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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 ( Results— Seventy-four patients (45.5%) showed target arterial residual stenosis (AOL 2). As to the TAL pathogenesis, 40 patients were classified into in situ thrombo-occlusion (54.1% of AOL 2 and 24.5% of M1 occlusion). The occurrence of instant or delayed reocclusion was independently associated with a low chance of favorable 3-month outcome. Furthermore, the occurrence of delayed reocclusion was associated with excellent pretreatment collateral flow and early neurological worsening, but not the severity of residual stenosis at the TAL. Conclusions— In population with a high prevalence of intracranial atherosclerotic disease, residual stenosis may be attributed to in situ thrombo-occlusion with underlying intracranial atherosclerotic disease in ≈25% of cases, hindering functional recovery via the occurrence of instant or delayed reocclusion.

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 (n¼19) vs March 2009 to August 2010: mPS technique (n¼20)) 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); p¼0.001). Favorable outcomes at 3 months (modified Rankin Scale score 0e2) were achieved in 9/20 and 3/19 in the mPS and MCD groups, respectively (45% vs 16%; p¼0.048). 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.

BackgroundIn patients with acute stroke and an extensive ischemic burden at baseline, the prognosis is usually poor despite timely reperfusion.ObjectiveTo 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.MethodsPatients 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.ResultsEighteen 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.ConclusionsThe use of post-reperfusion cooling as a rescue treatment in patients with substantial ischemia at baseline might improve clinical outcome.

For a large hemispheric infarction, the clinical decision for decompressive surgery is commonly made on the basis of both radiological data showing brain swelling with herniation and concomitant neurological deterioration. However, for early decompressive surgery before clinical deterioration, strict cutoff criteria with a high specificity are required on the basis of timely assessment of the infarct volume.Sixty-one patients who presented with a hemispheric infarction were initially evaluated using diffusion-weighted images (DWIs) within 14 h and computed tomography (CT) scans 24 ± 4 h after stroke onset to assess the infarct volume and midline shift. In addition, brain atrophy was evaluated using the bicaudate ratio. Twenty-one patients developed a malignant course, while 40 patients experienced a non-malignant course.According to a receiver-operating characteristic curve analysis for 50 patients with a bicaudate ratio0.16, an initial infarct volume160 ml in the DWI achieved a 97% specificity and 76% sensitivity, while an initial infarct volume135 ml achieved an 86% specificity and 91% sensitivity. For the follow-up CT scans, an infarcted lesion volume220 ml and midline shift3.7 mm provided a 100% and 98% specificity, respectively.For the patients who presented with an acute hemispheric infarction and had a bicaudate ratio0.16, an initial infarct volume160 ml in a DWI within 14 h after stroke onset is highly predictive of a malignant course. In addition, an infarct volume220 ml or midline shift3.7 mm in the follow-up CT approximately 24 h after stroke onset facilitates early surgical decompression before clinical deterioration.

a Neurology, b Neuroradiology, and c Daegu-Gyeongbuk Cardio-Cerebrovascular Abstract To date, the long-term effects of reperfusion on the salvaged brain tissues have not been addressed in the literature. We report 4 cases presenting subacute neurological deteriorations with selective axonal injury following reperfusion therapies for acute ischemic stroke. Our case series based on 4 patients showed common features distinct from those of early reperfusion injury in that (1) the neurological symptoms developed after 1-2 months of reperfusion therapies, (2) these symptoms were accompanied by the subcortical white matter changes on brain MRI, and (3) these findings were mostly reversible with time. This suggests that axons in the reperfused brain may be vulnerable to further neurological injury.

BACKGROUND AND PURPOSE: Although the PS has been the most promising mechanical thrombectomy device in terms of recanalization rates, even the PS cannot recanalize all cases of occlusion. Under such circumstances, we simply modified the PS, identified certain advantages, and applied this modification as a primary technique for recanalization. Here we describe and discuss the technical details and results of our preliminary experience. MATERIALS AND METHODS: This study included 22 consecutive patients with acute ischemic stroke secondary to large-artery occlusion who underwent modified thrombectomy by using the PS for recanalization. Direct wedging between the tip of the reperfusion catheter and the proximal part of the clot followed by forceful suction by using a 20- or 50-mL syringe is a unique feature of this technique. What is distinctive is that this does not require use of a separator or aspiration pump. RESULTS: All treated vessels (100%) were successfully recanalized. A TICI scale of 2b or 3 was achieved in 81.9% of patients. A 3-month favorable functional outcome (mRS score, 0–2) was achieved in 45.5% of patients. The only procedural complication was a transient dissection of the proximal ICA, which developed while advancing the guide catheter. CONCLUSIONS: Forced-suction thrombectomy is a simple modification of the PS. On the basis of our data, this technique allows safe and effective revascularization in acute large-vessel occlusion. Thus, for achieving the best outcome, the modified PS technique is proposed as a viable option for acute stroke management, either by itself or in conjunction with other devices or drugs.

Received August 20, 2014 Revised October 13, 2014 Accepted October 13, 2014 Address for correspondence: Yang-Ha Hwang, MD Department of Neurology, School of Medicine, Kyungpook National University, 130 Dongduk-ro, Jung-gu, Daegu 700-721, Korea Tel : +82-53-420-5758 Fax : +82-53-422-4265 E-mail : yangha.hwang@gmail.com 69세 남자가 15분간 지속되다가 회복된 우측 상하지의 위약 과 감각이상을 주증상으로 응급실을 방문하였다. 활력징후는 정상이었으며 신경학적진찰에서 이상소견은 없었다. 임상적으 로 일과성허혈발작(transient ischemic attack)이 의심되었고, 뇌

Background and Purpose: Co g n itive imp a irmen ts a re fre que n t c o n s e qu e n c e s o f e p ile p s y, with in te lle c tu a l a bility re p o r te dly bein g lo wer in p a tie n ts with id io p a thic g en er a lize d epi lepsi e s tha n in the g eneral p opul a tio n. Ho we ver, neuropsy c ho lo gi c al in vest ig at io ns ha ve be en r arel y p erf o rme d in p a tie n ts with ju ven ile myo c lo n ic ep ilep s y (JME). We a ime d to qu a n tify the c o g n itive fu n c tio n in JME p a tien ts u s in g va rio us n europsy c ho lo gi c al te st s . M et h ods: We c o mp a re d c o g n itive fu n c tio n in 27 JME p a tie n ts with tha t in 27 he al thy vo lun te ers u si n g te st s exa min in g c o g n itive p er fo rma n c e , s uc h a s the ve rba l a n d vis ua l me mo ry, fro nt a l fu nct io n, a tte nt io n, IQ s core, a nd mo o d . In the JME g ro u p , we e xa min e d ris k fa c to rs fo r c o g n itive fu n c tio n s uc h a s a g e , s ex, fa mily his to r y, ed u c a tio n le vel, a g e a t s e izur e o n s e t, s eizu re fr equ en c y, EEG a bn o rma lity , d is e a s e d u ra tio n , a n d p re vio u s in ta k e o f a n tiepi le pt ic d rugs. Resul t s: Ve rba l learni n g wa s s ig ni fic ant ly lo we r in JME p at ie nt s tha n i n c ont ro ls , a nd a tte nt io n a nd verb a l flu ency wer e imp a ir ed in JME p a tien ts c o mp a r ed with c o n tr o ls . Ho we ve r, g e n e ra l in telle c tu a l a bility a n d mo o d d id n o t d iffe r be twe en the g roups. Ea rly o nset o f s ei zur e a nd lo ng d urat io n o f dis ea s e wer e c lo s ely re la te d to imp a ir ed c o g n itive fu n c tio n . C oncl usi ons: JME p a tie n ts ma y exhibit imp a ire d c o g n itive fu n c tio n , in te rms o f memo ry a n d e xe c utio n , d es p ite ha vin g n o r ma l in tellig en c e a n d mo o d . J Clin Neurol 3(2):86-92, 2007

BACKGROUND AND PURPOSE: Although intracranial atherosclerotic disease is often encountered during endovascular treatment for acute vertebrobasilar occlusions, its clinical implication is not well-known. We aimed to evaluate whether intracranial atherosclerotic disease influences the clinical outcomes following endovascular treatment of acute vertebrobasilar occlusive stroke. MATERIALS AND METHODS: Fifty-one patients with acute vertebrobasilar occlusive stroke were included. The onset-to-groin puncture time was ≤12 hours, and aspiration- or stent-based thrombectomy was used as the primary treatment method. Following primary endovascular treatment, intracranial atherosclerotic disease (IAD group) was angiographically diagnosed when a fixed focal stenosis was observed at the occlusion site, whereas embolism (embolic group) was diagnosed if no stenosis was observed. Clinical and treatment variables were compared in both groups, and IAD was evaluated as a prognostic factor for clinical outcomes. RESULTS: The baseline NIHSS score tended to be lower (14 versus 22, P = .097) in the IAD group (n = 19) than in the embolic group (n = 32). The procedural time was longer in the IAD group (96 versus 61 minutes, P = .002), despite similar rates of TICI 2b–3 (89.5% versus 87.5%, P = 1.000). The NIHSS score at 7 days was higher (21 versus 8, P = .060) and poor outcomes (mRS 4–6 at 3 months) were more frequent in the IAD group (73.7% versus 43.8%, P = .038). IAD (odds ratio, 5.469; 95% CI, 1.09–27.58; P = .040) was independently associated with poor outcomes. CONCLUSIONS: An arterial occlusion related to IAD was associated with a longer procedural time and poorer clinical outcome. Further studies are warranted to elucidate the appropriate endovascular strategy.

Importance In atrial fibrillation (AF)–related acute ischemic stroke, the optimal oral anticoagulation strategy remains unclear. Objective To test whether rivaroxaban or warfarin sodium is safer and more effective for preventing early recurrent stroke in patients with AF-related acute ischemic stroke. Design, Setting, and Participants A randomized, multicenter, open-label, blinded end point evaluation, comparative phase 2 trial was conducted from April 28, 2014, to December 7, 2015, at 14 academic medical centers in South Korea among patients with mild AF-related stroke within the previous 5 days who were deemed suitable for early anticoagulation. Analysis was performed on a modified intent-to-treat basis. Interventions Participants were randomized 1:1 to receive rivaroxaban, 10 mg/d for 5 days followed by 15 or 20 mg/d, or warfarin with a target international normalized ratio of 2.0-3.0, for 4 weeks. Main Outcomes and Measures The primary end point was the composite of new ischemic lesion or new intracranial hemorrhage seen on results of magnetic resonance imaging at 4 weeks. Primary analysis was performed in patients who received at least 1 dose of study medications and completed follow-up magnetic resonance imaging. Key secondary end points were individual components of the primary end point and hospitalization length. Results Of 195 patients randomized, 183 individuals (76 women and 107 men; mean [SD] age, 70.4 [10.4] years) completed magnetic resonance imaging follow-up and were included in the primary end point analysis. The rivaroxaban group (n = 95) and warfarin group (n = 88) showed no differences in the primary end point (47 [49.5%] vs 48 [54.5%]; relative risk, 0.91; 95% CI, 0.69-1.20;P = .49) or its individual components (new ischemic lesion: 28 [29.5%] vs 31 of 87 [35.6%]; relative risk, 0.83; 95% CI, 0.54-1.26;P = .38; new intracranial hemorrhage: 30 [31.6%] vs 25 of 87 [28.7%]; relative risk, 1.10; 95% CI, 0.70-1.71;P = .68). Each group had 1 clinical ischemic stroke, and all new intracranial hemorrhages were asymptomatic hemorrhagic transformations. Hospitalization length was reduced with rivaroxaban compared with warfarin (median, 4.0 days [interquartile range, 2.0-6.0 days] vs 6.0 days [interquartile range, 4.0-8.0];P Conclusions and Relevance In mild AF-related acute ischemic stroke, rivaroxaban and warfarin had comparable safety and efficacy. Trial Registration clinicaltrials.gov Identifier:NCT02042534

An intra-arterial (IA) mechanical thrombectomy has increased the recanalization rates for acute occlusion of proximal intracranial arteries. However, the current failure rate of endovascular recanalization remains at approximately 10%, resulting in the need for surgical rescue treatment. The authors applied a minimally invasive and rapid surgical embolectomy (MIRSE) as a final rescue treatment after the failure of endovascular recanalization, and investigated the incidence, technical feasibility, and treatment results.For two years, from 2012 to 2013, a total of 131 patients with acute occlusion of proximal intracranial arteries underwent an IA mechanical thrombectomy using a Penumbra System and a Solitaire stent, yet ten (7.6%) patients still experienced final recanalization failure. Four (40%) of these ten patients subsequently underwent a MIRSE consisting of a superciliary keyhole approach, arteriotomy to remove the embolus, and arteriotomy repair techniques using aneurysm clips as the final repair material, or a temporary compartmentalizing clip.Four patients aged 39 to 78 years with an embolic occlusion in the middle cerebral artery (n = 1) and internal carotid artery (n = 3) were treated using a MIRSE. Complete recanalization was achieved in all four patients, and the time from skin incision to reperfusion was 40-50 minutes. The modified Rankin Scale (mRS) scores at 3 months after surgery were 1 (n = 2), 2 (n = 1), and 3 (n = 1), respectively.A MIRSE can be an effective rescue treatment after the failure of endovascular recanalization therapies for acute occlusion of proximal intracranial arteries if the patient is within the therapeutic time window.

A 62-year-old male complained of contralateral hyperhidrosis following an anterior thalamic infarction without the presence of a hypothalamic lesion. We speculated that the thalamus could share sudomotor fiber components in the crossed contralateral inhibitory sweating pathway.

Background: Clinical outcome following reperfusion can be affected by the adequacy of baseline collaterals during endovascular therapy. We examined the relationship between onset-to-reperfusion time (ORT), collateral grade, and clinical outcome with the hypothesis that there is a narrow therapeutic time window for good clinical outcomes in patients having poor collaterals. Methods: Among 300 patients who underwent endovascular therapy for acute large vessel occlusion in the anterior circulation, we identified 220 patients having a final TICI score of 2 or more. Patients’ collateral grades, using the ASITN/SIR scale on baseline angiography, were dichotomized into poor (0-1) versus partial/complete (2-4). Favorable functional outcome was defined as a 3-month mRS of 0-2. Results: Angiographic data on collaterals were available for 207/220 patients, with 76 in the poor collateral group and 131 in the partial/complete group. The TICI 2b-3 reperfusion rates were similar between the two groups [51/76 (67%) vs. 89/131 (68%), p=0.902], though functional outcomes were significantly different [35/76 (46%) vs. 81/131 (63%), p=0.027]. In the poor collateral group, the odds of favorable outcome significantly dropped for patients reperfused beyond 6-hour from onset [28/53 (54%) vs. 7/24 (29%); odds ratio 0.35 (95% CI 0.13-0.99); p=0.045], whereas the probability of favorable outcome in partial/complete group was not as influenced by reperfusion beyond the 6-hour time window [56/85 (66%) vs. 25/46 (54%); odds ratio 0.62 (95% CI 0.30-1.29); p=0.195]. In subgroup analysis of the poor collateral group, each 30-minute increase in ORT was associated with a decreased chance of favorable outcome despite reperfusion after adjustment for age, baseline NIHSS score, and baseline ASPECTS score [odds ratio 0.77 (95% CI 0.64-0.93); p=0.006]. Conclusions: Onset-to-reperfusion time in patients with poor collaterals is an another important factor affecting favorable outcome, and future trials would benefit from a non-invasive imaging technique to detect poor collaterals along with a strategy for early reperfusion.

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).

Among the procedural complications related to carotid artery stenting (CAS), internal carotid artery (ICA) flow arrest is one of the most drastic complications, as it can cause major ischemic stroke. Acute carotid stent thrombosis (ACST) is a rare etiology of ICA flow arrest during carotid artery stenting with distal filter protection, but the most devastating. Moreover, no definitive management strategy has been established so far for treating ACST. We introduce a rescue management strategy for differential diagnosis of ICA flow arrest and for recanalization of ACST with a simple endovascular mechanical thrombectomy technique. In three cases of ICA flow arrest caused by ACST, selective angiography with a 1.7 F microcatheter provided confirmative diagnosis. Recanalization was then achieved with a Penumbra System (PS) reperfusion catheter using the forced arterial suction thrombectomy (FAST) technique. Successful recanalization with a Thrombolysis In Cerebral Infarction score of 3 was achieved for all three patients. Recanalization was confirmed with follow-up angiography at least 24 h after the procedure. No complications associated with this technique occurred. Based on our preliminary experiences, selective microangiography can be helpful for rapid diagnosis of ACST, and the present mechanical thrombectomy technique, using a modification of the PS, can play a role in adjuvant management or as a last resort for the treatment of ACST during CAS.

Background and Purpose— Unclear-onset strokes are generally excluded from time-based thrombolytic therapy. We examined the safety and feasibility of magnetic resonance imaging-based reperfusion therapy in unclear-onset stroke. Methods— This prospective, multicenter, single-arm study screened consecutive unclear-onset stroke patients within 6 hours of symptom detection. Patients with perfusion-diffusion mismatch >20% and negative or subtle fluid-attenuated inversion recovery changes were treated with intravenous tissue plasminogen activator, intra-arterial therapy, or a combination. The safety outcome was symptomatic intracranial hemorrhage within 48 hours after treatment. The primary efficacy outcome was a 3-month modified Rankin Scale score of 0 to 2. Controls were untreated unclear-onset stroke patients prospectively captured in stroke registries. Results— Of 430 unclear-onset stroke patients, 83 (19.3%) received reperfusion therapy (mean age, 67.5 ± 10.4 years; males, 66.3%; median baseline National Institutes of Health Stroke Scale, 14). Symptomatic intracranial hemorrhage with any neurological decline developed in 5 patients (6.0%). Symptomatic intracranial hemorrhage with National Institutes of Health Stroke Scale worsening ≥4 developed in 3 patients (3.6%). Thirty-seven patients (44.6%) achieved modified Rankin Scale score of 0 to 2, and 24 (28.9%) had modified Rankin Scale score of 0 to 1. Female, baseline National Institutes of Health Stroke Scale score, no immediate or early recanalization, and more white blood cells were independent predictors of poor outcome. Compared with untreated controls, the treated group was significantly associated with good outcomes of modified Rankin Scale score of 0 to 2 after adjusting for age, sex, and baseline National Institutes of Health Stroke Scale in logistic regression analysis (odds ratio, 2.25; 95% CI, 1.14–4.49). Conclusions— In unclear-onset stroke patients, magnetic resonance imaging-based reperfusion therapy was feasible and safe. Randomized controlled trials are warranted to confirm the benefit of reperfusion therapy for unclear-onset stroke.

Background The diagnosis of transient ischemic attack (TIA) based on clinical history and objective findings, even including multiparametric MRI, can be misleading. We report two patients who presented with TIA-like deficits with isolated perfusion lesions in corresponding areas but were finally diagnosed as transient neurological symptoms associated with dural arteriovenous fistula (dAVF). Case presentation Two patients presented with transient focal neurological symptoms lasting less than one hour. An isolated perfusion deficit with no diffusion change in the clinically relevant area was shown on brain MRI, indicating transient ischemia as the most plausible cause of neurological symptoms. However, cerebral angiography let to diagnosis of dAVF in both cases. Intracerebral hemorrhage occurred after the initial diagnosis of TIA in one patient, and the small area of perfusion abnormality accompanied by the enlarged cortical vein in the other case helped to identify the dAVF through the further investigation. The pattern of perfusion-weighted imaging in both cases revealed increase of mean transit time and relative cerebral blood volume denoting the venous congestion in a clinically corresponding area. Conclusion Reported cases are uncommon clinical presentation of a dAVF, which can be misdiagnosed as TIA on clinical grounds. In rare cases, the isolated perfusion deficits could be attributable to venous congestion, despite the similar pattern of clinical presentation, such as with TIA.

No definite conclusive management has been established in the treatment of thromboembolism during coil embolization of cerebral aneurysms. To date, intravenous heparin, intra-arterial fibrinolytic agent, and intravenous or intra-arterial glycoprotein IIb-IIIa inhibitors have been the mainstay of treatment. However, in practice, 2 major concerns may arise; first, recanalization is not always possible despite every effort of management; second, rehemorrhagic risk is increased if the event occurred during coiling of ruptured cerebral aneurysms.We introduce a new endovascular mechanical thrombectomy technique to overcome the aforementioned concerns.In 4 refractory cases involving conventional pharmaceutical treatment of thromboembolism during coiling, we practiced rescue suction thrombectomy using the reperfusion catheter of the Penumbra System.All 4 of the patients to whom this technique was applied were successfully recanalized; 2 were Thrombolysis In Cerebral Infarction scale of 2b and the other 2 were a scale of 3. Recanalization was confirmed at the follow-up angiography at least 12 hours after the procedure. No complication associated with this technique occurred.Forced-suction thrombectomy is a simple modification of the Penumbra System. Based on our preliminary data, this technique can play a role as an adjuvant management or as a last resort combined with injection of glycoprotein IIb-IIIa inhibitors in thromboembolic events that occur in coil embolization of a ruptured cerebral aneurysm.

Population pharmacokinetic (PK) and pharmacodynamic (PD) modeling of clopidogrel was developed from pooled data from healthy volunteers (n = 44) and stroke patients (n = 35). The PK modeling used plasma concentrations of the clopidogrel metabolite (SR26334), and the PD modeling used platelet aggregation. The models were developed using NONMEM and evaluated via visual predictive check (VPC). Data were analyzed by 2-compartment modeling with Erlang's absorption and first-order elimination. There was no statistically significant covariate for each model parameter. The typical point estimates of PK were k(tr) (identical transfer rate constant) = 5.97 h(-1), k(e) (elimination rate constant) = 0.126 h(-1), k(d) (distribution rate constant) = 0.212 h(-1), V(2) (volume of central compartment) = 21.0 L, and V(3) (volume of peripheral compartment) = 38.8 L. The typical point estimates of PD were k(in) (input rate) = 27.9 h(-1), E(max) (maximum effect on input rate) = 0.292 h(-1), EC(5) (0) (median effective concentration) = 0.00629 ng/mL, and BASE (predose aggregation) = 66.7%. The final model was used to estimate individual parameters using patient data and showed good predictions using VPC.

Background and PurposezzLevetiracetam (LEV) is a new antiepileptic drug that has been found to be effective as an adjunctive therapy for uncontrolled partial seizures. However, the results of several studies suggested that LEV has negative psychotropic effects, including irritability, aggressiveness, suicidality, and mood disorders. We investigated the impact of adjunctive LEV on psychiatric symptoms and quality of life (QOL) in patients with drug-refractory epilepsy (DRE) and determined the risk factors provoking psychiatric adverse events. MethodszzA 24-week, prospective, open-label study was conducted. At enrollment, we interviewed patients and reviewed their medical charts to collect demographic and clinical information. They were asked to complete self-report health questionnaires designed to measure various psychiatric symptoms and QOL at enrollment and 24 weeks later. ResultszzSeventy-one patients were included in the study, 12 patients (16.9%) of whom discontinued LEV therapy due to serious adverse events including suicidality. The risk factor for premature withdrawal was a previous history of psychiatric diseases (odds ratio 4.59; 95% confidence interval, 1.22-17.32 ). LEV intake resulted in significant improvements in Beck Anxiety Inventory score (p

Objective The purpose of the study was to delineate how affective symptoms (AS) influence quality of life (QOL) for individuals with drug-refractory epilepsy (DRE) and those with well-controlled epilepsy (WCE) independently. Methods All subjects participating in the study were asked to complete reliable and validated self-report health questionnaires, including AS, measured with the Korean versions of the Beck Depression Inventory, Beck Anxiety Inventory, and Quality of Life in Epilepsy Inventory-31 (QOLIE-31). We examined predictors of QOLIE-31 scores among the various demographic and clinical factors. We compared the effects of AS on QOL between patients with DRE and those with WCE and investigated the differential effects of seizure control and AS on QOL. Results Two hundred forty-nine patients with DRE or WCE were included in the study. The strongest predictor of QOL was AS, followed by seizure control and MRI abnormality. Affective symptoms had almost two times the effect of seizure control and six times the effect of MRI abnormality. Poorest QOL was noted in patients with DRE with AS, followed by those with WCE with AS, DRE without AS, and WCE without AS. Conclusion The major determinant of QOL in patients with epilepsy is AS rather than DRE or WCE status.

Objective Although an intra-arterial mechanical embolectomy extends the therapeutic time window for restoration of the cerebral blood flow, its suboptimal recanalization rate also necessitates a salvage procedure if the patient is still within the therapeutic time window. As such, a surgical embolectomy can be performed in a rapid and less invasive manner for an acute middle cerebral artery (MCA) occlusion. The technical details of this procedure are discussed and demonstrated. Methods Four patients with an acute MCA occlusion were treated using a novel surgical embolectomy technique after unsuccessful intra-arterial mechanical recanalization therapy. Unique to the proposed surgical technique are a laterally extended superciliary approach, small (3-mm) arteriotomy, and closure of the arteriotomy using an aneurysm clip after removal of the intravascular embolus. Results Occluded MCAs were successfully recanalized using the present technique, and the operative time from skin incision to recanalization was 1 to 1.5 hours in each patient. One to 3 arteriotomies were made in each patient. Six of the 8 arteriotomies in the present series were closed using an aneurysm clip, whereas the other 2 arteriotomies were repaired using microsutures. Postoperative angiograms demonstrated patent MCAs without remarkable clip-induced stenosis. The successful recanalization provided considerable neurological improvement in all patients without procedural complications, except for 1 patient with a fatal putaminal hemorrhage resulting from a reperfusion injury. Conclusion A laterally extended superciliary approach and clip application for arteriotomy closure enable a surgical embolectomy to become a rapid and less invasive procedure.

Background: The aim of this study was to examine the rate of early neurological deterioration (END) and favorable outcomes after acute lacunar stroke following the use of intravenous recombinant tissue plasminogen activator (IV rtPA). Methods: A total of 76 acute lacunar stroke patients (Results: END/favorable outcomes were observed in 24/31% of the subjects in group A and 21/23% in group B (p = 0.77/0.46). Subgroup analysis of the etiologic subtype of small-vessel occlusion showed that END/favorable outcomes were observed in about 33/33% and 15/19% of the patients in groups A and B, respectively (p = 0.21/0.34). Conclusions: The authors showed that the use of rtPA in cases of no lysible clots might not affect the END and favorable outcomes.

Background and Purpose: Zo n is a mid e (ZNS) is a us e fu l a n tie p ile p tic d ru g with a bro a d the ra p eu tic s p e c tr um. Ho we ver , the re is limite d in fo rma tio n o n the lo n g -ter m us e o f Z NS a s a mo not he rapy . This s tud y in ve st ig at e d the lo n g -ter m effe c ts o f ZNS a s a mo n o the ra p y fo r the tre a tmen t o f epi le psy . Met h ods: We r etro s p ec tive ly a n a lyze d the re c o rd s o f e p ile p s y p a tien ts tr ea te d with ZNS mo n o ther a p y a t o u r c lin ic . We id e n tifie d o u tc o mes fo r p a tien ts tre a ted with ZNS mo not he rapy fo r a min imu m o f 6 mo nt hs . Effic acy wa s qu a n tifie d a s the p er c en ta g e c ha n g e in s e izur e fre qu e n c y, a n d s af e ty wa s a ssessed by the fre que ncy a nd typ es of a dv e rse eve nt s . Resul t s: Sixty p a tie n ts who re c e ive d ZNS fo r a min imu m o f 6 mo n ths we re in cl u ded. The me an d urat io n o f tre a tmen t wa s 19.8 mo n ths (r a n g e , 6-37 mo n ths ), a n d the mea n ZNS d o s a g e wa s 255 mg /d a y (ra n g e , 100-500 mg /da y). Twe n ty-s e ven p a tien ts (45%) we re s eizu re -fre e, a n d a n a d d itio n a l 20 p a tien ts (33%) ha d a bo ve 50% s eizu re fre qu e n c y re du c tio n a t the la s t fo llo w-u p vis it. P a rtial s e izur es with o r witho ut s e c o n d a ry g e n e ra liza tio n a n d g e n e ra lized s e izu re s we re we ll c o n tr o lle d by ZNS, wher ea s c o mp l ex p art ia l s eizu res were n ot . Fo rty-e ig ht p at ie nt s (80%) re port e d mild-to -mo derat e a dv erse e vent s , in cl u din g memo r y lo s s (35%), a tte n tio n de fic it (27%), a n d we ig ht lo ss (20%). Concl usi ons: Lo n g -te rm ZNS mo n o ther a p y is e ffec tive a t tre a tin g a bro a d s p ec tru m o f s ei zu re d is ord e rs , exc ept complex partial seizures. However, a specific adverse event, such as cognitive impairment, is common and long-lasting.

This study was a prospective, randomized, open-label investigation of the long-term effects of zonisamide (ZNS) monotherapy on cognition and mood of patients with epilepsy. Forty-three patients with epilepsy received ZNS, with final dose groups of 100, 200, 300, and 400 mg/day. Cognitive and mood tests were done twice, at baseline and 1 year after starting medication. Nine patients were withdrawn prior to their follow-up tests. Three patients (33%) dropped out during the titration period because of cognitive and mood problems. Thirty-four patients completed follow-up neuropsychological tests. After 1 year of treatment, 16 patients (47%) complained of cognitive deficits. Only 5 patients (15%) experienced mood changes. Although ZNS decreased seizure frequency and EEG abnormalities and did not elicit significant mood changes, it had negative effects on several cognitive tests. Worse performance on delayed word recall, Trail Making Test Part B, and verbal fluency was related to dose. In conclusion, ZNS has adverse effects on cognition even after 1 year of treatment.

Background: This study was carried out to examine indications for angiographic evaluation in the case of spontaneous putaminal hemorrhage. Methods: Angiographic examinations were performed on 62 consecutive adults with spontaneous putaminal hemorrhage without remarkable subarachnoid hemorrhage. Most patients were evaluated using conventional catheter angiography except for hypertensive patients over the age of 60 who underwent a magnetic resonance angiogram or a computed tomography angiogram. Computed tomography and clinical factors such as age and hypertension were correlated with the angiographic findings. Results:Nine of the 62 patients (15%) exhibited angiographic abnormalities, including middle cerebral artery aneurysm (n = 1), arteriovenous malformations (n = 3), moyamoya disease (n = 2), and the moyamoya phenomenon associated with a proximal middle cerebral artery occlusion (n = 3). The angiographic yield was significantly higher (1) among patients at or below the median age of 55 compared with those above (9/33, 27%, versus 0/29, 0%; p < 0.01), and (2) among patients without hypertension compared with those with hypertension (5/9, 56%, versus 4/53, 8%; p < 0.01). Conclusions: Although our data could be biased due to the patient selection procedure, they suggest that angiographic evaluation is highly useful for spontaneous putaminal hemorrhage regardless of volume and shape of the hematomas, excepting hypertensive patients over 55 years of age.

In a patient receiving 5-fluorouracil and levamisole, neurologic deficits suggest the cerebral demyelinating syndrome as a differential diagnosis. The authors report a patient diagnosed as multifocal inflammatory leukoencephalopathy for which thallium-201 (201Tl) single photon emission computed tomography (SPECT) and proton magnetic resonance spectroscopy (MRS) were employed as noninvasive diagnostic tools. 201Tl SPECT study was negative and proton MRS showed an increase of choline and lactate and well preserved N-acetylaspartate. These findings support histopathologic findings of multifocal inflammatory leukoencephalopathy revealing demyelination with relative axonal sparing in the patient.

A 55-year-old woman collapsed with chest pain and cardiac arrest. Her pulse was restored after 6 minutes of cardiopulmonary resuscitation, but she remained comatose. Brain MRI (figure) revealed bilateral basal ganglia and right hemispheric cortical lesion, which was typical for anoxic brain injury1 except for the unilateral cortical involvement. Neck CT angiography showed severe stenosis in the right proximal internal carotid artery. The unilateral cortical injury could be explained by compromised cerebral blood flow due to preexisting carotid stenosis.2 This case demonstrates an atypical pattern of anoxic brain injury secondary to focal vascular stenosis.

a ; Soon-Hak Kwon, MD, PhD b Background and PurposezzThe risk of suicide or suicide attempts is reported higher in peo- ple with epilepsy (PWE) than in the general population. Although epileptic, psychiatric, and psy- chosocial factors are known risk factors for suicide or suicide attempt, no studies have evaluated the predictors of the severity of suicidal ideation-which is a warning sign for suicide attempts-in PWE. Therefore, we measured the severity of suicidal ideation and its risk factors. MethodszzConsecutive PWE who were medicated with antiepileptic drugs (AEDs) and attended epilepsy clinic were included in the study. The subjects completed self-reported questionnaires, which included the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Symptom Checklist-90-Revised (SCL-90-R), and Scale for Suicide Ideation-Beck (SSI-Beck). We com- pared the patients' demographic and clinical variables, and BDI, BAI, and SCL-90-R scores with their SSI-Beck score, and used our findings to determine the predictors for suicidal ide - ation. ResultszzIn total, 257 PWE were enrolled in the study. SSI-Beck scores correlated strongly with several seizure-related variables, duration of education, IQ, BDI and BAI scores, and nine domains of the SCL-90-R questionnaire. However, the strongest predictor for suicidal ideation was BDI score (β=0.41, p

Although the Penumbra System (PS) is the most promising device in terms of recanalization rate, the PS cannot recanalize all cases, especially when clot is too hard, or if clot is located on tortuous segment of vessel. Under such circumstances, we simply modified the PS, identified certain advantages, and applied this as a primary modality for recanalization. Direct wedging between the tip of reperfusion catheter and the clot followed by forceful suction using a 50 cc syringe is a unique feature of this technique. Recently, a 45-year-old male of TICI 0 occlusion of the left MCA was completely recanalized (TICI 3) from single forceful suction of this technique. The interval from arterial puncture to revascularization was 12 minutes and 27 mm-sized entire clot was retrieved from the procedure.

Background and Purpose: This s tud y c o mp a re d the c o g n itive e ffec ts o f 1 ye a r o f tre a tmen t with la mo trig in e (LTG) a nd o xc arb a ze pi n e (OXC) in e pi le psy p at ient s . Met h ods: This r et ro spect ive s tu dy in ve st ig at e d 60 e pi le psy p at ie nt s u nd ergoi n g n europsy c ho lo gi c al test s who were e ither n ew ly dia gnosed o r u nt re at e d in the p recedi n g 6 mo n ths . The c o g n itive fu n c tio n in 30 p a tie n ts re c e ivin g LTG mo not he rapy a nd 30 a ge- ma tc he d p at ie nt s r ecei vin g OXC mo not he ra py wa s c om p ared a fte r 1 year . The neuropsy c ho lo gi c al s cores a t ba sel in e a nd a ll o f the epi lepsy -r el e va nt va ria bles e xc ept s ei zu re typ e did n ot d iffer be twe en the g ro u p s . The mea n d a ily d o s a g es o f LTG a n d OXC a t 1 ye ar we re 93 mg a nd 825 mg , re spect ively. Resul t s: The p o s ttre a tmen t lis t-le a r n in g p er fo rma n c e wa s bette r in the LTG g roup tha n in the OXC g roup (p