The association between CMB burden and 3-month mRS was evaluated using multivariable ordinal logistic regression, and mediation analyses were conducted to estimate percent mediation. Of 577 patients, CMBs were present in 91 (15.8%); 67 (11.6%) had 1-4 CMBs, and 24 (4.2%) had ≥ 5. Increases in CMBs were associated with hemorrhagic complications (β = 0.27 [0.06-0.047], p = 0.010) in multivariable analysis. The CMB effect on outcome was partially mediated by post-procedural HT degree (percent mediation, 14% [0-42]), WMH (23% [7-57]) and lower rates of successful reperfusion (6% [0-25]). In conclusion, the influence of CMBs on clinical outcomes is mediated by small-vessel disease burden, post-procedural HT, and lower reperfusion rates, listed in order of percent mediation size., (© 2022. The Author(s).)

Minor stroke due to large vessel occlusion (LVO) is associated with poor outcomes. Hypoperfused tissue fate may be more accurately predicted by severity-weighted multiple perfusion strata than by a single perfusion threshold. We investigated whether poor perfusion profile evaluated by multiple Tmax strata is associated with early neurological deterioration (END) in patients with minor stroke with LVO. Ninety-four patients with a baseline National Institute of Health Stroke Scale score ≤5 and anterior circulation LVO admitted within 24 hours of onset were included. Tmax strata proportions (Tmax 2-4 s, 4-6 s, 6-8 s, 8-10 s, and >10 s) against the entire hypoperfusion volume (Tmax >2 s) were measured. The perfusion profile was defined as the shift of the distribution of the Tmax strata proportions towards worse hypoperfusion severity compared with that of the entire cohort using the Wilcoxon-Mann-Whitney generalised odds ratio (OR); its performance to predict END was tested. The area under the curve of perfusion profile was 0.785 (95% confidence interval [CI]: 0.691-0.878, p  < 0.001). Poor perfusion profile (generalised OR >1.052) was independently associated with END (adjusted OR 13.42 [95% CI: 4.38-41.15], p  < 0.001). Thus, perfusion profile with severity-weighted multiple Tmax strata may predict END in minor stroke and LVO.

Background/objective: Targeted temperature management (TTM) may be more beneficial after endovascular treatment (EVT) in patients with a large ischemic core. Therefore, we assessed the usefulness of TTM for such patients from a multicenter endovascular registry., Methods: Anterior circulation stroke patients who underwent endovascular recanalization were included; acute ischemic stroke with malignant traits was designated as (1) baseline Alberta Stroke Program Early CT Score (ASPECTS) below 6 and (2) diffusion-weighted imaging (DWI) lesion volume measurement (> 82 ml) or National Institutes of Health Stroke Scale score > 20 and item Ia > 0. TTM (34.5 °C) was maintained for at least 48 h., Results: We evaluated baseline demographics, risk factors, EVT parameters, and clinical outcomes between the TTM and non-TTM groups. Among the 548 patients, the TTM group (n = 91) significantly had a lower baseline ASPECTS (p < 0.001) and a higher DWI volume (p < 0.001) than the non-TTM group (n = 457). TTM group had a lower prevalence of favorable outcome (0-2 of modified Rankin Scale at 3 months; p = 0.008) than the non-TTM group. In a subgroup analysis of malignant trait patients (n = 80), TTM patients (n = 28) had more favorable outcome (32.1% vs. 7.7% p = 0.009) and less hemorrhagic transformation (none vs. any hemorrhage, p = 0.007) than non-TTM patients (n = 52). After adjusting for potential outcome predictors, TTM (odds ratio [OR] 4.63; confidence interval [CI] 1.20-17.89; p = 0.026) and hypertension (OR 0.18; CI 0.04-0.74; p = 0.018) were found to be independent determinants., Conclusions: Our data suggest that TTM attenuates impending hemorrhagic transformation and leads to favorable clinical outcomes in EVT patients with malignant trait.

During mechanical thrombectomy in the anterior cerebral circulation, thrombus embolization resulting in Willisian collateral failure may lead to critical stroke outcomes due to a shutdown of leptomeningeal collaterals. We hypothesized that the outcomes of dynamic Willisian collateral failure (DWF), induced during mechanical thrombectomy, would be associated with grave outcomes. We evaluated this hypothesis in consecutive patients, between January 2011 and May 2016, who underwent mechanical thrombectomy for anterior circulation occlusions, with an onset-to-puncture of 24 h. Patients with initial Willisian collateral failure (IWF) were identified first, with remaining patients classified into the DWF and Willisian collateral sparing (WCS) groups. Comparative and multivariable analyses were performed to predict grave outcomes (3-month modified Rankin Scale score of 5-6). Among 567 patients, 37 were in the IWF group, 38 in the DWF group, and 492 in the WCS group. Compared to the WCS and DWF groups, the IWF group had a higher baseline National Institute of Health Stroke Scale score and lower Alberta Stroke Program Early CT Score. The prevalence of grave outcomes was similarly high in the IWF (48.6%) and DWF (47.4%) groups, but lower in the WCS group (22.0%; p < 0.001). IWF and DWF were independent risk factors for a grave outcome.

Background: First pass recanalization (FPR, defined as achieving a modified Thrombolysis in Cerebral Ischemia (mTICI) grade 2c/3 with a single pass of a thrombectomy device) effect has not yet been evaluated in contact aspiration thrombectomy (CAT). We evaluated FPR effect on clinical outcomes and FPR predictors in CAT., Methods: All consecutive patients who underwent frontline CAT for anterior circulation large vessel occlusion with recanalization (mTICI 2b-3) were identified from registries at six stroke centers. The patients were dichotomized into FPR and non-FPR groups. Clinical features and outcomes were compared between the groups. Multivariate analyses were performed to determine whether FPR was independently associated with clinical outcomes and to identify predictors of FPR., Results: Of the 429 patients who underwent frontline CAT, recanalization was successful in 344 patients (80.2%; mean age 68.7±11.0 years; M:F ratio 179:165). The FPR group had a higher rate of good outcome (modified Rankin Scale score 0-2) than the non-FPR group. Furthermore, the good outcome rate was higher in the FPR group than in patients who achieved mTICI 2c/3 with multiple passes or rescue treatment. FPR (OR 2.587; 95% CI 1.237 to 5.413) remained independently associated with good outcomes, in addition to age, baseline National Institute Health Stroke Scale, and coronary artery disease. The use of a balloon guide catheter (OR 3.071; 95% CI 1.699 to 5.550) was the only predictor of FPR., Conclusions: Patients in the FPR group had better clinical outcomes than the non-FPR group in CAT. FPR was independently associated with a good outcome. The use of a balloon guide catheter was the only predictor of FPR., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Backgroud: The need for rescue treatment (RT) may differ depending on first-line modality (stent retriever (SR) or contact aspiration (CA)) in endovascular thrombectomy (EVT). We aimed to investigate whether the type of first-line modality in EVT was associated with the need for RT., Methods: We identified all patients who underwent EVT for anterior circulation large-vessel occlusion from prospectively maintained registries of 17 stroke centers. Patients were dichotomized into SR-first and CA-first. RT involved switching to the other device, balloon angioplasty, permanent stenting, thrombolytics, glycoprotein IIb/IIIa antagonist, or any combination of these. We compared clinical characteristics, procedural details, and final recanalization rate between the two groups and assessed whether first-line modality type was associated with RT requirement and if this affected clinical outcome., Results: A total of 955 patients underwent EVT using either SR-first (n=526) or CA-first (n=429). No difference occurred in the final recanalization rate between SR-first (82.1%) and CA-first (80.2%). However, recanalization with the first-line modality alone and first-pass recanalization rates were significantly higher in SR-first than in CA-first. CA-first had more device passes and higher RT rate. The RT group had significantly longer puncture-to-recanalization time (93±48 min versus 53±28 min). After adjustment, CA-first remained associated with RT (OR, 1.367; 95% CI, 1.019 to 1.834). RT was negatively associated with good outcome (OR, 0.597; 95% CI, 0.410 to 0.870)., Conclusion: CA was associated with requiring RT, while recanalization with first-line modality alone and first-pass recanalization rates were higher with SR. RT was negatively associated with good outcome., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Tandem cervical carotid and intracranial occlusions are a well-known cause of complicated endovascular thrombectomy (EVT) in acute ischemic stroke. We aimed to evaluate safety and efficacy of an anterograde approach, which involved carotid balloon angioplasty (BA) alone without carotid artery stenting (CAS) followed by intracranial target recanalization (TR)., Methods: Between April 2009 and March 2017, 62 patients with tandem lesions confirmed in the cervical carotid and simultaneously in the intracranial arteries had EVT performed to target these lesions. Clinical, imaging, and angiographic outcomes for these patients were analyzed and compared., Results: Overall, successful reperfusion was achieved in 80.6% (50/62) and a favorable outcome in 61.3% (38/62) of patients. BA alone was enough to maintain access for TR in 85.5% (group A and B; 53/62), although more than one half (31/53; group B) required rescue CAS at the end of EVT due to elastic recoil. In contrast, emergent CAS was additionally required for the remaining 9 patients to maintain distal access (group C). In a subgroup comparison, procedure time (PT) to target recanalization was significantly shorter in group A and B than group C (P = 0.002). A multivariate regression model revealed age, parenchymal hematoma, and PT to target recanalization as independent predictors of favorable outcome., Conclusions: EVT for tandem cervical carotid and intracranial occlusions showed optimistic results in terms of clinical and angiographic outcome. The anterograde EVT strategy of cervical BA alone then intracranial TR was effective in 85.5% of patients, which was likely to reduce PT to target recanalization., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background and Purpose- Based on its mechanism, the use of balloon guide catheters (BGCs) may be beneficial during endovascular treatment, regardless of the type of mechanical recanalization modality used-stent retriever thrombectomy or thrombaspiration. We evaluated whether the use of BGCs can be beneficial regardless of the first-line mechanical endovascular modality used. Methods- We retrospectively reviewed consecutive acute stroke patients who underwent stent retriever thrombectomy or thrombaspiration from the prospectively maintained registries of 17 stroke centers nationwide. Patients were assigned to the BGC or non-BGC group based on the use of BGCs during procedures. Endovascular and clinical outcomes were compared between the BGC and non-BGC groups. To adjust the influence of the type of first-line endovascular modality on successful recanalization and favorable outcome, multivariable analyses were also performed. Results- This study included a total of 955 patients. Stent retriever thrombectomy was used as the first-line modality in 526 patients (55.1%) and thrombaspiration in 429 (44.9%). BGC was used in 516 patients (54.0%; 61.2% of stent retriever thrombectomy patients; 45.2% of thrombaspiration patients). The successful recanalization rate was significantly higher in the BGC group compared with the non-BGC group (86.8% versus 74.7%, respectively; P<0.001). Furthermore, the first-pass recanalization rate was more frequent (37.0% versus 14.1%; P<0.001), and the number of device passes was fewer in the BGC group (2.5±1.9 versus 3.3±2.1; P<0.001). The procedural time was also shorter in the BGC group (54.3±27.4 versus 67.6±38.2; P<0.001). The use of BGC was an independent factor for successful recanalization (odds ratio, 2.18; 95% CI, 1.54-3.10; P<0.001) irrespective of the type of first-line endovascular modality used. The use of BGC was also an independent factor for a favorable outcome (odds ratio, 1.40; 95% CI, 1.02-1.92; P=0.038) irrespective of the type of first-line endovascular modality used. Conclusions- Regardless of the first-line mechanical endovascular modality used, the use of BGC in endovascular treatment was beneficial in terms of both recanalization success and functional outcome.

Background: Recent aspiration thrombectomy devices tend to have a more flexible distal tip and larger bore for easy target access and effective reperfusion. Here, this study primarily focused on the efficacy and safety of the SOFIA catheters when it was used as a frontline contact aspiration thrombectomy (CAT) tool for acute intracranial large vessel occlusion in comparison with the data from a period when the Penumbra catheter was used., Methods: The subjects comprised 189 patients who underwent CAT (90 with Penumbra Max family and 99 with SOFIA/SOFIA plus). Patients' data were retrospectively analyzed to evaluate overall clinical and angiographic outcomes and compared between the devices., Results: Baseline characteristics were similar between groups. But, intravenous alteplase was more frequently administered in the Penumbra group (43.3% vs. 29.3%, p = 0.045), while incidence of ICA occlusion was higher in SOFIA group (18.9% vs. 38.4%, p = 0.013). The modified thrombolysis in cerebral infarction 2b-3 of reperfusion was 94.4% for the Penumbra group and 92.9% for the SOFIA group (p = 0.656). The first-pass effect was more frequently achieved in the SOFIA group (20.0% vs. 39.4%, p = 0.004) and endovascular procedure time was significantly shorter (55.5 min vs. 36 min, p < 0.001). However, clinical outcomes did not differ significantly regarding mortality (11.1% vs. 6.1%, p = 0.213), hemorrhagic complications, and mRS 0-2 at 3 months (63.3% vs. 58.6%; p = 0.504)., Conclusion: CAT using SOFIA may be safe and comparable to thrombectomy using the Penumbra reperfusion catheter. And, the SOFIA catheter could be advantageous for rapid reperfusion and first-pass effect without any significant complications.

Background and Purpose- Several studies have reported partial reversal of diffusion-weighted imaging (DWI) lesions after acute stroke reperfusion treatment. However, factors associated with DWI reversal have not yet been systematically investigated. We evaluated the factors associated with DWI reversal after endovascular treatment (EVT). Methods- We retrospectively analyzed consecutively encountered patients with acute ischemic stroke who underwent EVT at 3 comprehensive stroke centers in Korea from January 2011 to February 2016. Patients who received EVT within 24 hours of anterior circulation infarction and had both baseline and follow-up DWIs were included. DWI reversal was defined as a decrease in DWI volume from baseline to follow-up. We compared the characteristics and outcomes between patients with and without DWI reversal and assessed independent factors associated with DWI reversal. Results- Of 720 patients encountered during the time period, 404 patients (56.1%) met the study criteria, with 63 patients (15.5%) showing DWI reversal after EVT. The mean time interval between baseline and follow-up DWI was 4.7±2.4 days. Mean baseline DWI volumes of patients with and without DWI reversal were 30.1±36.7 versus 22.0±30.7 mL ( P=0.106), and follow-up DWI volumes were 17.8±24.9 versus 68.7±77.5 mL ( P<0.001). Patients with DWI reversal showed better functional outcomes at 3 months than those without DWI reversal (modified Rankin Scale [interquartile range], 1 [0-3] versus 2 [1-4]; P=0.001). In a multivariate analysis, complete reperfusion (odds ratio, 1.954; 95% CI, 1.063-3.582) and shorter time from baseline DWI to final reperfusion (odds ratio, 0.991; 95% CI, 0.983-0.998) were independently associated with DWI reversal. Conclusions- Complete reperfusion and shorter imaging time to recanalization were independently associated with DWI reversal among patients with acute ischemic stroke who received EVT.

We evaluated the effects of admission hyperglycemia with different cut-off levels on 3-month outcomes, infarct growth, and hemorrhagic transformation in acute stroke patients with large artery occlusion of anterior circulation who received endovascular treatment (EVT). Between January 2011 and May 2016, patients that underwent EVT with pre-procedural and post-procedural diffusion-weighted imaging were identified from a multicenter registry. Normoglycemia was defined as a glucose level ≤ 110 mg/dL, moderate hyperglycemia as >110 and ≤170 mg/dL, and overt hyperglycemia as >170 mg/dL. Its effects on poor outcomes (3-month modified Rankin Scale score 3-6), infarct growth, and parenchymal hematoma type 2 were analyzed. Of 720 patients encountered, 341 patients were eligible. There was a statistically significant difference in glycated hemoglobin levels between the normoglycemia/moderate hyperglycemia and overt hyperglycemia groups (p < 0.001). Moderate hyperglycemia (odds ratio 2.37 [95% confidence interval 1.26-4.45], p = 0.007) and overt hyperglycemia (2.84 [1.19-6.81], p = 0.019) were associated with poor outcomes. Post-procedural infarct volumes were significantly greater in hyperglycemic patients (p adjusted  = 0.003). Only overt hyperglycemia (9.28 [1.66-51.88], p = 0.011) was associated with parenchymal hematoma type 2. Overall hyperglycemia was associated with poor outcomes and infarct growth, whereas overt hyperglycemia was associated with parenchymal hematoma type 2.

Background: The average life expectancy is increasing worldwide, surpassing 80 years in some countries. Recently, mechanical thrombectomy (MT) using modern devices and techniques has led to improved clinical outcomes following acute ischemic stroke. However, thus far, it remains uncertain whether MT is effective in elderly patients aged over 80 years., Methods: Between July 2013 and June 2016, 207 patients with acute ischemic stroke in the anterior circulation received MT at our center. The applied MT strategies were forced arterial suction thrombectomy (FAST) and stent retriever thrombectomy. Patients were divided into those <80 years (n = 173) and those ≥80 years (n = 34). We compared clinical and angiographic parameters between groups., Results: The median age was 67.5 in the younger group and 82 in the elderly group; 92.5% of the younger group and 70.6% of the elderly group received MT via the FAST technique. Angiographic outcomes, including procedural time, mTICI 2b-3 reperfusion (85.5% vs. 82.4%, p = 0.633), and symptomatic intracranial hemorrhage, were not different between the groups. A favorable clinical outcome rate was significantly higher in the younger group (62.4% vs. 44.1%, p = 0.047). Younger age, a low NIHSS score, and fast onset to reperfusion time were favorable prognostic factors in elderly patients., Conclusion: Modern MT in elderly patients with acute ischemic stroke is safe and effective compared to younger patients despite a lower favorable clinical outcome. Our findings may suggest that an appropriate MT strategy with respect to the location of the target occlusion and vascular tortuosity might be helpful to achieve fast reperfusion and improved outcomes for elderly patients.

Background: To date there has been no direct comparison of two frequently used endovascular thrombectomy (EVT) methods (forced arterial suction thrombectomy (FAST) and stent retriever thrombectomy) in M2 occlusions. We review our experiences with EVT performed using FAST and stent retriever thrombectomy in such cases., Methods: The subjects comprised 41 patients with an M2 occlusion who underwent EVT (25 with FAST, 16 with stent retriever thrombectomy). The patients' data were retrospectively analyzed to evaluate the technical characteristics and angiographic outcome of the two EVT techniques., Results: Thrombolysis In Cerebral Infarction (TICI) grades 2b-3 using the first chosen technique did not differ significantly between the two techniques (FAST 64.0% vs stent retriever thrombectomy 81.2%, p=0.305). Time from groin puncture to reperfusion was significantly shorter for stent retriever thrombectomy (53.0 vs 38.5 min; p=0.045). Distal embolization occurred in three cases (12.0%) in the FAST group and in four (26.7%) in the stent retriever group (p=0.362). However, the two techniques did not differ significantly in the final TICI 2b-3 rate (72.0% vs 87.5%; p=0.441). A frequent angiographic finding regarding the failure of FAST was that the M2 occlusion was located immediately after severe acute angulation between M1 and M2., Conclusions: Stent retriever thrombectomy may provide faster reperfusion than FAST, while the FAST technique might be associated with lower distal embolization and a higher reperfusion rate for the first thrombectomy attempt, but without any significant difference in clinical outcome. When choosing the EVT method for M2 occlusions, consideration of the location of the occlusion and tortuosity between M1 and M2 might be helpful to achieve a better angiographic outcome., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: In patients with acute stroke and an extensive ischemic burden at baseline, the prognosis is usually poor despite timely reperfusion., Objective: To overcome universally poor outcomes in such patients, by applying immediate 'post-reperfusion cooling' in order to reduce reperfusion-related complications, and to describe the clinical and imaging characteristics., Methods: Patients having (1) an acute anterior large vessel occlusive stroke within 4.5 h since last known well, (2) Alberta Stroke Program Early CT Score (ASPECTS) ≤5 on baseline imaging, and (3) targeted temperature management with endovascular cooling after confirmed reperfusion were included in this study., Results: Eighteen patients (mean±SD age 59.5±10.9 years, median National Institutes of Health Stroke Scale score of 17, and median ASPECTS of 3) were analyzed. Median lesion volumes at baseline and after treatment were 130.2 and 110.6 mL, respectively. Median time from onset to the start of hypothermia and hypothermia duration were 213 min and 51 h, respectively. Favorable outcome (modified Rankin Scale ≤2) at 3 months was observed in 10 (55.6%) patients. Symptomatic intracranial hemorrhage, malignant brain edema, and pneumonia were observed in 2, 6, and 8 patients, respectively., Conclusions: The use of post-reperfusion cooling as a rescue treatment in patients with substantial ischemia at baseline might improve clinical outcome., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: An in situ thromboocclusion (IST) is defined as an infarct extensively involving all or most of a stenosed arterial territory, which is one major stroke mechanism related to intracranial atherosclerosis (ICAS). We focused on ISTs occurring in major cerebral arteries and analyzed their rate of instant reocclusion during mechanical thrombectomy (MT) compared with non-ISTs. Also, we introduced a treatment strategy of low-dose intra-arterial tirofiban administration to prevent such reocclusion following repeat recanalization, and evaluated its safety and efficacy., Methods: We analyzed 168 consecutive patients treated with MT over a 2-year period from May 2011 to April 2013. During MT, if angiography following a successful recanalization showed stenosis at the occlusion site, we performed additional angiographic runs every 10 min for 30 min after the recanalization. Then, if angiography revealed reocclusion, we performed a repeat recanalization, using the same MT technique but additionally followed by low-dose intra-arterial tirofiban infusion. Time-of-flight MR angiography or CT angiography was performed to confirm any underlying ICAS at the occlusion site 5-7 days after the procedure. The patients who had confirmed underlying ICAS were included in the IST cohort., Results: Of 168 enrolled patients, we excluded 36 who could not be checked for underlying ICAS at the occlusion site for one of the following reasons: recanalization failure (n = 11), rescue stenting after tirofiban failure (n = 5) and lack of follow-up vascular imaging (n = 20). The incidence of IST was 30.3% (40/132). All IST patients were confirmed to have underlying ICAS by follow-up vascular imaging. Instant reocclusion after successful recanalization was significantly more frequent in the IST cohort [26/40 (65%) vs. 3/92 (3.3%); p < 0.001]. Regarding the efficacy of low-dose intra-arterial tirofiban infusion, 85.7% of the reocclusion patients finally achieved a thrombolysis in cerebral infarction score 2/3 recanalization, but in the remaining 14.3% of the cases, the condition was refractory to the procedure and required rescue stenting. There were no cases of symptomatic intracranial hemorrhage following the procedure., Conclusions: In situ thromboocclusion was characterized by a significantly higher chance of instant reocclusion during MT. In such cases, low-dose intra-arterial tirofiban administration may be effective and safe. However, future confirmation by prospective multicenter trials seems necessary., (© 2014 S. Karger AG, Basel.)

Background and Purpose: We introduce the concept of a switching strategy for mechanical thrombectomy with period-to-period analysis. In period 1, forced arterial suction thrombectomy with a Penumbra reperfusion catheter was performed, even in difficult cases; in period 2, forced arterial suction thrombectomy was initially performed, with switching to Solitaire in difficult cases., Methods: We analyzed 135 consecutive patients treated with mechanical thrombectomy with acute large vessel occlusion in the anterior circulation, 61 from period 1 and 74 from period 2. We defined difficult case for both periods as ≥3 failed attempts at recanalization., Results: Period 2 showed a trend for better angiographic outcome of Thrombolysis in Cerebral Infarction 2b-3 (73.8%, period 1 versus 85.1%, period 2; P=0.10). In interperiod subgroup analysis of difficult cases, switching significantly outperformed nonswitching in Thrombolysis in Cerebral Infarction 2b-3 recanalization (52.7% versus 82.9%; P=0.030). Differences in puncture-to-recanalization time, symptomatic intracranial hemorrhage incidence, and procedure-related complications were not statistically significant., Conclusions: A switching strategy using 2 mechanical thrombectomy techniques (forced arterial suction thrombectomy to Solitaire) may harbor better angiographic outcomes than a 1 technique only strategy (forced arterial suction thrombectomy).

Objectives: Ischemic stroke from acute intracranial distal internal carotid artery (ICA) occlusion usually carries a poor prognosis. Despite the intra-arterial revascularization therapies, the results are still unsatisfactory. The aim of this study was to compare the outcomes between two endovascular techniques, the modified Penumbra System (mPS) and mechanical clot disruption (MCD), and to confirm the influence of recanalization on the outcomes., Methods: In a retrospective review of 39 consecutive cases of acute distal ICA occlusion, the recanalization rates and functional outcomes at 3 months of the two intra-arterial techniques during two consecutive periods (May 2006 to February 2009: MCD technique (n=19) vs March 2009 to August 2010: mPS technique (n=20)) were compared. Univariate and multivariate analyses were performed to determine the predictors of a favorable functional outcome., Results: The rate of successful recanalization (Thrombolysis In Cerebral Infarction score 2 or 3) was significantly higher in the mPS group than in the MCD group (85% (17/20) vs 32% (6/19); p=0.001). Favorable outcomes at 3 months (modified Rankin Scale score 0-2) were achieved in 9/20 and 3/19 in the mPS and MCD groups, respectively (45% vs 16%; p=0.048). Binary logistic regression analysis showed that younger age and successful recanalization were independent predictors of a favorable functional outcome., Conclusions: Forced-suction thrombectomy using the mPS technique may be a viable option for acute distal ICA occlusion and could result in more successful recanalization and a more positive clinical outcome.

BACKGROUND AND PURPOSE: Acute intracranial occlusion can be associated with in situ thrombo-occlusion in relation to preexisting intracranial atherosclerotic disease. We aimed to assess residual stenosis at the site of a target arterial lesion (TAL) to determine whether residual stenosis at the TAL is associated with underlying intracranial atherosclerotic disease. METHODS: One hundred and sixty-three patients who underwent endovascular therapy for M1 middle cerebral artery occlusion and achieved angiographic reperfusion were selected for analysis. The presence of residual stenosis at the TAL was classified using the Arterial Occlusive Lesion (AOL) scale at postprocedural angiography, and the severity of stenosis was grouped into none, mild (

Background: Regional eloquence of brainstem structures may contribute to neurological status in basilar artery occlusion (BAO) stroke. The corticospinal tract (CST) which is vulnerable to BAO is important for motor activity. This study investigated the impact of CST salvage on outcomes and its associated factors in patients with BAO treated with thrombectomy. Methods: We retrospectively investigated 88 patients with BAO admitted ≤24 h after onset and presented with motor deficits and who underwent thrombectomy. Patients with a pre-stroke modified Rankin Scale (mRS) score of 4–5 who did not undergo baseline brain computed tomography angiography were excluded. CST salvage was evaluated using follow-up imaging (magnetic resonance imaging [MRI] or computed tomography when MRI was not available) after thrombectomy. A good outcome was defined as a 3-month mRS score of ≤2 or 3 if a patient's pre-stroke mRS score was 3. The associations between CST salvage and outcomes and clinical parameters were analyzed using logistic regression analyses. Results: Thirty-nine (44.3%) patients had CST salvage and the same number of patients had good outcomes. CST salvage was independently associated with a good outcome [adjusted odds ratio (aOR): 18.52, 95% confidence interval (CI): 4.31–79.67, p < 0.001]. After adjusting for confounders, atrial fibrillation (aOR: 3.92, 95% CI: 1.18–13.00, p = 0.026), location of occlusion (mid-BAO; aOR: 0.21, 95% CI: 0.06–0.72, p = 0.013), length of occlusion (involved segment of BAO <2; aOR: 4.77, 95% CI: 1.30–17.59, p = 0.019), and onset-to-puncture-time ≤180 min (aOR: 4.84, 95% CI: 1.13–20.75, p = 0.034) were significantly associated with CST salvage. Conclusion: CST salvage was associated with good functional outcomes in patients with BAO treated with thrombectomy. The presence of atrial fibrillation, location and length of BAO may predict CST salvage after thrombectomy, and rapid treatment with thrombectomy may protect this eloquent tract in these patients. [ABSTRACT FROM AUTHOR]

Background: Ischemic stroke and cancer are frequent in the elderly and are the two common causes of death and disability. They are related to each other, and cancer may lead to ischemic stroke and vice versa. If patients with cancer exhibited recurrent acute neurological deficits after index stroke, a cancer-related stroke could be considered. However, a brain metastasis is another common cause of neurological complications and has a poor prognosis in patients with ischemic stroke and comorbid cancer. Here, we report a rare case of metastatic cancer that occurred after index stroke in a patient with renal cell carcinoma (RCC) and unusual imaging findings. Through the case, we discuss the pathophysiology and probable predisposing factors for metastatic disease in areas of infarction. Case Presentation: A 48-year-old man presented with sudden onset of left facial palsy and hemiparesis. He had a history of hypertension and RCC with pulmonary metastases treated with radical nephrectomy and chemotherapy. Brain magnetic resonance imaging (MRI) revealed multiple scattered acute infarctions in the right insular, frontal, parietal, and left occipital cortices. There were no definite sources of embolism. Eight months after the index stroke, he presented with subacute onset of progressive left hemiparesis. He had no focal neurological deficits except left-sided weakness and left nasolabial fold blunting. MRI scan demonstrated partial diffusion restriction on the right frontotemporal cortices without decline of apparent diffusion coefficient values on the corresponding lesions and T1 hypointensities and T2 hyperintensities with perilesional vasogenic edema on the right insular, frontal, parietal, and left occipital cortices, indicative of brain metastases confined to the area of previous infarctions. Conclusions: Cerebral infarctions can cause neovascularization and disruption of the blood–brain barrier. Moreover, the compartmentalized cavity formed by the ischemic injury may accept a large volume of metastatic tumor cells. Such an altered microenvironment of infarcted tissue would be suitable for the colonization and proliferation of metastatic seed. Further, brain metastases should be considered, in addition to recurrence, when new focal neurological deficits develop in patients with ischemic stroke and comorbid cancer. [ABSTRACT FROM AUTHOR]

Background: Since the global pandemic of coronavirus disease 2019 (COVID-19), the process of emergency medical services has been modified to ensure the safety of healthcare professionals as well as patients, possibly leading to a negative impact on the timely delivery of acute stroke care. This study aimed to assess the impact of the COVID-19 pandemic on the acute stroke care processes and outcomes in tertiary COVID-19-dedicated centers in South Korea. Methods: We included 1,213 patients with acute stroke admitted to three centers in three cities (Seoul, Seongnam, and Daegu) through the stroke critical pathway between September 2019 and May 2020 (before and during the COVID-19 pandemic). In all three centers, we collected baseline characteristics and parameters regarding the stroke critical pathway, including the number of admitted patients diagnosed with acute stroke through the stroke critical pathway, door to brain imaging time, door to intravenous recombinant tissue plasminogen activator time, door to groin puncture time, and door to admission time. We performed an interrupted time series analysis to determine the impact of the COVID-19 outbreak on outcomes and critical pathway parameters. Results: Three centers modified the protocol of the stroke critical pathway during the COVID-19 pandemic. There was an immediate decrease in the number of patients admitted with acute ischemic stroke after the outbreak of COVID-19 in Korea, especially in the center of Daegu, an epicenter of the COVID-19 outbreak. However, the number of patients with stroke soon increased to equal that before the Covid-19 outbreak. In several critical pathway parameters, door to imaging time showed a temporary increase, and door to admission was transiently decreased after the COVID-19 outbreak. However, there was no significant effect on the timely trend. Moreover, there was no significant difference in the baseline characteristics and clinical outcomes between the periods before and during the COVID-19 pandemic. Conclusion: This study demonstrated that the COVID-19 outbreak immediately affected the management process. However, it did not have a significant overall impact on the trends of stroke treatment processes and outcomes. The stroke management process should be modified according to changing situations for optimal acute management. [ABSTRACT FROM AUTHOR]

Background: Recent aspiration thrombectomy devices tend to have a more flexible distal tip and larger bore for easy target access and effective reperfusion. Here, this study primarily focused on the efficacy and safety of the SOFIA catheters when it was used as a frontline contact aspiration thrombectomy (CAT) tool for acute intracranial large vessel occlusion in comparison with the data from a period when the Penumbra catheter was used. Methods: The subjects comprised 189 patients who underwent CAT (90 with Penumbra Max family and 99 with SOFIA/SOFIA plus). Patients' data were retrospectively analyzed to evaluate overall clinical and angiographic outcomes and compared between the devices. Results: Baseline characteristics were similar between groups. But, intravenous alteplase was more frequently administered in the Penumbra group (43.3% vs. 29.3%, p = 0.045), while incidence of ICA occlusion was higher in SOFIA group (18.9% vs. 38.4%, p = 0.013). The modified thrombolysis in cerebral infarction 2b-3 of reperfusion was 94.4% for the Penumbra group and 92.9% for the SOFIA group (p = 0.656). The first-pass effect was more frequently achieved in the SOFIA group (20.0% vs. 39.4%, p = 0.004) and endovascular procedure time was significantly shorter (55.5 min vs. 36 min, p < 0.001). However, clinical outcomes did not differ significantly regarding mortality (11.1% vs. 6.1%, p = 0.213), hemorrhagic complications, and mRS 0–2 at 3 months (63.3% vs. 58.6%; p = 0.504). Conclusion: CAT using SOFIA may be safe and comparable to thrombectomy using the Penumbra reperfusion catheter. And, the SOFIA catheter could be advantageous for rapid reperfusion and first-pass effect without any significant complications. [ABSTRACT FROM AUTHOR]

Background: The average life expectancy is increasing worldwide, surpassing 80 years in some countries. Recently, mechanical thrombectomy (MT) using modern devices and techniques has led to improved clinical outcomes following acute ischemic stroke. However, thus far, it remains uncertain whether MT is effective in elderly patients aged over 80 years. Methods: Between July 2013 and June 2016, 207 patients with acute ischemic stroke in the anterior circulation received MT at our center. The applied MT strategies were forced arterial suction thrombectomy (FAST) and stent retriever thrombectomy. Patients were divided into those <80 years ( n = 173) and those ≥80 years ( n = 34). We compared clinical and angiographic parameters between groups. Results: The median age was 67.5 in the younger group and 82 in the elderly group; 92.5% of the younger group and 70.6% of the elderly group received MT via the FAST technique. Angiographic outcomes, including procedural time, mTICI 2b-3 reperfusion (85.5% vs. 82.4%, p = 0.633), and symptomatic intracranial hemorrhage, were not different between the groups. A favorable clinical outcome rate was significantly higher in the younger group (62.4% vs. 44.1%, p = 0.047). Younger age, a low NIHSS score, and fast onset to reperfusion time were favorable prognostic factors in elderly patients. Conclusion: Modern MT in elderly patients with acute ischemic stroke is safe and effective compared to younger patients despite a lower favorable clinical outcome. Our findings may suggest that an appropriate MT strategy with respect to the location of the target occlusion and vascular tortuosity might be helpful to achieve fast reperfusion and improved outcomes for elderly patients. [ABSTRACT FROM AUTHOR]