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Purpose: Carotid artery web (CaW) is a rare focal fibromuscular dysplasia that can lead to embolic strokes with large vessel occlusion. This condition can be effectively treated with endovascular thrombectomy (EVT). Our study aims to assess the prevalence of CaW among patients with acute ischemic stroke (AIS) who underwent EVT and to compare the clinical characteristics of CaW with other carotid artery pathologies. Methods: We enrolled consecutive patients with AIS who underwent EVT at a single medical center and two regional teaching hospitals in Taiwan from September 2014 to December 2021. We compared CaW with carotid dissection (CaD) and carotid large artery atherosclerosis (CaLAA) in terms of patient demographics and thrombus histological findings. Results: Of the 576 AIS patients who underwent EVT, four (mean age: 50 years) were diagnosed with CaW, resulting in a prevalence of 0.69%. Among these four patients, three experienced successful reperfusion after EVT and achieved functional independence (defined as a modified Rankin Scale score ≤2) three months post-stroke. Importantly, none of the CaW patients suffered a recurrent stroke within one year. Patients with CaW were younger than those with CaD or CaLAA, and exhibited fewer vascular risk factors. Additionally, CaW was associated with distal occlusion sites. The thrombus composition in CaW patients was similar to that in CaD patients. Conclusion: In conclusion, CaW is a rare finding among Asian patients with carotid artery disease who undergo for AIS. It is more prevalent in younger patients with a limited number of vascular risk factors.

Background In direct oral anticoagulant (DOAC) users with stroke due to large artery occlusion, endovascular thrombectomy is an effective treatment when intravenous thrombolytic therapy is unsuitable. The purpose of this study is to investigate the association between emergent DOAC levels and endovascular thrombectomy outcomes. Methods Participants with atrial fibrillation, who had a premorbid modified Rankin Scale score of ≤3 and had undergone endovascular thrombectomy for acute stroke, were enrolled. Drug levels upon hospital arrival were measured in the prestroke DOAC users. Head noncontrast computed tomography and computed tomographic angiography images were used to quantify thrombus permeability. The primary outcome was functional independence at 3 months (modified Rankin Scale 0–2 or a return to premorbid status for patients with a premorbid modified Rankin Scale of 3). Results The study included 250 patients (antithrombotic agent nonusers, 42.0%; oral anticoagulant users, 34.0%; and antiplatelet users, 24.0%). The primary outcomes did not differ among the 3 groups. Among oral anticoagulant users, 78.8% were DOAC users. Of the 59 DOAC users with available drug level measurements, 62.7% had low levels (

Accurate forecasting of the coronavirus disease 2019 (COVID-19) spread is indispensable for effective public health planning and the allocation of healthcare resources at all levels of governance, both nationally and globally. Conventional prediction models for the COVID-19 pandemic often fall short in precision, due to their reliance on homogeneous time-dependent transmission rates and the oversight of geographical features when isolating study regions. To address these limitations and advance the predictive capabilities of COVID-19 spread models, it is imperative to refine model parameters in accordance with evolving insights into the disease trajectory, transmission rates, and the myriad economic and social factors influencing infection. This research introduces a novel hybrid model that combines classic epidemic equations with a recurrent neural network (RNN) to predict the spread of the COVID-19 pandemic. The proposed model integrates time-dependent features, namely the numbers of individuals classified as susceptible, infectious, recovered, and deceased (SIRD), and incorporates human mobility from neighboring regions as a crucial spatial feature. The study formulates a discrete-time function within the infection component of the SIRD model, ensuring real-time applicability while mitigating overfitting and enhancing overall efficiency compared to various existing models. Validation of the proposed model was conducted using a publicly available COVID-19 dataset sourced from Italy. Experimental results demonstrate the model’s exceptional performance, surpassing existing spatiotemporal models in three-day ahead forecasting. This research not only contributes to the field of epidemic modeling but also provides a robust tool for policymakers and healthcare professionals to make informed decisions in managing and mitigating the impact of the COVID-19 pandemic.

BackgroundHyperglycemia affects the outcomes of endovascular therapy (EVT) for acute ischemic stroke (AIS). This study compares the predictive ability of diabetes status and glucose measures on EVT outcomes using nationwide registry data.MethodsThe study included 1,097 AIS patients who underwent EVT from the Taiwan Registry of Endovascular Thrombectomy for Acute Ischemic Stroke. The variables analyzed included diabetes status, admission glucose, glycated hemoglobin (HbA1c), admission glucose-to-HbA1c ratio (GAR), and outcomes such as 90-day poor functional outcome (modified Rankin Scale score ≥ 2) and symptomatic intracranial hemorrhage (SICH). Multivariable analyses investigated the independent effects of diabetes status and glucose measures on outcomes. A receiver operating characteristic (ROC) analysis was performed to compare their predictive abilities.ResultsThe multivariable analysis showed that individuals with known diabetes had a higher likelihood of poor functional outcomes (odds ratios [ORs] 2.10 to 2.58) and SICH (ORs 3.28 to 4.30) compared to those without diabetes. Higher quartiles of admission glucose and GAR were associated with poor functional outcomes and SICH. Higher quartiles of HbA1c were significantly associated with poor functional outcomes. However, patients in the second HbA1c quartile (5.6–5.8%) showed a non-significant tendency toward good functional outcomes compared to those in the lowest quartile (

Background: Long-chain ceramides are associated with the mechanisms and clinical outcomes of acute ischemic stroke (AIS). This study aimed to investigate the plasma ceramides and sphingosine-1-phosphate in AIS patients undergoing endovascular thrombectomy (EVT) and their associations with outcomes. Methods: Plasma samples were collected from 75 AIS patients who underwent EVT before (T1), immediately after (T2), and 24 h after (T3) the procedures and 19 controls that were matched with age, sex, and co-morbidities. The levels of ceramides with different fatty acyl chain lengths and sphingosine-1-phosphate were measured by UHPLC–ESI–MS/MS. A poor outcome was defined as a modified Rankin Scale score of 3–6 at 3 months after stroke. Results: The plasma levels of long-chain ceramides Cer (d18:1/16:0) at all three time points, Cer (d18:1/18:0) at T1 and T3, and Cer (d18:1/20:0) at T1 and very-long-chain ceramide Cer (d18:1/24:1) at T1 were significantly higher in AIS patients than those in the controls. In contrast, the plasma levels of sphingosine-1-phosphate in AIS patients were significantly lower than those in the controls at all three time points. Among the AIS patients, 34 (45.3%) had poor functional outcomes at 3 months poststroke. Multivariable analysis showed that higher levels of Cer (d18:1/16:0) and Cer (d18:1/18:0) at all three time points, Cer (d18:1/20:0) at T1 and T2, and Cer (d18:1/24:0) at T2 remained significantly associated with poor functional outcomes after adjustment for potential confounding factors. Conclusion: Plasma ceramides were elevated early in AIS patients with acute large artery occlusion. Furthermore, Cer (d18:1/16:0) and Cer (d18:1/18:0) could be early prognostic indicators for AIS patients undergoing EVT.

Background Cerebral hyperperfusion syndrome (CHS) is a failure of autoregulation after a revascularization procedure. It has rarely been reported in patients with no pre-existing cerebral hypoperfusion. Case Report We present a rare case of a patient who underwent stent graft implantation to treat postirradiated carotid blowout syndrome. The patient developed hypertension, focal neurological deficit, and seizures after the procedure; neuroimages revealed ipsilateral cerebral edema, swelling, and increased cerebral perfusion. CHS was diagnosed based on clinical and radiological findings. The patient recovered gradually after receiving supportive care. Conclusion Owing to the risk of CHS, monitoring for cerebral perfusion and prevention of hypertension is suggested for patients who undergo stent graft placement for postirradiated carotid blowout syndrome.

Background Endovascular thrombectomy (EVT) is the standard therapy for patients with acute ischemic stroke secondary to large‐artery occlusion. In January 2019, the Taiwan Stroke Society established a nationwide TREAT‐AIS (Taiwan Registry of Endovascular Thrombectomy for Acute Ischemic Stroke). Here, we provide the study design, current progress, and baseline data of TREAT‐AIS. Methods TREAT‐AIS is a multicenter prospective registration program in Taiwan. Patients aged ≥20 years who underwent EVT for acute ischemic stroke were recruited. The key items on the registration form were divided into general stroke demographics and EVT‐related sections. The main outcome of effectiveness was functional independence (modified Rankin Scale score, 0–2) at 3 months. The influence of sex on post‐EVT outcomes was also analyzed in the presented study. Results By the end of June 2022, there were 10 medical centers and 9 community hospitals participating in the TREAT‐AIS and a total of 1522 patients (mean±SD age, 71.2±13.6 years; men, 55.6%) being enrolled. The median National Institutes of Health Stroke Scale score on admission was 18 (interquartile range, 12–23). The major cause of stroke was cardioembolism (43.6%), followed by large‐artery atherosclerosis (36.8%) and an undetermined cause (15.4%). Functional independence at 3 months poststroke was achieved in 36.2% of the patients. Male patients were more likely to have functional independence at 3 months compared with female patients (40.4% versus 30.8%; P

Background/Purpose: Our previous study demonstrated that indirect revascularization is effective in the treatment of adult moyamoya patients. This prospective study aims to evaluate the long-term effectiveness of indirect revascularization in moyamoya patients in middle adulthood. Methods: From January 2013 to June 2019, moyamoya patients more than 40 years of age underwent indirect revascularizations were studied. The hypoperfusion area of brains was revascularized. The cerebral angiography and time-to-peak (TTP) scoring (ranged 0–14) of the magnetic resonance perfusion study were used to evaluate the revascularization effect. Results: During the study period, 50 consecutive adult moyamoya patients underwent indirect revascularization. Seventeen patients (27 cerebral hemispheres) more than 40 years of age were included. The mean age was 47.9 ± 6.4 years, and 13 patients were female. The pre-operative Suzuki stages were I, II, III, IV, V, and VI in 1, 1, 9, 13, 0, and 3 hemispheres, respectively. After a mean follow-up period of 52.5 ± 20.6 months, all patients had improvement or stabilization of their clinical conditions. Available post-operative angiography demonstrated Matsushima grading A in 18 of 20 hemispheres. The mean TTP score of all 27 hemispheres improved from 5.0 ± 3.3 pre-operatively to 12.0 ± 2.1 after surgery (p

Background/Purpose: Several risk scores have been developed to predict symptomatic intracerebral hemorrhage (SICH) after acute reperfusion therapy for ischemic stroke. We compared the performance of established risk scores in predicting SICH after EVT under different SICH criteria. Methods: A total of 258 patients with anterior circulation large vessel occlusion who received EVT in two medical centers of Taiwan were recruited. Three definitions of SICH, the European Collaborative Acute Stroke Study II (ECASS II), ECASS III, and the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST), were used. The HAT, SITS-SICH, SEDAN, and TAG risk scores were applied. Logistic regression and area under the receiver operating characteristic curve (AUC) were used to evaluate the performance of each risk model. Results: In the 258 included patients (mean age, 71.9 ± 11.8 years; men, 48.1%), the observed rates of SICH according to ECASS II, ECASS III, and SITS-MOST criteria were 10.1%, 5.0%, and 4.7%, respectively. Higher glucose level (>160 mg/dL) and unsuccessful recanalization independently predicted SICH under all criteria. Among the different risk scores, only SEDAN and TAG consistently predicted SICH. SEDAN and TAG scores exhibited the highest AUC in predicting SICH for ECASS III (SEDAN 0.72, TAG 0.72) and SITS-MOST (SEDAN 0.73, TAG 0.70) criteria. Conclusion: Among various risk scores, the TAG and SEDAN scores best predict SICH after EVT. Higher glucose level and unsuccessful recanalization, which are included in the TAG and SEDAN scores, are independent risk factors of SICH in the present cohort, highlighting their detrimental effects.

Background and Purpose: Carotid blowout syndrome (CBS) is a devastating complication of head and neck cancer (HNC). In this study, we describe radiological features that can predict imminent (

Background/Purpose: Recently optimized models for selecting the locations of hospitals capable of providing endovascular thrombectomy (EVT) did not consider the accuracy of the prehospital stroke scale assessment and possibility of secondary transport. Our study aimed to propose a new model for selecting existing hospitals with intravenous thrombolysis capability to become EVT-capable hospitals. Methods: A sequential order was provided to upgrade hospitals providing intravenous thrombolysis, using a mixed integer programming model based on current medical resource allocation. In addition, we drafted a centralized plan to redistribute existing EVT resources by redetermining locations of EVT-capable hospitals. Using historical data of 7679 on-scene patients with suspected stroke, the model was implemented to determine the hospital that maximizes the number of patients receiving EVT treatment within call-to-definitive-treatment time. Results: All suspected stroke patients were sent to EVT-capable hospitals directly under the current medical resource allocation model. After upgrading one additional hospital to become an EVT-capable hospital, the percentage of patients receiving definitive treatment within the standard call-to-definitive-treatment time was elevated from 68.82% to 72.97%. In the model, assuming that there is no hospital providing EVT, all patients suspected of stroke will be sent to EVT-capable hospitals directly after upgrading three or more hospitals to be able to provide treatment. Conclusion: All patients eligible for acute stroke treatment are sent to EVT-capable hospitals in the simulation under the current medical resource allocation model. This model can be utilized to provide insights for capacity redistribution in other regions.

Background: Endovascular thrombectomy (EVT) for acute ischemic stroke associated with tandem lesion is challenging. Achieving rapid intracranial revascularization and managing the extracranial lesion without complications are the main challenges. Materials and Methods: The balloon angioplasty followed by aspiration of large-vessel occlusion (BAFALO) technique was used to address this clinical issue. A review of a prospectively maintained stroke registry from January 2015 to April 2020 was performed. Patients had stroke with TO and treated with the BAFALO technique were included. Results: Twelve patients were enrolled: 11 had anterior circulation stroke, and 1 had posterior circulation stroke. There were 10 ipsilateral internal carotid artery stenosis/occlusion, one left common carotid artery to subclavian artery bypass stenosis, and 1 vertebral artery orifice stenosis. The median National Institutes of Health Stroke Scale score was 16 (interquartile range [IQR]: 14–16). Revascularization with a Modified Thrombolysis in Cerebral Infarction score of 2b or more was achieved in 11 (92%) patients. The median puncture-to-revascularization time was 25 min (IQR: 19.5–31). Emergent stent implantation was performed in five (42%) patients. Three had distal protection devices (DPDs) with no distal embolization. Two patients did not use a DPD, and one had intracranial reocclusion. Eight (67%) proximal stenotic vessels remained patent. No symptomatic intracranial hemorrhage occurred. Eight (67%) patients had favorable clinical outcomes (modified Rankin Score 0–2 at 90 days). Conclusion: While managing TO, the BAFALO technique could achieve rapid intracranial revascularization and treat extracranial lesions under embolic protection. These merits translate into favorable clinical outcomes.

Background Patients with advanced renal cell carcinoma with sarcomatoid features (sRCC) have a poor prognosis and limited therapeutic options. First-line nivolumab plus ipilimumab (NIVO+IPI) provided efficacy benefits over sunitinib (SUN) in patients with intermediate/poor-risk sRCC at 42 months minimum follow-up in the phase 3 CheckMate 214 trial. In this exploratory post hoc analysis, we report clinical efficacy of NIVO+IPI in sRCC after a minimum follow-up of 5 years.Methods In CheckMate 214, patients with clear cell advanced RCC were randomized to NIVO 3 mg/kg plus IPI 1 mg/kg every 3 weeks (four doses), then NIVO 3 mg/kg every 2 weeks versus SUN 50 mg once daily (4 weeks; 6-week cycles). Randomized patients with sRCC were identified via independent central pathology review of archival tumor tissue or histological classification per local pathology report. Overall survival (OS), as well as progression-free survival (PFS) and objective response rate (ORR) per independent radiology review using Response Evaluation Criteria in Solid Tumors V.1.1, were evaluated in all International Metastatic Renal Cell Carcinoma Database Consortium intermediate/poor-risk sRCC patients and by baseline tumor PD-L1 expression level (≥1% vs

Abstract Background Timely endovascular thrombectomy (EVT) significantly improves outcomes in patients with acute ischemic stroke (AIS) with large vessel occlusion type. However, whether certain central nervous system-specific plasma biomarkers correlate with the outcomes is unknown. We evaluated the temporal changes and prognostic roles of the levels of these biomarkers in patients with AIS undergoing EVT. Methods We enrolled 60 patients who received EVT for AIS and 14 controls. The levels of plasma biomarkers, namely neurofilament light chain (NfL), glial fibrillary astrocytic protein (GFAP), tau, and ubiquitin C-terminal hydrolase L1 (UCHL1), were measured with an ultrasensitive single molecule array before, immediately after, and 24 h after EVT (T1, T2, and T3, respectively). The outcomes of interest were death or disability at 90 days (defined as a modified Rankin Scale score of 3–6) and types of hemorrhagic transformation (hemorrhagic infarction or parenchymal hemorrhage). Results Of the 180 blood samples from the 60 patients who received EVT, the plasma NfL, GFAP, and UCHL1 levels at T1 were significantly higher than those of the controls, and the levels of all four biomarkers were significantly higher at T3. Patients with parenchymal hemorrhage had a significantly higher rate of increase in GFAP (P interaction = 0.005) and UCHL1 (P interaction = 0.007) levels compared with those without parenchymal hemorrhage. In a multivariable analysis with adjustment for age, sex, National Institute of Health Stroke Scale score, history of atrial fibrillation, and recanalization status, higher NfL levels at T1 (odds ratio [OR] 2.05; 95% confidence interval [CI], 1.03–4.08), T2 (OR, 2.08; 95% CI, 1.05–4.01), and T3 (OR, 3.94; 95% CI, 1.44–10.79) were independent predictors of death or disability at 90 days. Conclusion Among patients with AIS who received EVT, those with hemorrhagic transformation exhibited significant increase in plasma GFAP and UCHL1 levels over time. Higher plasma NfL were predictive of unfavorable functional outcomes.

Abstract The South China Sea (SCS) is a high biodiversity region in the world ocean, supports abundant marine resources to the peripheral nations, and affects weather/climate in southeast Asia. A better understanding of its circulation is important to better prediction and management of the SCS. Here we reveal sizable intraseasonal oscillations at period ~ 50 days between May and November 2017 in the acoustic Doppler current profiler observed velocity in the central SCS. Satellite observed wind and sea level data together with a process-oriented numerical experiment suggest that the oscillations were caused by locally-generated and remotely-penetrated westward-propagating Rossby waves. The summer southwesterly monsoon strengthening/weakening and the resultant Ekman pumping velocity and shoreward Ekman transport increase/decrease and consequent coastal sea level rise/fall off the west coast of Palawan create westward-propagating Rossby waves causing velocity oscillations in the central SCS. Besides the local generation, Rossby waves with sea level anomaly > 0.2 m propagating from the Pacific through the Sulu Sea into the SCS could contribute to the intraseasonal velocity oscillations in the central SCS.

Excessive tortuosity is a notable cause of failed endovascular thrombectomy for acute large-vessel occlusion stroke. Transcervical access (TCA) is a commonly proposed solution for overcoming this difficulty. However, the large-bore catheter usually used in TCA increases the risk of serious local complications. This paper presents a modified technique for TCA that uses a pull-through buddy wire (PTBW) to track a large-bore femoral guiding sheath (GS) into the carotid artery via a small carotid puncture site. The carotid puncture site can be easily managed through gentle manual compression. Two illustrative cases using this technique to deal with a large aortic arch and tortuous left common carotid artery are reported. In both cases, recanalization was achieved after successful GS placement. Using a PTBW is feasible in TCA.

Background: The transbrachial approach (TBA) is an alternative method to the transfemoral approach (TFA). We herein aimed to evaluate the safety and efficacy of the TBA for endovascular thrombectomy (EVT) in patients with acute large vessel occlusion stroke. Methods: We reviewed the records of 297 patients who had undergone EVT from January 2015 to July 2019. Eighteen patients who had undergone 19 procedures were included. Indications for arterial access, devices, recanalization rates, complication rates, and clinical outcomes were evaluated. Results: There were 15 and 4 cases of anterior and posterior circulation stroke, respectively. The mean patient age was 80.1 years. Eight patients were male. The median National Institutes of Health Stroke Scale score was 18. The total procedure duration tended to be longer when the TBA was used after failure of the TFA (n = 6, 32%, median: 60.5 min) than when the TBA was used as the first treatment approach (n = 13, 68%, median: 22 min). Optimal recanalization (a modified Thrombolysis in Cerebral Infarction score of 2b or 3) was achieved for 15 procedures. Local complications were observed in two cases: one with brachial artery pseudoaneurysm and another with brachial artery occlusion. Three patients with anterior circulation stroke exhibited good clinical outcomes (modified Rankin score ≤ 2) at 90 days. Symptomatic intracranial hemorrhage occurred in one patient. Mortality was noted in four patients. Conclusion: The TBA for EVT is a suitable alternative when adoption of the TFA is difficult or impossible.

Abstract Moyamoya disease (MMD) is a chronic, steno-occlusive cerebrovascular disorder of unknown etiology. Surgical treatment is the only known effective method to restore blood flow to affected areas of the brain. However, there are lack of generally accepted noninvasive tools for therapeutic outcome monitoring. As dynamic susceptibility contrast (DSC) magnetic resonance imaging (MRI) is the standard MR perfusion imaging technique in the clinical setting, we investigated a dataset of nineteen pediatric MMD patients with one preoperational and multiple periodic DSC MRI examinations for four to thirty-eight months after indirect revascularization. A rigid gamma variate model was used to derive two nondeconvolution-based perfusion parameters: time to peak (TTP) and full width at half maximum (FWHM) for monitoring transitional bolus delay and dispersion changes respectively. TTP and FWHM values were normalized to the cerebellum. Here, we report that 74% (14/19) of patients improve in both TTP and FWHM measurements, and whereof 57% (8/14) improve more noticeably on FWHM. TTP is in good agreement with Tmax in estimating bolus delay. Our study data also suggest bolus dispersion estimated by FWHM is an additional, informative indicator in pediatric MMD monitoring.

Carotid blowout syndrome (CBS) is a fatal complication of head and neck cancer. Endovascular treatment, particularly deconstructive embolization, is effective for CBS, but it might result in thromboembolic events. We report the case of a 57-year-old man with underlying recurrent head and neck cancer who had CBS. The patient received endovascular embolization of the right internal, external, and common carotid arteries. Right internal carotid artery to middle cerebral artery embolic occlusion was noted immediately after the procedure, and left-sided weakness and facial palsy were found. Ipsilateral suprabulbar cervical internal carotid artery puncture was performed under fluoroscopic guidance, and rescue suction thrombectomy was successful. The patient had no significant neurological sequela. Transcarotid intraarterial thrombectomy is a reasonable method for managing postembolization large vessel occlusion, even in the neck, after irradiation.

Background Simultaneous multivessel occlusions (MVOs) are a rare condition, which may be encountered during endovascular thrombectomy (EVT) for acute ischemic stroke. This study aimed to investigate the prevalence, associated factors, and outcome of patients with acute ischemic stroke and MVO who underwent EVT. Methods Consecutive patients with acute ischemic stroke who received EVT between September 2014 and April 2021 were included. Acute MVO was defined as simultaneous occlusions of ≥2 intracranial or extracranial major vessels in either bilateral anterior circulation or anterior plus posterior circulation. Patients’ baseline characteristics and outcome of MVO were analyzed. Results Of 602 patients with acute ischemic stroke (mean age, 71±13 years; male, 53.1%) who received EVT, 11 patients (1.8%) had acute MVO. The involved vessels included bilateral internal carotid arteries in 3, bilateral middle cerebral arteries in 4, vertebral artery and distal middle cerebral artery in 1, and internal carotid artery and distal posterior cerebral artery in 3 patients. Preadmission dependence (modified Rankin scale score >2), higher initial stroke severity, and posterior cerebral artery occlusion were more frequently found in MVO. The cause of MVO included large vessel atherosclerosis in 4, cardioembolic in 4, cancer‐related hypercoagulability in 2, and postpartum in 1 patient. Several patients had received simultaneous multitargeted EVT, but only 4 of them achieved optimal reperfusion in both vessels. Compared with patients without MVO, those with MVO had higher mortality (adjusted odds ratio, 6.75; 95% CI, 1.93–23.6) and poor functional outcome (common odds ratio for 1‐point improvement at modified Rankin scale, 0.14, 95% CI, 0.05–0.45) at 90 days. Conclusion Acute simultaneous MVO in patients who underwent EVT is a rare yet devastating condition. Multitarget mechanical thrombectomy to achieve reperfusion is challenging but still possible.

Background To mitigate uncertainty that may arise in the judgment of emergency medical technicians when relying on a prehospital stroke scale at the scene, we propose a hospital selection protocol that considers the uncertainty of a prehospital stroke scale and the actual door‐to‐treatment durations, and we have developed a web‐based system to be used with mobile devices. Methods and Results This hospital selection protocol incorporates real‐time, estimated transport time obtained from Google Maps, historical median door‐to‐treatment duration at hospitals that only provide the standard intravenous thrombolysis treatment, and at hospitals with endovascular thrombectomy for probable large‐vessel occlusion cases. We have validated the efficiency of the proposed protocol and compared it with other strategies used by emergency medical technicians when deciding on a receiving hospital. Using the proposed protocol for the triage reduces the time from onset to receiving definitive treatment by nearly 11 minutes. We found that the nearest endovascular thrombectomy–capable hospital from the scene may not be the most ideal if the door‐to‐treatment durations are discriminative. The results show that, when the tolerable bypass transport threshold and administration time are reduced to 9 minutes and 30.5 minutes, respectively, 228 patients out of 7678 cases, whose receiving hospitals were changed to endovascular thrombectomy–capable hospitals, received definitive treatment in a shorter time. The results of our analysis give recommendations for appropriate allowable bypass transport time for regional planning. Conclusions By applying almost‐real value parameters, we have validated a web‐based model, which can be universally adapted for optimal, time‐saving hospital selection for patients with stroke.

Rupture of a postirradiated internal carotid artery (ICA) pseudoaneurysm in patients with nasopharyngeal carcinoma (NPC) is a rare yet life-threatening emergency. In contrast to pseudoaneurysms found in patients with other head and neck malignancies, those identified in NPC patients have a propensity to occur in the petrous segment of the ICA, which pose a serious challenge to clinical physicians. Over the past few decades, endovascular treatment with covered stents has widely been adopted as the treatment of choice for patients at risk of brain ischemia after occluding the parent vessel of the pseudoaneurysm. Although recent series have demonstrated that immediate hemostasis can be achieved in most of the patients undergoing covered stent placement, a high incidence of delayed complications has been reported, including delayed cerebral ischemia, in-stent thrombosis, and septic thromboembolism.We present two NPC patients with a postirradiated pseudoaneurysm involving the petrous segment of the internal carotid artery. As direct parent vessel occlusion was infeasible, we established an emergency high-flow extracranial-intracranial (EC-IC) bypass followed by endovascular parent vessel occlusion. Both of the patients were followed-up for more than 24 months without neurological deficit or rebleeding. We suggest that EC-IC bypass with parent vessel occlusion should be considered as a practical and durable treatment option for patients with postirradiated ICA pseudoaneurysms who cannot tolerate direct carotid occlusion. Keywords: Pseudoaneurysm, Nasopharyngeal carcinoma, High-flow bypass

Background/purpose: Endovascular thrombectomy has been strongly recommended for treatment of acute ischemic stroke (AIS) with large vessel occlusion. This study aimed to evaluate its efficacy and safety in an Asian population from a single center in Taiwan. Methods: Patients who experienced AIS and received endovascular thrombectomy during the period of September 2014 to September 2016 at National Taiwan University Hospital were included. Factors related to favorable outcome, defined as modified Rankin scale 0–2 at 90 days after stroke, were analyzed. Results: During the study period, 65 patients (mean age, 71.9 ± 12.4 years; 44.6% females) received endovascular thrombectomy, including 33 who received intravenous thrombolysis before the endovascular treatment. A significant trend of increasing thrombectomy therapy was observed. The median National Institutes of Health Stroke Scale (NIHSS) score on admission was 19 (interquartile range, 15–26). The sites of vessel occlusion were middle cerebral artery in 47 (72.3%) patients, intracranial internal carotid artery in 8 (12.4%), anterior cerebral artery in 1 (1.5%), and basilar artery in 9 (13.8%). The median times from stroke onset to groin puncture and from groin puncture to recanalization time were 200 and 29.5 min, respectively. Successful revascularization was achieved in 41 (63.1%) patients. Two (3.1%) patients had symptomatic hemorrhagic transformation. At 90 days, 25 (38.5%) patients achieved favorable outcome. A shorter time from onset to puncture, and successful recanalization were independent predictors of favorable outcome. Conclusion: This study demonstrated the therapeutic promise of endovascular thrombectomy for treatment of AIS with large vessel occlusion in a clinical setting. Keywords: Acute ischemic stroke, Outcome, Thrombectomy, Thrombolysis

This paper focuses on the development of a 3D-printed threadless ball screw (TLBS) for the applications that require miniaturization, customization, and accuracy controllability. To enhance the efficiency of the TLBS, a novel model of the TLBS for analyzing the mechanical efficiency is presented to obtain the key affecting factors. From these factors, the design parameters for fabrication are determined. For miniaturization, a novel 3D-printed one-piece preloaded structure of light weight of 0.9 g is implemented as the TLBS nut part. Experimental results show that the measured mechanical efficiency of TLBS is close to that predicted by the theoretical model with a normalized root mean square error of 3.16%. In addition, the mechanical efficiency of the present TLBS (maximum efficiency close to 90%) is better than that of the lead screw and close to the ball screw. The unique characteristic of the present TLBS is that its total torque loss is a weak function of the load, a phenomenon not observed in either the ball screw or the lead screw. This characteristic is advantageous in enhancing the controllability of accuracy at different loads.

ObjectiveIn-hospital stroke (IHS) is an uncommon but serious medical emergency. Early recanalization through endovascular thrombectomy (EVT) may offer a vital therapeutic choice. This study compared the clinical features and outcomes between IHS and community-onset stroke (COS).MethodsFrom a single-center registry of 2813 patients with ischemic stroke, those who had received EVT for acute ischemic stroke were included and classified into the IHS and COS groups based on their stroke onset scenario. We compared the outcomes including successful recanalization, symptomatic intracranial hemorrhage, functional independence (modified Rankin Scale score, 0-2) at 90 days, and mortality between the two groups.ResultsA total of 24 patients with IHS (mean age, 70 years; 54% men) and 105 patients with COS (mean age, 73 years; 47% men) were included. The most frequently reported reasons for admission in patients with IHS were cardiovascular and oncological diseases. The initial National Institutes of Health Stroke Scale (NIHSS) scores and main occluded vessels were similar between the two groups. Patients with IHS received a higher number of active malignancy diagnoses, were more likely to withhold antithrombotic agents, and exhibited higher prestroke functional dependency. The median onset-to-puncture time was 192 min in IHS and 217 min in COS (P = 0.15). The percentages of successful recanalization (79% vs 71%), symptomatic hemorrhage (0% vs 9%), functional independence (42% vs 40%), and mortality (17% vs 12%) were comparable between the two groups. After adjustment for covariates, initial NIHSS scores and successful recanalization were the most important predictors for functional independence at 90 days.ConclusionsDespite having disadvantages at baseline, patients with IHS could still benefit from timely EVT to achieve favorable outcomes. A well-designed acute stroke protocol tailored for IHS should be developed.

The cerebral hypoperfusion caused by chronic progressive stenosis or occlusion of intracranial arteries in moyamoya disease can be treated by direct bypass or indirect revascularization procedures. The extent of collaterals from the external carotid artery (ECA) after indirect revascularization surgery is the key point of angiographic follow-up, and the invasiveness of angiography impelled us to investigate the role of ultrasonography in the evaluation of collaterals. We hypothesized that the collaterals shown on angiography might produce corresponding hemodynamic changes in color Doppler ultrasonography. We prospectively recruited moyamoya patients who underwent indirect revascularization surgery and received both preoperative and postoperative angiography and color Doppler ultrasound studies. The collaterals on angiography were graded according to Matsushima method. A total of 21 patients (age, 17 ± 10.2 years) with 24 operated hemispheres were enrolled. Patients who showed better collateral establishment by angiography had higher end-diastolic velocity (EDV), lower resistance index (RI), and larger flow volume in the superficial temporal artery (STA) and ECA (all p < 0.05). In STA, increase of EDV greater than 13.5 cm/sec or reduction of RI greater than 0.19 after operation corresponded to 94% of Matsushima grade A+B. In ECA, post-operative EDV greater than 22 cm/sec or increase of EDV greater than 6.4 cm/sec also corresponded to 94% of Matsushima grade A+B. Our findings revealed potential roles of color Doppler ultrasonography in identifying patients with poor collaterals after indirect revascularization procedures.

PURPOSE:To assess the inter session reproducibility of automatic segmented MRI-derived measures by FreeSurfer in a group of subjects with normal-appearing MR images. MATERIALS AND METHODS:After retrospectively reviewing a brain MRI database from our institute consisting of 14,758 adults, those subjects who had repeat scans and had no history of neurodegenerative disorders were selected for morphometry analysis using FreeSurfer. A total of 34 subjects were grouped by MRI scanner model. After automatic segmentation using FreeSurfer, label-wise comparison (involving area, thickness, and volume) was performed on all segmented results. An intraclass correlation coefficient was used to estimate the agreement between sessions. Wilcoxon signed rank test was used to assess the population mean rank differences across sessions. Mean-difference analysis was used to evaluate the difference intervals across scanners. Absolute percent difference was used to estimate the reproducibility errors across the MRI models. Kruskal-Wallis test was used to determine the across-scanner effect. RESULTS:The agreement in segmentation results for area, volume, and thickness measurements of all segmented anatomical labels was generally higher in Signa Excite and Verio models when compared with Sonata and TrioTim models. There were significant rank differences found across sessions in some labels of different measures. Smaller difference intervals in global volume measurements were noted on images acquired by Signa Excite and Verio models. For some brain regions, significant MRI model effects were observed on certain segmentation results. CONCLUSIONS:Short-term scan-rescan reliability of automatic brain MRI morphometry is feasible in the clinical setting. However, since repeatability of software performance is contingent on the reproducibility of the scanner performance, the scanner performance must be calibrated before conducting such studies or before using such software for retrospective reviewing.

Emphysematous prostatitis is a rare condition that is characterized by gas and abscess accumulation in the prostate. We report a 60-year-old man with emphysematous prostatitis caused by Klebsiella pneumoniae. He had a history of recently diagnosed diabetes mellitus and a 16-year history of alcoholic liver cirrhosis. He was admitted due to fever, dysuria and difficult urination. Physical examination revealed lower abdominal tenderness and prostatic fluctuance on digital examination. Leukocytosis, pyuria and elevated C-reactive protein were found. Abdominal radiography disclosed a collection of abnormal air pockets in the lower pelvic cavity and computed tomography scans corroborated the existence of extensive air collection in the prostate. Under the impression of emphysematous prostatitis, the patient was successfully treated with transurethral incision of the prostate and antibiotics for 6 weeks; there were no urinary sequelae during 6 months of follow-up. [J Formos Med Assoc 2007;106(1):74-77]

Web usage mining is used to discover interesting user navigation patterns and can be applied to many real-world problems, such as improving Web sites/pages, making additional topic or product recommendations, user/customer behavior studies, etc. This article provides a survey and analysis of current Web usage mining systems and technologies. A Web usage mining system performs five major tasks: i) data gathering, ii) data preparation, iii) navigation pattern discovery, iv) pattern analysis and visualization, and v) pattern applications. Each task is explained in detail and its related technologies are introduced. A list of major research systems and projects concerning Web usage mining is also presented, and a summary of Web usage mining is given in the last section.

Liver cancer is the third leading cause of cancer mortality worldwide. The aim of this study was to investigate the frequency and characteristics of cerebral lipiodol embolism (CLE) in patients with hepatocellular carcinoma (HCC) receiving transarterial embolization/chemoembolization (TAE/TACE).We reviewed all HCC patients who received TAE/TACE during the period of 2007 and 2013 at a university medical center. The frequency of CLE per procedure and the clinical manifestations of CLE, including the review of previous reported cases (n = 24), were analyzed.During the study period, a total of 7855 TAE/TACE procedures were conducted on 3277 patients. There were 8 patients (mean age 59±11 years; 5 males and 3 females) who developed CLE. The frequency of TAE/TACE-related CLE was 1.02 (95% CI, 0.44-2.01) per 1000 procedures. Acute disturbance of consciousness and respiratory distress after TAE/TACE were the most common presentations of CLE. All patients had disseminated infarcts involving both the anterior and posterior cerebral circulations. For 3 patients with shunting between the tumor feeding artery and the pulmonary vein, a specific imaging pattern of coexisting scattered hyperdense spots was found. Furthermore, combined with our 8 cases, the total of 32 cases indicated that old age and female sex were the two risk factors for poor outcome after CLE.CLE is a rare but potentially serious complication in HCC patients receiving TAE/TACE. The clinical characteristics of CLE summarized in our study would help facilitate the ability of clinicians to provide timely diagnosis and management.

A role for microbes has been suspected in prostate cancer but difficult to confirm in human patients. We show here that a gastrointestinal (GI) tract bacterial infection is sufficient to enhance prostate intraepithelial neoplasia (PIN) and microinvasive carcinoma in a mouse model. We found that animals with a genetic predilection for dysregulation of wnt signaling, Apc (Min/+) mutant mice, were significantly susceptible to prostate cancer in an inflammation-dependent manner following infection with Helicobacter hepaticus. Further, early neoplasia observed in infected Apc (Min/+) mice was transmissible to uninfected mice by intraperitoneal injection of mesenteric lymph node (MLN) cells alone from H. hepaticus-infected mutant mice. Transmissibility of neoplasia was preventable by prior neutralization of inflammation using anti-TNF-α antibody in infected MLN donor mice. Taken together, these data confirm that systemic inflammation triggered by GI tract bacteria plays a pivotal role in tumorigenesis of the prostate gland.