Cerebral Small Vessel Disease Burden for Bleeding Risk during Antithrombotic Therapy: Bleeding with Antithrombotic Therapy 2 Study

OBJECTIVE

This study was undertaken to determine the excess risk of antithrombotic-related bleeding due to cerebral small vessel disease (SVD) burden.

METHODS

In this observational, prospective cohort study, patients with cerebrovascular or cardiovascular diseases taking oral antithrombotic agents were enrolled from 52 hospitals across Japan between 2016 and 2019. Baseline multimodal magnetic resonance imaging acquired under prespecified conditions was assessed by a central diagnostic radiology committee to calculate total SVD score. The primary outcome was major bleeding. Secondary outcomes included bleeding at each site and ischemic events.

RESULTS

Of the analyzed 5,250 patients (1,736 women; median age = 73 years, 9,933 patient-years of follow-up), antiplatelets and anticoagulants were administered at baseline in 3,948 and 1,565, respectively. Median SVD score was 2 (interquartile range = 1-3). Incidence rate of major bleeding was 0.39 (per 100 patinet-years) in score 0, 0.56 in score 1, 0.91 in score 2, 1.35 in score 3, and 2.24 in score 4 (adjusted hazard ratio [aHR] for score 4 vs 0 = 5.47, 95% confidence interval [CI] = 2.26-13.23), that of intracranial hemorrhage was 0.11, 0.33, 0.58, 0.99, and 1.06, respectively (aHR = 9.29, 95% CI = 1.99-43.35), and that of ischemic event was 1.82, 2.27, 3.04, 3.91, and 4.07, respectively (aHR = 1.76, 95% CI = 1.08-2.86). In addition, extracranial major bleeding (aHR = 3.43, 95% CI = 1.13-10.38) and gastrointestinal bleeding (aHR = 2.54, 95% CI = 1.02-6.35) significantly increased in SVD score 4 compared to score 0.

INTERPRETATION

Total SVD score was predictive for intracranial hemorrhage and probably for extracranial bleeding, suggesting the broader clinical relevance of cerebral SVD as a marker for safe implementation of antithrombotic therapy. ANN NEUROL 2024;95:774-787.

Improvement of cerebral blood flow after balloon angioplasty and stenting for symptomatic middle cerebral artery stenosis

OBJECTIVE

Although reports of endovascular treatment for intracranial arterial stenosis have been increasing recently, their efficacy remains to be elucidated. This study aimed to investigate the changes in cerebral hemodynamics of severe middle cerebral artery (MCA) stenosis patients by performing CT perfusion (CTP) after endovascular treatment.

METHODS

Subjects were those who underwent balloon angioplasty and stenting for symptomatic MCA M1 stenosis refractory to medical therapy at our hospital between 2008 and 2022. We included 36 patients (mean age 63.69 ± 15.24 years, 20 males) who underwent CTP before and within three weeks after treatment. The CTP parameters such as relative cerebral blood flow (rCBF), relative cerebral blood volume (rCBV), and relative mean transit time (rMTT) were calculated as ipsilateral values divided by contralateral value.

RESULTS

Endovascular treatment consisted of 26 balloon angioplasty and 10 stenting procedures performed at an average of 1 month from onset. CTP was performed at an average of 5.5 days postoperatively. The mean overall stenosis rate decreased from 79.0% to 30.3%. In the balloon angioplasty group, it decreased from 77.6% to 35.3%, and in the stent group, it decreased from 82.7% to 17.5%. After treatment, rCBF and rMTT measured by CTP improved significantly (both p < 0.001), whereas there was no significant change in rCBV. The improvement rates of rCBF and rMTT were mild higher in the stent group, but not significantly so.

CONCLUSION

Balloon angioplasty and stenting for symptomatic MCA improved cerebral hemodynamics, resulting in significantly increased rCBF and decreased rMTT.

Japan Trevo Registry: Real-world Registry of Stent Retriever Alone or in Combined Therapy with Aspiration Catheter for Acute Ischemic Stroke in Japan

Endovascular therapy (EVT) for real-world patients after extended time frames is associated with concerns about its efficacy and safety. We conducted a prospective registry at 77 centers between November 2019 and October 2020. The registry criteria included patients treated with Trevo Retriever alone or in combined therapy with an aspiration catheter. The primary outcome was effective reperfusion (thrombolysis in cerebral infarction grade ≥ 2b), the secondary outcome was a modified Rankin scale 0-2 at 90 days, and the safety outcomes were worsening of neurologic symptoms within 24 h postoperatively, intracranial hemorrhage (ICH) within 24 h after EVT and mortality. We also exlpored the difference between patients whose last known well time (LKWT) to a puncture was less than 6 h (0-6 h) and those whose LKWT was 6 h or more but less than 24 h (6-24 h). Among the 1041 patients registered, 1025 patients were analyzed. The mean age was 76.9 years, and 53.6% of the participants were males. The 6-24 h group was 206/998 (20.6%), the median National Institute of Health Stroke Scale (NIHSS) score at admission was 18, and the median Alberta Stroke Program Early CT score was 8. Combined technique as the first pass was used on 817 (79.7%) patients. The primary outcome was 934 (91.1%). The secondary outcome was 433/1021 (42.4%). Symptomatic ICH, any ICH, and mortality were 10/1019 (1.0%), 311/1019 (30.5%), and 75 (7.3%). In the subanalysis, the 6-24 h group was lower in NIHSS (median;18 vs 16), and the secondary outcome was not significantly different in the <6 h group. Even after treatment time expansion, this result was comparable to other Trevo-based trials and nationwide registries.

Ischemic stroke patients with low DWI ASPECTS scores require puncture to recanalization within 30 min for large vessel occlusion

BACKGROUND

The clinical benefits of faster recanalization in acute large vessel occlusion are well recognized, but the optimal procedure time remains uncertain. The aim of this study was to identify patient characteristics that necessitate puncture-to-recanalization (P-R) time within 30 min to achieve favorable outcome.

METHODS

We evaluated the patients from a prospective, multicenter, observational registry of acute ischemic stroke patients. The study included patients who underwent endovascular therapy for ICA or MCA M1 occlusion and achieved successful recanalization. Patients were categorized into subgroups based on pre-treatment characteristics and the frequency of favorable outcomes was compared between P-R time < 30 min and ≥ 30 min. Interaction terms were incorporated into the models to assess the correlation between each patient characteristic and P-R time.

RESULTS

A total of 1053 patients were included in the study. Univariate analysis within each subgroup revealed a significant association between P-R < 30 min and favorable outcomes in patients with DWI ASPECTS ≤6, age > 85 and NIHSS ≥16. In the multivariable analysis, NIHSS, age, time from symptom recognition to puncture, and DWI ASPECTS were significant independent predictors of favorable outcomes. Notably, only DWI ASPECTS exhibited interaction terms with P-R < 30 min. The multivariable analysis indicated that P-R < 30 min was an independent predictor for favorable outcome in DWI ASPECTS ≤6 group, whereas not in DWI ≥7.

CONCLUSIONS

P-R time < 30 min is predictive of favorable outcomes; however, the effect depends on DWI ASPECTS. Target P-R time < 30 min is appropriate for patients with DWI ASPECTS ≤6.

Extraovarian Dysgerminoma Involving the Uterine Cervix: A Rare Case Report With Literature Review

Primary extraovarian dysgerminoma (EOD) is a very rare disease. There is no literature about primary EOD involving the uterine cervix. We herein present details of a unique case of primary EOD involving the uterine cervix. A 46-year-old woman with uterine cervical tumor was referred to our institution with atypical genital bleeding. A polypoid tumor localized to the uterine cervix was found. Cervical biopsy detected malignant components of likely nonepithelial cell origin. Preoperative imaging examinations showed a uterine cervical tumor measuring ~5 cm, suggestive of malignancy without distant or lymph node metastases. The patient underwent abdominal radical hysterectomy with pelvic lymph node dissection according to the standard treatment for stage IB3 cervical cancers. The pathological diagnosis was dysgerminoma involving the uterine cervix and the right fallopian tube. Immunohistochemical results were as follows: SALL4 (+), octamer-binding transcription factor 4 (+), D2-40 (+), and c-Kit (+). She received 3 cycles of adjuvant chemotherapy with bleomycin, etoposide, and cisplatin. The disease did not recur up to 14 months after surgery. This is the first-ever published case of primary EOD involving the uterine cervix among previously reported EOD cases. Reported cases of EOD in female genital tract are also reviewed. Our case provides more extensive insights for pathologists to consider the differential diagnosis of cervical lesions. In our case, combination therapy involving a surgical approach-according to cervical cancers and adjuvant chemotherapy as used for ovarian dysgerminomas-was effective. Future verification is needed regarding the best approach for treating uterine cervical dysgerminomas.

The impact of SAH finding on CT to the clinical outcome after mechanical thrombectomy for large vessel occlusion

BACKGROUND AND PURPOSE

Whether subarachnoid haemorrhage (SAH) after mechanical thrombectomy affects the clinical outcomes of patients with acute large-vessel occlusion remains unclear. This study aimed to investigate the clinical impact of SAH on computed tomography (CT) after mechanical thrombectomy.

METHODS

The SKIP study was an investigator-initiated, multicentre, randomised, open-label clinical trial. This study was performed in 23 hospital networks in Japan from January 1, 2017, to July 31, 2019. Among the 204 patients, seven were excluded because they did not undergo mechanical thrombectomy (MT) and had a modified Rankin scale (mRS) score > 2. The main outcome was the association between SAH within 36 h after mechanical thrombectomy and the clinical outcome at 90 days.

RESULTS

Among 197 patients, the median age was 74 (67-79) years, 62.9% were male. Moreover, 26 (13.2%) patients had SAH (seven isolated SAH) on CT within 36 h. The SAH rate did not differ according to IV rt-PA administration (p = 0.4). The rate of favourable clinical outcomes tended to be lower in patients with SAH rather than patients without SAH (11 [42%] vs. 106 [62%], p = 0.08). Among the seven patients with isolated SAH, 6 showed favourable outcomes at 90 days. In the multivariate regression analysis, the presence of SAH within 36 h from onset was not associated with clinical outcome (Odd ratio, 0.59; 95% confidence interval, 0.18-1.95; p = 0.38).

CONCLUSIONS

Among patients with acute stroke treated with MT, SAH, especially isolated SAH findings on CT, were not associated with poor clinical outcomes after 90 days.

TRIAL REGISTRATION NUMBER

UMIN000021488.

Ultra-early rt-PA administration should improve patient outcome on mechanical thrombectomy: Post hoc analysis of SKIP

BACKGROUND

To investigate whether ultra-early recombinant tissue-plasminogen activator (rt-PA) administration can improve patient outcomes on mechanical thrombectomy (MT) in patients with large vessel occlusion (LVO).

METHODS

Participants comprised rt-PA-eligible 204 patients with internal carotid artery or middle cerebral artery occlusion in the SKIP trial, who were randomly assigned to receive mechanical thrombectomy alone or combined intravenous thrombolysis (rt-PA: alteplase at 0.6 mg/kg) plus mechanical thrombectomy. We assessed associations between onset-to-puncture time and onset-to-rt-PA administration time and frequency of favorable outcome at 90 days and any intracerebral hemorrhage (ICH) at 36 h after onset.

RESULTS

As a cut-off onset-to-puncture time for favorable outcome, receiver operating characteristic curves defined 2.5 h (57% sensitivity, 62% specificity). For onset-to-puncture times ≤2.5 h and > 2.5 h, frequencies of favorable outcomes were 72% and 63% (p = 0.402) in patients with rt-PA therapy and 44% and 58% (p = 0.212) in patients without rt-PA therapy, respectively. In terms of onset-to-rt-PA administration time, frequencies of favorable outcomes among patients with ultra-early rt-PA administration at ≤100, >100 min after onset, and without rt-PA therapy with onset-to-puncture time ≤ 2.5 h, and with and without rt-PA therapy with onset-to-puncture time > 2.5 h were 84% and 64%, 63%, and 44% and 58%, respectively (p = 0.025). Frequencies of any ICH among those patients were 37% and 32%, 32%, and 63% and 40%, respectively (p = 0.006).

CONCLUSION

Ultra-early rt-PA administration should improve patient outcomes on mechanical thrombectomy among patients with LVO. Relatively late rt-PA administration might increase the frequency of any ICH.

Increased door-to-puncture time during off-duty hours results in poor treatment outcomes for acute ischemic stroke: A subanalysis of the K-NET registry

BACKGROUND

For patients who undergo endovascular treatment for acute ischemic stroke, the total time for treatment may increase during off-duty hours leading to worse outcomes. The present study compared endovascular treatment outcomes for on-duty and off-duty hours and examined factors that could be responsible for the prolonged treatment of patients in a multicenter registry.

METHODS

The study group comprised 1571 patients listed in the multicenter stroke registry (K-NET) who had undergone endovascular treatment between January 2018 and June 2020. The modified Rankin Scale (mRS), evaluated at 90 days after stroke onset, was utilized as the primary outcome. Patients were divided into on-duty and off-duty patients based on admission time. Multivariate logistic regression analysis was used to identify the independent factors that increased the time from admission to puncture during the off-duty period.

RESULTS

The mean mRS score at 90 days after stroke onset was 2.9, similar in both on-duty and off-duty patients, with no significant difference (p = 0.77); however, significant differences were observed in time from door-to-puncture (74.7 vs. 88.8, p < 0.01). Additionally, the mRS score at 90 days worsened significantly for door-to-puncture time >60 min in the off-duty period. Multivariate logistic regression analysis revealed that a low National Institute of Health Stroke Scale (NIHSS) score, high pre-mRS score, posterior circulation, and diabetes were independent indicators of door-to-puncture time >60 min during the off-duty period.

CONCLUSION

Door-to-puncture time >60 min during off-duty hours was associated with poor outcomes related to low NIHSS, high pre-mRS, posterior circulation, and diabetes.

Changes in Target Coverage and Dose to the Normal Brain during Fractionated Stereotactic Radiotherapy for Metastatic Brain Tumors

PURPOSE/OBJECTIVE(S)

Fractionated stereotactic radiotherapy (SRT) has been applied to large brain metastases to reduce the risk of radiation necrosis. For fractionated SRT, potential of interfractional tumor changes during the treatment period, such as tumor size, shape, and geometry, must be considered to improve the tumor local control. Our center performs adaptive re-planning for large brain metastases based on repeat MRI verification with a contrast agent in the middle of the treatment period. Purpose of this study is to evaluate the dosimetric impact of the changes in tumor size, shape, and geometry on the doses to the targets and normal brain in patients with brain metastases undergoing fractionated SRT.

MATERIALS/METHODS

Fifteen solitary large intracranial metastatic lesions treated with fractionated SRT were investigated. Standardized planning MRI (MRI-1) and repeat verification MRI (MRI-2) were performed during the middle of the irradiation period. The GTV on the MRI-1 and MRI-2 scans was contoured by the same oncologist. The PTV was created by adding an isotropic margin of 1 mm from the GTV in all directions. Volumetric modulated arc therapy (VMAT) with beam energies of 6 MV (flattening filter-free mode) was used and plans were normalized such that PTV D95% or D98% was equal to the prescribed dose. Beam configuration and intensity on the initial VMAT plan were used to evaluate the dose to the tumor and the normal brain on MRI-2. We evaluated the impact of D98% on the GTV using the plans on the MRI-1 and MRI-2 scans. For the normal brain, the V90%, V80%, and V50% were investigated.

RESULTS

The median GTV changed from 9.8 cc (range of 3.2-33.0 cc) to 9.7 cc (range of 2.8-36.5 cc) (p = 0.482). Three and four tumors exhibited volume shrinkage and enlargement changes of >10%. Five tumors exhibited volume shrinkage and enlargement changes of <10%. Three tumors showed no volume changes. Of the 15 large brain metastases, 12 tumors required treatment plan modification. The dosimetric parameters of the GTV, PTV, and normal brain did not significantly differ between the MRI-1 and MRI-2 scans. Regarding the tumor dose, the D98% to the GTV increased in patients with tumor shrinkage because of dose inhomogeneity and decreased in patients with tumor enlargement. The V90%, V80%, and V50% increase with decreasing tumor volumes and were linearly related to the tumor volume difference, with a coefficient of determination of 0.97, 0.98, and 0.97, respectively.

CONCLUSION

Our study demonstrated the usefulness of repeat verification MRI for adaptive radiotherapy in the middle of the treatment period due to changes in tumor size, shape, and geometry in patients with brain metastases. Repeated MRI should be considered to evaluate the dose to the target and normal brain, which improves tumor local control and reduces brain necrosis, to reduce the magnitude of underdosing to the target or overdosing to the normal brain during the treatment period.

Abstract WMP90: Is Endovascular Thrombectomy More Effective Than IV-tPA For Distal Vessel Occlusions? Propensity Score-matched Analysis From K-net Registry

Background and Purpose: The benefit of endovascular thrombectomy (EVT) for acute ischemic stroke due to primary distal vessel occlusions is unclear. We assessed whether outcome of acute ischemic stroke patients treated with EVT for primary distal vessel occlusions was better than intravenous tissue-type plasminogen activator (IV-tPA) alone.

Materials and Methods: We investigated data from K-NET Registry, which is a prospective, multicenter, observational registry of acute ischemic stroke patients treated with EVT or IV t-PA in Kanagawa, Japan. We evaluated the patients who had primally distal vessel occlusion and were treated with EVT (with or without IV-tPA) or IV tPA alone. Distal vessel occlusion was defined as middle cerebral artery M2-M3, anterior cerebral artery or posterior cerebral artery occlusion. Propensity score-matched analysis was conducted to compare outcomes between EVT and IV-tPA alone. Primary outcome was good outcome at 90 days, defined as mRS of 0 to 2 or not worsening compared to pre-stroke mRS. Safety outcome was the occurrence of all hemorrhage and symptomatic hemorrhage.

Results: 703 patients with distal vessel occlusion (MCA M2, 436 cases, M3, 167 cases, ACA 48 cases, PCA 52 cases) were included in this study. 461 cases were treated with EVT and 242 were IV-tPA alone. Propensity-score matching paired 110 patients with EVT and 110 patients with IV-tPA. There were no significant differences in good clinical outcome (EVT 65.4%, IV-tAP 60.0%), all hemorrhage (EVT 15.4%, IV-tAP 11.8%) and symptomatic hemorrhage (EVT 4.5%, IV-tAP 1.8%). Dividing EVT group into EVT with IV-tPA and EVT alone, there were no significant differences in outcomes compared to IV-tPA alone.

Conclusions: The benefit of EVT for acute primary distal vessel occlusions was similar as IV-tPA alone. Although IV-tPA is a first line treatment for primary distal vessel occlusions, EVT is a feasible treatment for patients who have contraindication to IV-tPA.

Abstract WMP56: Selection Of Magnetic Resonance Imaging Or Computed Tomography Before Mechanical Thrombectomy For Acute Ischemic Stroke

Introduction: Evaluation of ischemic core and penumbra by magnetic resonance imaging (MRI) or computed tomography (CT) is useful in determining the indication for mechanical thrombectomy (MT) for acute ischemic stroke, however, it is still uncertain which imaging modality is superior. In this study, we compared the clinical outcomes after MT by imaging modality in the K-NET registry (Kanagawa intravenous and endovascular treatment of acute ischemic stroke registry).

Methods: The K-NET registry (January 2018 to December 2021) is a Japanese multicenter prospective registry study of patients treated with Intravenous thrombolysis with recombinant tissue plasminogen activator (alteplase), endovascular treatment of cerebral infarction, or both for acute ischemic stroke. Patients who were enrolled by December 2020 and underwent MT were included in the study. We compared the favorable outcome at 90 days (modified Rankin Scale [mRS] score 0-2 or mRS shift [prestroke - day 90] = 0) between the MRI group and the CT alone group.

Results: Of the 2348 patients enrolled in K-NET, 1763 underwent MT. Median age was 77 years (70-84) and 745 (42.2%) were female. There were 1311 patients in the MRI group and 452 in the CT group. There were no notable differences in patient characteristics. Despise the time from presentation to imaging was significantly shorter in the CT group (MRI: 14 minutes [9-21]; CT: 8 minutes [4-15]; P<0.001), there was no difference in time from presentation to recanalization. The rate of favorable outcome at 90 days was higher in the MRI group (MRI: 46.4%; CT: 40.7%; P=0.03). There was no difference in outcome between the two groups within 6 hours of onset, however, after 6 hours, the MRI group had a better outcome (MR 41.1%; CT: 28.2%; P=0.05). Compared due to SSS-TOAST classification, the MRI group had a better outcome in atherothrombotic patients (MRI group: 53.8%; CT group: 40.3%; P=0.04), while other subtypes of stroke did not show any difference.

Conclusions: MRI imaging before MT was associated with favorable outcome. In addition, patients after 6 hours of onset and those with atherothrombotic disease had more favorable outcomes in the MRI group, suggesting that MRI may be useful as an imaging modality before thrombus retrieval in these patients.

Abstract WP162: Primary Results Of Mechanical Thrombectomy For Acute Ischemic Stroke In Clinical Practice: K-net Registry

Background: Endovascular treatment (EVT) for acute large vessel occlusion has been found to be effective in several randomized controlled trials. We conducted a prospective cohort study to evaluate the real-world efficacy of EVT in patients with acute ischemic stroke in a metropolitan area with a high population density and a large number of comprehensive stroke centers.

Methods: We analyzed the Kanagawa Intravenous and Endovascular Treatment of Acute Ischemic Stroke registry, a prospective, multicenter observational study of patients treated by EVT and/or intravenous tissue-type plasminogen activator (tPA), in Kanagawa, Japan. Of the 2488 patients enrolled from January 2018 to June 2020, 1764 patients treated with EVT were included. The primary outcome was a good outcome, which was defined as a modified Rankin Scale (mRS) of 0 to 2 at 90 days. Secondary analysis included predicting a good outcome using multivariate logistic regression analysis.

Results: The median age was 77 years and the median National Institute of Health Stroke Scale (NIHSS) score was 18. Pretreatment mRS score 0-2 was 87%, and direct transport was 92%. The rate of occlusion in anterior circulation was 90.3%. Successful recanalization was observed in 88.7%. The median time from onset to recanalization was 193 minutes. Good outcomes at 90 days were 43.3% in anterior circulation and 41.9% in posterior circulation. Furthermore, 49.3% of patients with anterior circulation obstruction who had pre-stroke mRS 0-2 had good outcome, which was higher than the HERMES trial. Overall mortality was 12.6%. Significant predictors for a good outcome were: age, male, direct transfer, NIHSS score, Alberta Stroke Program Early Computed Tomography Score, intravenous tPA, and successful recanalization.

Conclusions: EVT in routine clinical use in a metropolitan area showed comparable good outcomes and lower mortality compared to previous registries and RCTs, despite the high proportion of patients with older age, pretreatment mRS score of > 2, posterior circulation occlusion, and higher NIHSS. Those results may have been associated with more direct transport and faster onset-to-recanalization times.

Abstract 3: Cerebral Small Vessel Disease Burden For Bleeding Risk During Antithrombotic Therapy -BAT2-

Background: Cerebral small vessel disease (SVD) has received attention as a risk stratification tool for antithrombotic-related intracranial hemorrhage but may also be a predictor for bleeding in other organs.

Purpose: To determine the excess risk of antithrombotic-related bleeding due to cerebral SVD burden.

Methods: Patients with cerebrovascular or cardiovascular diseases taking oral antithrombotic agents were prospectively enrolled from 52 hospitals across Japan between 2016 and 2019. Multimodal brain MRI was acquired at baseline for all patients under prespecified conditions. All MRI examinations were interpreted by a central diagnostic radiology committee for cerebral microbleeds, lacunes, white matter hyperintensities, and enlarged basal ganglia perivascular spaces, for calculation of a total SVD score (range 0-4). The primary outcome was major bleeding during 2-year follow-up. Secondary outcomes included bleeding in each site and ischemic events. Event risks according to SVD score were estimated with multivariable Cox proportional hazards models.

Results: Of the analyzed 5250 patients (1736 women; median age, 73 years; 9933 patient-years follow-up), antiplatelets and anticoagulants were administered at baseline in 3948 and 1565, respectively. Median of the total SVD score was 2 (IQR 1-3). As SVD score increased, advanced age, hypertension, anemia, and chronic kidney disease were more prevalent (P<0.001 for each). A unit increase of SVD score was associated with a higher risk of major bleeding (adjusted hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.29-1.85) and intracranial hemorrhage (adjusted HR 1.61, 95% CI 1.28-2.03). With SVD score 4 compared to score 0, extracranial major bleeding (adjusted HR 3.37, 95% CI 1.12-10.15) and gastrointestinal bleeding (adjusted HR 2.54, 95% CI 1.02-6.35) were also significantly increased. A higher SVD score was associated with a mild but significant elevation of ischemic event risk (adjusted HR per unit increase 1.17, 95% CI 1.06-1.29).

Conclusions: The total SVD score was predictive for intracranial hemorrhage and probably for extracranial bleeding, suggesting a broader clinical relevance of cerebral SVD as a marker for safe implementation of antithrombotic therapy.

Long-term outcome and factors associated with restenosis after combination therapy of balloon angioplasty and stenting for symptomatic intracranial stenosis

BACKGROUND

The optimal treatment for intracranial artery stenosis (ICAS) has not been established. We retrospectively examined the initial and long-term outcomes associated with restenosis of a combination therapy of balloon angioplasty and stenting for symptomatic atherosclerotic ICAS.

METHODS

Consecutive patients who underwent balloon angioplasty and/or stenting for ≥ 70% ICAS between 2006 and 2020 were analyzed. Patients within 48 h of stroke onset were excluded. The following procedures were established as standards at our institution: (1) primary balloon angioplasty alone was initially performed; (2) stenting for insufficient dilatation, recoiling, or dissection was conducted; and (3) stenting was considered for restenosis. Intracranial ischemic and hemorrhagic complications within 30 days after treatment were used to evaluate periprocedural safety. Recurrent ischemic events, restenosis and restenosis related factors were used to be evaluate the long-term outcome.

RESULTS

A total of 160 patients were recruited. Initial treatment consisted of balloon angioplasty (n = 101) and stenting (n = 59). Intracranial complications within 30 days after treatment were ischemic in five (3.1%) and hemorrhagic in four patients (2.5%). The incidence of these complication was 3.1% in the stenting group and 2.5% in the balloon angioplasty group. The mean follow-up period was 53.9 months. Restenosis was found in 42 patients (26%). Recurrent ischemic events during follow-up were noted in 14 patients (8.8%), of which six patients had TIA and eight patients had ischemic stroke. Restenosis-associated factors included diabetes, coronary artery disease, percent stenosis after treatment, and balloon angioplasty in logistic univariate analysis. Multivariate Cox regression analysis showed that diabetes (HR: 2.084, CI: 1.039-4.180, p = 0.0386), length of lesion (HR; 1.358, CI: 1.174-1.571, p < 0.0001), and balloon angioplasty (HR: 4.194, CI: 1.083-16.239, p = 0.0379) were independent predictors for restenosis.

CONCLUSION

Combination therapy of balloon angioplasty and stenting for symptomatic ICAS had a low perioperative stroke rate and may improve long-term outcome. Balloon angioplasty, diabetes, and length of lesion were significantly associated with restenosis.

Primary results of mechanical thrombectomy for acute ischemic stroke: The K-NET registry in the Japanese metropolitan area

BACKGROUND

Endovascular treatment (EVT) for acute large vessel occlusion has proven to be effective in randomized controlled trials. We conducted a prospective cohort study to evaluate the real-world efficacy of EVT in a metropolitan area with a large number of comprehensive stroke centers and to compare it with the results of other registries and randomized controlled trials (RCTs).

METHODS

We analyzed the Kanagawa Intravenous and Endovascular Treatment of Acute Ischemic Stroke registry, a prospective, multicenter observational study of patients treated by EVT and/or intravenous tissue-type plasminogen activator (tPA). Of the 2488 patients enrolled from January 2018 to June 2020, 1764 patients treated with EVT were included. The primary outcome was a good outcome, which was defined as a modified Rankin Scale (mRS) of 0-2 at 90 days. Secondary analysis included predicting a good outcome using multivariate logistic regression analysis.

RESULTS

The median age was 77 years, and the median National Institute of Health Stroke Scale (NIHSS) score was 18. Pretreatment mRS score 0-2 was 87%, and direct transport was 92%. The rate of occlusion in anterior circulation was 90.3%. Successful recanalization was observed in 88.7%. The median time from onset to recanalization was 193 min. Good outcomes at 90 days were 43.3% in anterior circulation and 41.9% in posterior circulation. Overall mortality was 12.6%. Significant predictors for a good outcome were as follows: age, male, direct transfer, NIHSS score, Alberta Stroke Program Early Computed Tomography Score, intravenous tPA, and successful recanalization.

CONCLUSION

EVT in routine clinical use in a metropolitan area showed comparable good outcomes and lower mortality compared to previous studies, despite the high proportion of patients with older age, pretreatment mRS score of >2, posterior circulation occlusion, and higher NIHSS. Those results may have been associated with more direct transport and faster onset-to-recanalization times.

Derivation and validation of a machine learning-based risk prediction model for in-hospital mortality in patients with acute heart failure

Background

Although risk stratification is important in patients with acute heart failure (AHF) to predict patient prognosis, pre-existing risk models have not often been used due to its complexity. Recently, machine learning methods have been presented as an alternative approach to analyzing the predictive probability of large clinical datasets.

Purpose

The aim of this study is to develop a user-friendly risk score developed by one of machine learning methods and compare the performance of the new risk score to the existing conventional risk models.

Methods

A machine-learning-based risk model was developed using least absolute shrinkage and selection operator (LASSO) regression by identifying predictors of in-hospital mortality in the derivation cohort (REALITY-AHF) and externally validating and comparing its performance with two pre-existing risk models: the Get With The Guidelines risk score incorporating brain natriuretic peptide and hypochloremia (GWTG-BNP-Cl-RS) and the acute decompensated heart failure national registry (ADHERE) risk model.

Results

In-hospital deaths in the derivation and validation (NARA-HF) cohorts were 76 (5.1%) and 61 (4.9%), respectively. The risk score comprised four variables (systolic blood pressure, blood urea nitrogen, serum chloride, and C-reactive protein) and was developed according to the results of the LASSO regression weighting the coefficient for selected variables using a logistic regression model (4V-RS). Even though 4V-RS comprised fewer variables, In the validation cohort, it showed a higher area under the receiver operating characteristic curve (AUC) than the ADHERE risk model (AUC, 0.783 vs. 0.740; P=0.059) and a significant improvement in net reclassification (0.359; 95% CI, 0.10–0.67; p=0.006). 4V-RS performed similarly to GWTG-BNP-Cl-RS in terms of discrimination (AUC, 0.783 vs. 0.759; p=0.426) and net reclassification (0.176; 95% CI, −0.08–0.43; p=0.178).

Conclusions

The 4V-RS model comprising only four readily available data points at the time of admission performed similarly to the more complex pre-existing risk model in patients with AHF.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Cardiovascular Research Fund

Effect on Physical Functions of Older Adults When Refraining from Going out due to COVID-19 Restrictions

The study investigated the effect of refraining from going out during the coronavirus disease 2019 pandemic on physical function in community-dwelling older adults. The study included 49 patients who underwent home-visit rehabilitation. Four parameters of physical function—grip strength, five-times sit-to-stand test, single-leg stance test, and standing test for imbalance and disequilibrium (SIDE)—were assessed. They were evaluated before (March 2020) and after (May 2020) the state emergency was imposed, and the results were compared. The grip strength decreased significantly. A significant difference was also observed in the proportion of different SIDE levels in the study group before and after the implementation of the state emergency. The number of SIDE 2a or lower patients increased during the state emergency (p < 0.001). Comprehensive community support and rehabilitation are necessary to maintain physical function in older individuals. In particular, we believe that there is a need to utilize remote rehabilitation using digital devices (such as internet-based guidance) so that older adults can continue to exercise at home.

Habitual exercise provides better prognosis for cardiac arrest with coronary artery disease

Background

Although regular physical activity has beneficial cardiovascular effects, exercise can trigger sudden cardiac arrest (SCA). Coronary artery disease (CAD) was identified as the most common cause of an exercise-related out-of-hospital cardiac arrest (OHCA). Regular exercise has been reported to reduce the risk of plaque rupture in animal studies and basic research. Therefore, we compared the coronary artery findings in CAD-OHCA patients with and without habitual exercise.

There have been few reports on whether regular exercise changes the prognosis in OHCA due to CAD (CAD-OHCA). We investigated the association between the better clinical outcome and the regular exercise in patients with CAD-OHCA.

Methods

This is a single-center retrospective analysis from 2006 to 2019. The consecutive 397 patients with OHCA due to myocardial ischemia underwent coronary angiography (CAG). After excluding 73 patients with vasospastic angina, the remaining 324 patients with CAD were enrolled in this study. We divided these patients into two groups according to whether they were habitually exercising (Exercise group: N=37) or not/unknown (Non-Exercise group: N=287).

Clinical outcome was a 30-day survival with minimal neurologic impairment represented by a Glasgow-Pittsburgh Cerebral Performance Categories Scale value 1 or 2.

Results

The patients in the Exercise Group were significantly younger (exercise vs. non-exercise, 57±12 vs. 64±12 years; P&lt;0.01) than those in the non-exercise group. The Exercise group had a lower incidence of diabetes mellitus (22% vs. 42%; P=0.02) and a higher incidence of dyslipidemia (81% vs. 62%; P=0.02) than the non-exercise group. The time from collapse to cardiopulmonary resuscitation (1.4±4.0 vs. 3.0±4.8min) and from collapse to return of spontaneous circulation (11.9±10.0 vs. 28.0±25.3min) were shorter in Exercise group (all p&lt;0.05). The ST-segment elevation was recorded on electrocardiography in fewer of the Exercise group (22% vs. 63%; P&lt;0.01). The finding of culprit lesion in the coronary arteries on arrival resulted significant differences between the 2groups (good collateral and/or TIMI3 flow: 62% vs. 25%, the plaque rupture and/or thrombus: 22% vs. 73%) (all p&lt;0.01) (Figure 1). Kaplan-Meier curve showed Exercise group has better neurological outcome at 30days compared than Non-Exercise (95% vs 51%; P&lt;0.001, log-rank test) (Figure 2). Multivariable Cox proportional hazards models revealed that a habitual exercise was one of the predictors of a good neurological outcome (HR 0.21, 95% CI 0.05–0.92; P=0.039).

Conclusions

The patients with habitual exercise had less plaque rupture, less coronary thrombosis than non-exercise. The patients with regular exercise had better clinical outcomes than non-exercise after CAD-OHCA.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Tokyo Metropolitan Goverment Figure 1. Findings of the culprit lesion in coronar arteriesFigure 2. Kaplan-Meier analysis

A Case Report of Contrast-Induced Encephalopathy after Repeated Percutaneous Transluminal Angioplasty for Acute Middle Cerebral Artery Occlusion

Objective

We report a case of contrast-induced encephalopathy (CIE) after repeated percutaneous transluminal angioplasty (PTA) for acute middle cerebral artery (MCA) occlusion.

Case Presentation

An 88-year-old woman with left hemiparesis was transferred to our hospital by ambulance. MRI revealed acute MCA M1 occlusion. We performed intravenous tissue plasminogen activator therapy and PTA for right MCA occlusion, leading to complete recanalization and improvement in hemiparalysis. After approximately one week, restenosis of right MCA developed and PTA was performed again on day 11. However, her left hemiparesis exacerbated shortly thereafter. CT demonstrated leakage of contrast medium, and an extensive high-intensity area (HIA) on the white matter in the right cerebral hemisphere was noted on MRI FLAIR. The HIA on MRI and neurological deficits gradually improved after conservative treatment, but diffuse atrophy of the right cerebral hemisphere occurred and higher brain dysfunction remained.

Conclusion

Repeated ischemia and reperfusion, and the frequent use of contrast media were considered the causes of CIE.

The Influence of Experience on Gazing Patterns during Endovascular Treatment: Eye-Tracking Study

Objective

In various fields, differences in eye-gazing patterns during tasks between experts and novices have been evaluated. The aim of this study was to investigate gazing patterns during neuro-endovascular treatment using an eye-tracking device and assess whether gazing patterns depend on the physician's experience or skill.

Methods

Seven physicians performed coil embolization for a cerebral aneurysm in a silicone vessel model under biplane X-ray fluoroscopy, and their gazing patterns were recorded using an eye-tracking device. The subjects were divided into three groups according to experience, highly experienced (Expert) group, intermediately experienced (Trainee) group, and less experienced (Novice) group. The duration of fixation on the anterior-posterior (AP) view screen, lateral (LR) view, and out-of-screen were compared between each group.

Results

During microcatheter navigation, the Expert and Trainee groups spent a long time on fixation to AP, while the Novice group split their attention between each location. In coil insertion, the Expert group gazed at both the AP and the LR views with more saccades between screens. In contrast, the Trainee group spent most of their time only on the AP view screen and the Novice group spent longer out-of-screen.

Conclusion

An eye-tracking device can detect different gazing patterns among physicians with several experiences and skill levels of neuroendovascular treatment. Learning the gazing patterns of experts using eye tracking may be a good educational tool for novices and trainees.

Intravenous Alteplase is Associated with First Pass Effect in Stent-retriever but not ADAPT Thrombectomy : Post Hoc Analysis of the SKIP Study

PURPOSE

To investigate the effect of alteplase, either combined with stent-retriever thrombectomy or a direct aspiration first pass technique (ADAPT), in patients with large-vessel occlusion stroke.

METHODS

This was a retrospective post hoc analysis of data from The Direct Mechanical Thrombectomy in Acute LVO Stroke (SKIP) study. Patients were divided into two groups according to the first-line thrombectomy technique: stent-retriever and ADAPT. Each group was further divided into two subgroups, namely MT and MT + alteplase. The procedural outcomes, such as first pass effect (FPE) ratio and number of passes, were evaluated. The clinical outcomes included mRS score at 3 months.

RESULTS

A total of 180 patients were included (116 in the stent-retriever group and 64 in the ADAPT group). No interaction was detected between the first-line technique and alteplase administration. In the stent-retriever group, after adjusting for factors associated with FPE, the adjusted odds ratio (95% confidence interval) of FPE of the MT + alteplase subgroup versus the MT subgroup was 3.57 (1.5-8.48) and in the ADAPT group it was 1.35 (0.37-4.91). With alteplase, the number of passes decreased with adjusted odds ratios of 0.59 (0.37-0.93) in the stent-retriever group but not in the ADAPT group. In both first-line technique groups, clinical outcomes did not differ between subgroups.

CONCLUSION

In the SKIP study, alteplase administration was associated with increased FPE when combined with stent-retriever thrombectomy, but not with ADAPT. We found no differences in the clinical outcomes.

CMR feature tracking cloud assess right ventricular functional reserve with pulmonary arterial hypertension

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): JSPS KAKENHI, Grant-in-Aid for Early-Career Scientists.

Background

  Pulmonary arterial hypertension (PAH) remains a fatal disorder characterized by elevated pulmonary arterial pressure. Survival of the patients with PAH is determined from right ventricular (RV) function. CMR has become an attractive modality for following up and providing prognosis in such patients, and CMR feature tracking has been used as a newer useful parameter to assess RV function. However, it has not yet been determined whether CMR feature tracking can assess RV functional reserve in patients with PAH.

Purpose

We investigated whether CMR feature tracking can estimate RV functional reserve using a rat model with PAH.

Methods

 Rats were received injections with monocrotaline (MCT-rats, n = 19) or solvent (Ctr-rats, n = 5). Four weeks after the injections, we performed CMR on 7-T MRI scanner and imaged retrospective ECG-gated cine MR (16 phases/beat). RV ejection fraction (RVEF) and RV strain were analyzed before and after addition of 0.5∼3 nmol endothelin-1 (ET-1). After the measurements, we dissected trabeculae (length = 1.45 ± 0.07 mm, width = 334 ± 27 µm, thickness = 114 ± 6 µm) from the RVs of rat hearts. Trabeculae were electrically stimulated with 2-s intervals at extracellular Ca2+ of 0.7 and 2.0 mmol/L (24°C). Force and maximum dF/dt (dF/dtmax) were then measured using a silicon strain gauge in the absence and presence of 0.1 µM ET-1.

Results

 MCT-rats showed higher systolic RV pressure (RVP), lower RVEF, and lower RV global longitudinal strain (RVGLS) in CMR imaging and showed lower developed force and lower dF/dtmax in their trabeculae. Correlation between RVGLS and dF/dtmax was higher (r = 0.53, p &lt; 0.05) than that between RVEF and dF/dtmax (r = 0.24). In 5 MCT-rats with preserved RVEF (&gt;50%), RVGLS had already been reduced, suggesting that RVGLS is reduced earlier than RVEF. ET-1 increased developed force and dF/dtmax in trabeculae from MCT-rats (12.2 ± 5.7 to 17.4 ± 3.1 mN/mm2 and 0.08 ± 0.03 to 0.14 ± 0.06 mN/mm2/sec, respectively, n = 6), and ET-1 also increased RVP in MCT-rats and Ctr-rats (49.0 ± 19.3 to 59.7 ± 16.8 mmHg in MCT-rats, n = 6, 17.3 ± 7.5 to 20.4 ± 7.8 mmHg in Ctr-rats, n = 2). According to RV global circumferential strain (RVGCS) and RVEF, we could divide MCT-rats into three groups as follows: MCT-rats with reduced-RVGCS (&gt; -20%)/preserved-RVEF (&gt; 50%), MCT-rats with increased-RVGCS (&lt; -30%)/preserved-RVEF and MCT-rats with reduced-RVGCS/reduced-RVEF. ET-1 reduced RVGCS in MCT-rats with reduced-RVGCS/preserved-RVEF, while ET-1 did not change RVGCS in MCT-rats with increased-RVGCS/preserved-RVEF. MCT-rats with reduced-RVGCS/reduced-RVEF died after injection of ET-1.  In Ctr-rats, ET-1 did not change RVGCS and RVEF.  These results suggest that RVGCS can be useful to assess RV functional reserve.

Conclusion

 CMR feature tracking can estimate RV functional reserve earlier and more accurately than RVEF in rats with PAH.  RV strain may become an important parameter to assess RV functional reserve in patients with PAH.

Prognostic impact of six versus eight cycles of standard regimen in patients with diffuse large B-cell lymphoma: propensity score-matching analysis

Background

R-CHOP-21 has been the standard treatment for diffuse large B-cell lymphoma (DLBCL), but there is a paucity of evidence focusing on the number of cycles of regimens.

Patients and methods

We conducted a retrospective study to compare the effectiveness of six cycles of standard regimens versus eight cycles for overall survival (OS) in DLBCL patients using propensity score matching, in consideration of relative dose intensity (RDI).

Results

A total of 685 patients with newly diagnosed DLBCL were identified in three institutions from 2007 to 2017. Patients treated using six cycles of standard regimens were matched by propensity scores with those treated using eight cycles. A 1 : 1 propensity score matching yielded 138 patient pairs. Eight cycles did not significantly improve OS in the conventional Cox proportional hazards model (hazard ratio 0.849, 95% confidence interval 0.453-1.588, P = 0.608). Restricted cubic spline Cox models for OS confirmed that the effect of the number of cycles was not modified by total average RDI, the International Prognostic Index, and age. Occurrence of adverse events did not differ between six and eight cycles.

Conclusion

Even considering the impact of RDI, six cycles of the initial standard regimen for DLBCL is not inferior to eight cycles.

•

The optimal number of cycles of standard regimens including R-CHOP-21 for newly diagnosed DLBCL has not been determined.

•

This study was conducted to verify whether six cycles or eight cycles of standard regimen improved the prognosis of DLBCL.

•

Propensity score matching and a Cox hazards model with restricted cubic spline were used in this study.

•

No survival benefit of eight cycles compared with six cycles was seen, even taking into account RDI.

•

Prognosis was no better with eight cycles of (R-)CHOP-21 or THP-COP-21 than with six cycles, after age and IPI modifications.

Effect of Mechanical Thrombectomy Without vs With Intravenous Thrombolysis on Functional Outcome Among Patients With Acute Ischemic Stroke: The SKIP Randomized Clinical Trial

IMPORTANCE

Whether intravenous thrombolysis is needed in combination with mechanical thrombectomy in patients with acute large vessel occlusion stroke is unclear.

OBJECTIVE

To examine whether mechanical thrombectomy alone is noninferior to combined intravenous thrombolysis plus mechanical thrombectomy for favorable poststroke outcome.

DESIGN, SETTING, AND PARTICIPANTS

Investigator-initiated, multicenter, randomized, open-label, noninferiority clinical trial in 204 patients with acute ischemic stroke due to large vessel occlusion enrolled at 23 hospital networks in Japan from January 1, 2017, to July 31, 2019, with final follow-up on October 31, 2019.

INTERVENTIONS

Patients were randomly assigned to mechanical thrombectomy alone (n = 101) or combined intravenous thrombolysis (alteplase at a 0.6-mg/kg dose) plus mechanical thrombectomy (n = 103).

MAIN OUTCOMES AND MEASURES

The primary efficacy end point was a favorable outcome defined as a modified Rankin Scale score (range, 0 [no symptoms] to 6 [death]) of 0 to 2 at 90 days, with a noninferiority margin odds ratio of 0.74, assessed using a 1-sided significance threshold of .025 (97.5% CI). There were 7 prespecified secondary efficacy end points, including mortality by day 90. There were 4 prespecified safety end points, including any intracerebral hemorrhage and symptomatic intracerebral hemorrhage within 36 hours.

RESULTS

Among 204 patients (median age, 74 years; 62.7% men; median National Institutes of Health Stroke Scale score, 18), all patients completed the trial. Favorable outcome occurred in 60 patients (59.4%) in the mechanical thrombectomy alone group and 59 patients (57.3%) in the combined intravenous thrombolysis plus mechanical thrombectomy group, with no significant between-group difference (difference, 2.1% [1-sided 97.5% CI, -11.4% to ∞]; odds ratio, 1.09 [1-sided 97.5% CI, 0.63 to ∞]; P = .18 for noninferiority). Among the 7 secondary efficacy end points and 4 safety end points, 10 were not significantly different, including mortality at 90 days (8 [7.9%] vs 9 [8.7%]; difference, -0.8% [95% CI, -9.5% to 7.8%]; odds ratio, 0.90 [95% CI, 0.33 to 2.43]; P > .99). Any intracerebral hemorrhage was observed less frequently in the mechanical thrombectomy alone group than in the combined group (34 [33.7%] vs 52 [50.5%]; difference, -16.8% [95% CI, -32.1% to -1.6%]; odds ratio, 0.50 [95% CI, 0.28 to 0.88]; P = .02). Symptomatic intracerebral hemorrhage was not significantly different between groups (6 [5.9%] vs 8 [7.7%]; difference, -1.8% [95% CI, -9.7% to 6.1%]; odds ratio, 0.75 [95% CI, 0.25 to 2.24]; P = .78).

CONCLUSIONS AND RELEVANCE

Among patients with acute large vessel occlusion stroke, mechanical thrombectomy alone, compared with combined intravenous thrombolysis plus mechanical thrombectomy, failed to demonstrate noninferiority regarding favorable functional outcome. However, the wide confidence intervals around the effect estimate also did not allow a conclusion of inferiority.

TRIAL REGISTRATION

umin.ac.jp/ctr Identifier: UMIN000021488.

Outcomes of Balloon Angioplasty and Stenting for Symptomatic Intracranial Atherosclerotic Stenosis at a High Volume Center

PURPOSE

This study investigated the periprocedural complication rates, long-term outcome, and restenosis of endovascular treatment for intracranial atherosclerotic stenosis (ICS) at our hospital.

METHODS

We retrospectively analyzed the clinical data of 217 patients comprising 256 endovascular treatments for high-grade symptomatic ICS. The lesion was located in the internal carotid artery in 77, the middle cerebral artery in 111, the basilar artery in 29, and the vertebral artery in 39. Patients were divided into two groups, before (early-phase group, 1999-2013) and after approval of Wingspan (late-phase group, 2014-2017).

RESULTS

In the early-phase group (n = 163), 157 lesions were treated by balloon angioplasty and 31 (17%) by coronary stenting. In the late-phase group (n = 54), 33 lesions were treated by balloon angioplasty and 35 (52%) by Wingspan stenting. Overall technical success rates were 96% in the balloon angioplasty and 100% in stenting groups. The 30-day rate of stroke, TIA, and death were 4.8% in the early-phase group and 4.4% in the late-phase group. There was one minor stroke and two TIAs during the follow-up period in the late-phase group.

CONCLUSIONS

Endovascular treatment for symptomatic ICS in this study appeared to be safe and effective if patients are properly selected. However, future well-designed randomized trials with different techniques and modified patients selection criteria are certainly warranted.

A Case of Acute Ischemic Stroke Treated with Endovascular Treatment for Tandem Occlusion of the Common Carotid Artery and Internal Carotid Artery Terminal Portion Related to Takayasu Arteritis

Objective

This report presents a case of mechanical thrombectomy for left internal carotid artery (ICA) terminal portion occlusion performed by left common carotid artery recanalization during hospitalization after diagnosing bilateral common carotid artery occlusion due to Takayasu arteritis.

Case Presentation

A 25-year-old woman with fever and cervix pain a few months ago visited our department after repeated transient aphasic attacks. Magnetic resonance imaging (MRI) demonstrated diffuse infarction in the left middle cerebral artery (MCA) area, and she was diagnosed with Takayasu arteritis due to bilateral common carotid artery occlusion and left subclavian artery stenosis. On the 20th day of hospitalization, the terminal portion of the left ICA was occluded and thrombectomy was performed after balloon dilation of the left common carotid artery. Lastly, left common carotid artery stenting was performed. Aphasia and sensory disturbance remained, but she was transferred to a rehabilitation hospital with a modified Rankin Scale (mRS) of 2 on the 65th day of hospitalization. Antithrombotic and immunosuppressive therapy were performed, and restenosis did not develop.

Conclusion

Angioplasty and stenting of common carotid artery occlusion can be effective treatments in thrombectomy for intracranial occlusion due to Takayasu disease.

Right ventricular longitudinal strain with CMR can more accurately estimate right ventricular functional reserve in rats with pulmonary arterial hypertension

Background

Right ventricular (RV) function is an important prognostic factor in patients with pulmonary arterial hypertension (PAH). Recently, CMR has become an attractive modality for follow up and providing prognosis in the patients, and strain has been used as a newer parameter to assess contractile properties of ventricle. It has not yet been established, however, whether RV strain with CMR can estimate RV functional reserve in the patients with PAH.

Purpose

We focused on CMR imaging of RV, investigating whether RV longitudinal strain can estimate RV functional reserve using a rat model with PAH.

Method

Rats were given a subcutaneous injection of 60 mg/kg monocrotaline (MCT-rats) or solvent (Ctr-rats). Four weeks after the injection, 25% of MCT-rats died due to RV failure. In the survivors of MCT- (n=19) and Ctr-rats (n=5), retrospective ECG-gated cine MR (16 phases/beat) was imaged with a 7T scanner. Subsequently, we measured RV pressure (RVP) via right internal jugular vein and dissected trabeculae (length = 1.45±0.07 mm, width = 334±27 μm, thickness = 114±6 μm) from RVs. We calculated weight ratio of RV free wall to left ventricle (LV) by RV/(LV+septum). Trabeculae were electrically stimulated with 2-s stimulus intervals, and force was measured using a silicon strain gauge (0.7 mM extracellular Ca2+, 24°C). To determine contractile properties of RV muscle, dF/dt was calculated. Using CMR imaging, we measured RV ejection fraction (RVEF) and RV longitudinal strain (RVLS). To modulate RVP, we intravenously injected 5 nmol endothelin-1 (ET-1) and again measured RVEF and RVLS.

Results

MCT-rats showed higher systolic RVP (62.5±16.6 vs. 25.9±1.86 mmHg, p&lt;0.01) and higher weight ratio of RV (0.60±0.03 vs. 0.28±0.02, p&lt;0.05). In CMR imaging, MCT-rats showed lower RVEF (36.1±11.2 vs. 64.8±8.4%, p&lt;0.001) and lower RVLS (−18±9 vs. −30±1%, p&lt;0.05). In trabeculae from RVs, MCT-rats showed lower developed force and lower dF/dt (p&lt;0.01). Correlation between RVLS and dF/dt was higher (n=20, r=0.53, p&lt;0.05) than that between RVEF and dF/dt (r=0.24). In addition, RVLS and dF/dt had already been decreased in 5 MCT-rats with relatively preserved RVEF (&gt;50%), suggesting that RVLS decreases earlier than RVEF in MCT-rats. Ten minutes after the injection of ET-1, RVP was increased from 49.4±7.9 to 57.9±6.4 mmHg in MCT-rats (n=6). In MCT-rats with preserved RVEF and decreased RVLS, the increase in RVP chiefly decreased RVEF while it did not change RVLS and RVEF in Ctr-rats, meaning that RV functional reserve had been decreased in MCT-rats. In trabeculae, developed force and dF/dt were increased after the addition of 0.1 μM ET-1 in MCT- (n=11, p&lt;0.01) and Ctr-rats (n=4, p&lt;0.01).

Conclusion

These results suggest that in rats with PAH, RVLS obtained from CMR can estimate RV functional reserve earlier and more accurately than RVEF. Therefore, RV strain with CMR may become an important parameter to assess RV functional reserve in patients with PAH.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Grant-in-Aid for Young Scientists

Preprocedural Carotid Plaque Echolucency as a Predictor of In-Stent Intimal Restenosis after Carotid Artery Stenting

OBJECTIVES

In-stent intimal restenosis (ISR) caused by neointimal hyperplasia can develop <24 months after carotid artery stenting (CAS). The utility of plaque imaging by carotid ultrasonography (US) or magnetic resonance imaging (MRI) has been investigated for the prediction of ipsilateral stroke. We aimed to investigate whether these imaging techniques are useful for detecting carotid plaques prone to ISR.

MATERIALS AND METHODS

We examined 133 patients (mean age of 72.1 ± 8.4 years old) that received CAS at a single hospital from 2014 to 2018. A pre-CAS carotid plaque evaluation was performed by carotid angiography, duplex carotid US, and black-blood carotid artery MRI (BB-MRI). The mean stenosis rate was 71.0 ± 12.3% by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) methods. Follow-up carotid angiography was performed 6 months after CAS in all patients according to a predefined protocol. ISR was defined as in-stent intimal hyperplasia more than 50% stenosed based on the NASCET criteria. The selection of the stent type was at the discretion of the treating physician. Predictors of ISR were determined by multivariate logistic regression analysis.

RESULTS

Follow-up angiography demonstrated ISR in 33 patients (24.8%). In 44 patients, more than two stents were deployed. Univariate logistic regression analyses demonstrated echolucent lesion, floating plaque, complete occlusive or pseudo-occlusive lesion, and closed-cell stent use as significantly associated with ISR (>50%). Multivariate logistic regression analysis demonstrated that echolucent lesion (OR 4.667, 95% CI 1.849-11.779) and closed-cell stent use (OR .378, 95% CI .148-.968) were significantly associated with ISR.

CONCLUSIONS

Preprocedural plaque characterization by carotid US appeared to be useful to predict ISR 6 months after CAS.

Effects of Aspiration and Re-transfusion Technique with Carotid Artery Stenting

Objective

Embolic stroke is the most serious complication after carotid artery stenting (CAS). The incidence rate of embolic stroke is reduced by the use of embolic protection devices (EPDs); however, there is no consensus on which EPD is the most effective. The aspiration and re-transfusion technique (ART) with CAS under distal balloon protection was adopted at our center to reduce the incidence of embolic complications. This retrospective study investigated the effects of ART.

Methods

From November 2010, 243 consecutive patients treated by CAS under distal balloon protection were included. ART was performed on 202 patients (ART group) and the other 40 patients only received distal balloon protection (non-ART group). In ART, the blood from the aspiration catheter was continuously returned through a filter to the femoral vein. The amount of debris was assessed intermittently using a small blood sample and the rest was returned. We investigated the diffusion-weighted imaging (DWI)-positive rate and symptomatic ischemic stroke one day after CAS.

Results

Compared with the non-ART group, the incidence of DWI-positive lesions (22.7% vs 37.5%, P = 0.07) and frequency of symptomatic ischemic stroke (0.9% vs 5.0%, P = 0.12) were reduced in the ART group. The hemoglobin reduction rate was significantly reduced by ART (11.1% vs 14.9%, P <0.01). In the ART group, the frequency of multiple lesions (more than 5) and large lesions (more than 10 mm) was lower than that in the non-ART group (P <0.01, P = 0.14).

Conclusion

CAS under distal balloon protection with ART was effective at reducing the incidence of DWI-positive lesions and may be useful to reduce the incidence of symptomatic ischemic stroke.

Sex Differences in Blood Pressure-Lowering Therapy and Outcomes Following Intracerebral Hemorrhage: Results From ATACH-2

BACKGROUND AND PURPOSE

Evidence regarding sex differences in clinical outcomes and treatment effect following intracerebral hemorrhage is limited. Using the ATACH-2 trial (Antihypertensive Treatment in Intracerebral Hemorrhage-2) data, we explored whether sex disparities exist in outcomes and response to intensive blood pressure (BP)-lowering therapy.

METHODS

Eligible intracerebral hemorrhage subjects were randomly assigned to intensive (target systolic BP, 110-139 mm Hg) or standard (140-179 mm Hg) BP-lowering therapy within 4.5 hours after onset. Relative risk of death or disability corresponding to the modified Rankin Scale score of 4 to 6 was calculated, and interaction between sex and treatment was explored.

RESULTS

In total, 380 women and 620 men were included. Women were older, more prescribed antihypertensive drugs before onset, and had more lobar intracerebral hemorrhage than men. Hematoma expansion was observed less in women. After multivariable adjustment, the relative risk of death or disability in women was 1.19 (95% CI, 1.02-1.37, P=0.023). The relative risk of death or disability between intensive versus standard BP-lowering therapy was 0.91 (95% CI, 0.74-1.13) in women versus 1.13 (95% CI, 0.92-1.39) in men (P for interaction=0.11), with inconclusive Gail-Simmon test (P=0.16).

CONCLUSIONS

Women had a higher risk of death or disability following intracerebral hemorrhage. The benefit of intensive BP-lowering therapy in women is inconclusive, consistent with the overall results of ATACH-2. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01176565.

Search for η^{'} Bound Nuclei in the ^{12}C(γ,p) Reaction with Simultaneous Detection of Decay Products

We measured missing mass spectrum of the ^{12}C(γ,p) reaction for the first time in coincidence with potential decay products from η^{'} bound nuclei. We tagged an (η+p) pair associated with the η^{'}N→ηN process in a nucleus. After applying kinematical selections to reduce backgrounds, no signal events were observed in the bound-state region. An upper limit of the signal cross section in the opening angle cosθ_{lab}^{ηp}<-0.9 was obtained to be 2.2  nb/sr at the 90% confidence level. It is compared with theoretical cross sections, whose normalization ambiguity is suppressed by measuring a quasifree η^{'} production rate. Our results indicate a small branching fraction of the η^{'}N→ηN process and/or a shallow η^{'}-nucleus potential.

Thrombolysis With Alteplase at 0.6 mg/kg for Stroke With Unknown Time of Onset: A Randomized Controlled Trial

Supplemental Digital Content is available in the text.

We assessed whether lower-dose alteplase at 0.6 mg/kg is efficacious and safe for acute fluid-attenuated inversion recovery-negative stroke with unknown time of onset.

Abstract WP181: Preprocedual Carotid Plaque Characterization by Duplex Ultrasonography as a Predictor of in-Stent Intimal Restenosis 6 months After Carotid Stenting

Background and Purpose: In-stent intimal restenosis (ISR) caused by neo-intimal hyperplasia generally occurs <24 months after carotid stenting (CAS). Although the real clinical impact of ISR are still unclear, several studies suggested the development of ISR significantly correlated with ipsilateral stroke and death. Also differences in the rate of ISR between open-cell and closed-cell stents have yet to be well evaluated. We aimed to investigate predictors of ISR 6 months after CAS.

Methods: We examined 133 patients (mean age of 72.1±8.4 years old) received CAS in a single hospital during 2014 and 2018. Preoperative carotid plaque evaluation was performed by carotid angiography, duplex carotid ultrasonography (CUS), and black-blood carotid artery MRI (BB-MRI). Mean stenosis rate (NASCET) was 71.0±12.3% (44%-100%). Follow-up carotid angiography was performed six months after CAS in all patients according to a predefined protocol. ISR was defined as in-stent intimal hyperplasia more than 50% stenosis based on the NASCET method. Selection of stent type was at the discretion of the treating physician. Predictors of ISR were determined by multivariate logistic regression analysis.

Results: Follow-up angiography demonstrated ISR in 33 patients (24.8%). In 44 patients, more than 2 stents were deployed. Univariate analyses demonstrated hypoechoic plaque, 1 mobile plaque with jerry fish sign, complete occlusive or pseudo occlusive lesion, closed-cell stent are significantly associated with ISR (>50%), however no association was observed in traditional risk factors, MRI plaque characterization, and implantation of multiple stents. Multivariate analysis demonstrated low echoic plaque in preoperative CUS (OR4.67; 95%CI, 1.85-11.78) and closed-cell stent (OR 0.378; 95%CI, 0.15-0.97) as significant predictors of ISR.

Conclusions: Preprocedual plaque characterization by CUS but not MRI appeared to be useful to predict ISR 6 months after CAS even after adjustment of stent type.

Comparison of neurosensory devices in detecting cutaneous thresholds related to protective sensibility: A cross-sectional study in São Paulo, Brazil

AIMS

To quantify the static and moving cutaneous sensibility threshold of diabetic patients using a neurosensory device for quantitative pressure detection.

METHODS

Three hundred thirty-four (n = 334) patients with type 2 diabetes and no previous history of wounds on the feet were studied using the one- and two-point static (1SP;2 SP) and one- and two-point moving (1MP;2 MP) tests through the pressure-specified sensory device (PSSD) on the cutaneous territory of the dorsal first web, hallux pulp, and medial calcaneal. In addition, patients were evaluated using the Semmes-Weinstein monofilament (SWM) No. 5.07 and tuning fork (128 Hz), which were used as normality parameters to detect the loss of protective sensibility. The same examinations were used to assess the control group (228 nondiabetic).

RESULTS

Altered values were observed for the static and moving tests over the three studied nerve territories. In comparing the sensibility threshold between diabetic patients who were sensitive and nonsensitive to SWM 5.07, we observed that this filament is not the most indicated for identifying the loss of sensibility in these patients. The prevalence of patients at risk varied between 85 and 89%. The biochemical marker associated with these high rates was HbA1c (p = 0.02).

CONCLUSIONS

Numeric quantification of the pressure threshold allowed us to determine the functional deficit of nerve fibers. Our findings suggest that the neurosensory device should be used as an adjuvant tool to evaluate the degree of loss of sensation on the skin.

P5626The clinical impact of the angle of OCT detected irregular protrusion after primary PCI at the STEMI culprit lesions

Background and introduction

The percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) shows worse clinical outcomes than that for stable angina. As the one of the reasons, a recent optical coherence tomography (OCT) registry showed that the presence of irregular protrusion (IP)after coronary stenting was the worse predictor of 1-year device-oriented clinical end points. However, the impact of the quantitative findings on IP has not been well investigated in ACS patients.

Aim

To investigate the clinical impact of the post stent OCT findings, especially IP, detected by OCT after coronary stenting in ACS patients.

Methods

Consecutive 256 ACS lesions treated with OCT-guided PCI in our Medical University Hospital from January 2013 to November 2016 was retrospectively analyzed. In 256 lesions, 173 lesions were enrolled which had ST-elevation acute myocardial infarction (STEMI) with the onset to recanalization time within 720 minutes. In 170 lesions, the OCT images were available. In OCT image, IP was detected in 140 lesions (82.3%). Quantitative analysis of IP in post-procedure OCT imaging was observed to identify the OCT predictors for clinical endpoint including cardiac death, target vessel revascularization ant stent thrombosis in 1 year after index PCI.

Result

In post-procedure OCT findings, stent edge dissection was detected in 32.4% of lesions. Incomplete stent apposition was detected in 74.1%. Maximum angle of irregular protrusion was 194±86 degree and the incidence of maximum IP angle >180 degree was 52.9%. Maximum height of IP was 0.26±0.11mm. Small minimal stent area, defined as a lesion with minimal stent area <5.0 mm2 in a drug-eluting stent or <5.6 mm2 in a bare metal stent, was observed in 32.4% of lesions. Maximum IP angle and that of >180degree was significantly associated with the clinical endpoint (p=0.0259 and 0.0429, respectively).

Conclusion

In STEMI patients, IP was frequently observed in post-procedure OCT imaging during primary PCI. The maximum angle of IP was significantly associated with the clinical end points. The prognostic impact of maximum IP angle in STEMI patient needs further investigations.

P3579Clinical characteristics of an intracoronary erosion and thrombus in patients with vasospastic angina

Background

Intracoronary erosion and thrombus are sometimes detected in patients with vasospastic angina (VSA) through intracoronary imaging modalities. However, the clinical characteristics of these intracoronary findings remain unclear. Therefore, we assessed the clinical and lesion characteristics of these intracoronary abnormalities in patients with VSA.

Methods

We included 48 patients with VSA who underwent coronary angiography (CAG), spasm provocation test (SPT), and coronary angioscopy (CAS). In all patients, acetylcholine was infused in the left and right coronary arteries. The vessels were classified into spastic vessels (SVs) and non-spastic vessels (NSVs) based on SPT results. SVs that could not be observed using CAS were excluded from the study. CAG and SPT findings were evaluated for the presence of atherosclerotic lesions (%stenosis <30%) and types of spasm (segmental or diffuse). Two experts examined the presence of an intracoronary erosion and thrombus on CAS. Other serious symptoms such as cold sweating or syncope were also assessed.

Results

Among the 48 patients, intracoronary erosion and thrombus were detected in 11 (23%) and 10 (21%) patients, respectively, and total intracoronary abnormalities were observed in 17 (35%) patients. Male sex (p<0.05), smoking (p<0.05), and presence of other serious symptoms (p<0.01) were associated with the presence of intracoronary abnormalities. The logistic regression analysis showed the presence of other serious symptoms to be the only factor associated with the presence of intracoronary abnormalities (p<0.05). In the lesion analyses, among the 72 vessels, intracoronary abnormalities were observed only in SVs (17/53, 33%) but not in NSVs (0/19, 0%, p<0.01). Among the 53 SVs, the presence of atherosclerotic lesions (p<0.05) and segmental spasm type (p<0.05) were found to be associated with the presence of intracoronary abnormalities.

Conclusions

Intracoronary erosion and thrombus were observed in approximately 35% of patients with VSA. Such intracoronary abnormalities may be partly affected by the forms of the coronary artery and coronary spasm, leading to the onset of serious symptoms of VSA.

Contrast-enhanced carotid ultrasonography and MRI plaque imaging to identify patients developing in-stent intimal hyperplasia after carotid artery stenting

AIM

In-stent intimal hyperplasia (ISH) observed after carotid artery stenting (CAS) may lead to in-stent restenosis. We aimed to investigate whether contrast-enhanced carotid ultrasonography (CEUS) and magnetic resonance imaging (MRI) plaque imaging prior to CAS are predictive for ISH at 6 months after CAS.

MATERIAL AND METHOD

A total of 14 patients (13 men, 1 woman; mean age, 74.2 years) were prospectively enrolled. CEUS and MRI plaque imaging were performed before CAS. ISH was diagnosed by carotid angiography at 6 months after CAS. Patients were divided into two groups based on the thicknessof ISH and age, risk factors, enhancement in CEUS, MRI plaque imaging and number of replaced stents were compared between groups.

RESULTS

Carotid angiography at 6 months after CAS revealed ISH in 10 patients. Plaque enhancement on CEUS was observed in 6 patients, all of whom showed ISH. A significant association was seen between plaque enhancement on CEUS and development of ISH (χ2 test, CEUS enhancement (+) 100% vs. CEUS enhancement (-) 50% p=0.040). Carotid plaques in 12 patients were diagnosed as unstable by MRI plaque imaging. Presence of ISH was significantly associated with unstable plaque diagnosed by MRI plaque imaging (χ2 test, unstable 83% vs. stable 0%; p=0.016).

CONCLUSION

Carotid plaque MRI and CEUS may be useful to predict ISH after CAS.

The randomized study of endovascular therapy with versus without intravenous tissue plasminogen activator in acute stroke with ICA and M1 occlusion (SKIP study)

Rationale

Bridging therapy with endovascular therapy (EVT) and intravenous thrombolysis (IVT) has been reported to improve outcomes for acute stroke patients with large-vessel occlusion in the anterior circulation. While the IVT may increase the reperfusion rate, the risk of hemorrhagic complications increases. Whether EVT without IVT (direct EVT) is equally effective as bridging therapy in acute stroke remains unclear.

Aim

This randomized study of endovascular therapy with versus without intravenous tissue plasminogen activator for acute stroke with ICA and M1 occlusion aims to clarify the efficacy and safety of direct EVT compared with bridging therapy.

Methods and design

This is an investigator-initiated, multicenter, prospective, randomized, open-treatment, blinded-endpoint clinical trial. The target patient number is 200, comprising 100 patients receiving direct EVT and 100 receiving bridging therapy.

Study outcome

The primary efficacy endpoint is a modified Rankin Scale score of 0–2 at 90 days. Safety outcome measures are any intracranial hemorrhage at 24 h.

Discussion

This trial may help determine whether direct EVT should be recommended as a routine clinical strategy for ischemic stroke patients within 4.5 h from onset. Direct EVT would then become the choice of therapy in stroke centers with endovascular facilities.

Trial registration

UMIN000021488.

Characterization of nucleolar localization and exclusion signals in terminal deoxynucleotidyltransferase interacting factor 2/estrogen receptor α-binding protein

Terminal deoxynucleotidyltransferase interacting factor 2/estrogen receptor α-binding protein (TdIF2/ERBP) is a multifunctional nucleolar protein. The nucleolar localization of TdIF2/ERBP is important for its functions because it promotes ribosomal RNA transcription. However, signal sequences that direct TdIF2/ERBP to the nucleolus are not well characterized. We examined the TdIF2/ERBP sequence using truncation and mutation analyses to determine whether the nucleosome binding and C-terminal domains of TdIF2/ERBP possess nucleolar localization signals (NoLSs). In these domains, four NoLSs that could direct the mCherry protein to the nucleolus were detected. In addition, a short stretch of hydrophobic residues (VLLVL) in the center of TdIF2/ERBP acted as a nucleolar exclusion signal, which reduced the nucleolar accumulation of mCherry-NoLS fusion proteins. These results would contribute to improving the prediction of NoLSs from protein sequences. The short, transferrable localization signals would be valuable tools for understanding the association between localization and functions of nucleolar proteins. Abbreviations TdIF2: terminal deoxynucleotidyltransferase interacting factor 2; ERBP: estrogen receptor α-binding protein; EGFP: enhanced green fluorescent protein; NLS: nuclear localization signal; NoLS: nucleolar localization signal; NoES: nucleolar exclusion signal; DAPI: 4',6-diamidino-2-phenylindole.

Abstract WP177: Long-Term Outcome of Balloon Angioplasty and Stenting for Symptomatic Intracranial Atherosclerotic Stenosis: Comparison Between Pre- and Post-Approval of Wingspan Stent

Purpose: Intracranial atherosclerotic stenosis (ICS) is an important cause of ischemic stroke, particularly in the Asian population. Endovascular treatment, such as balloon angioplasty with and without stenting have emerged as therapeutic options for symptomatic (ICS) since the 1990s and the Wingspan stent was approved at 2014 in Japan. This study was to investigate the periprocedural complication rates, long-term outcome and restenosis of endovascular treatment for ICS in our hospital.

Methods: We retrospectively analyzed the clinical data of 223 patients with 265 endovascular treatments for high-grade (more than 70%) symptomatic ICS between 1999 and 2017. The lesion was located in in the internal carotid artery in 79, the middle cerebral artery in 113, the basilar artery in 29 and the vertebral artery in 42. Patients were classified into two groups, before (A group, between 1999 and 2013) and after approval of Wingspan (B group, between 2014 and 2017). We selected mainly balloon angioplasty without stenting in the primary treatment. Perioperative and long-term outcomes such as restenosis and the recurrence of strokes were assessed.

Results: In A group (n=163, aged 63.5±10.2 years), 157 lesions were treated with balloon angioplasty and 31 (16.5%) with coronary stent. In B group (n=60, aged 66.4±13.3 years), 39 lesions were treated with balloon angioplasty and 38 (49%) with Wingspan stent. Overall technical success rates were 96% in balloon angioplasty and 100% in stenting groups. The 30-day rate of stroke, TIA and death were 4.3% in A group and 3.9 % in B group. In B group, there was one patient who had subacute in-stent thrombosis with major stroke and 2 minor strokes. There were no stroke and vascular events during follow-up periods in B group. Eight patients (13%) in B group had restenosis after the procedure and 7 patients were retreated.

Conclusions: This study demonstrates the safety and efficacy of balloon angioplasty with and without stenting for symptomatic intracranial atherosclerotic stenosis if patients are properly selected. We suggest that a more judicious use of intracranial stents may be responsible for better postprocedure outcome.

Abstract WP91: Influence of Patient Age on Appearance and Enlargement of DWI Abnormal Lesion After Successful Recanalization by Mechanical Thrombectomy for Acute Ischemic Stroke

Introduction: We have often experienced that young patients tend to have good outcome even with low DWI ASPECTS after mechanical thrombectomy for acute ischemic stroke. As a cause of this phenomenon, we made hypothesis that the appearance of DWI abnormal lesion was influenced by patient age. In this study we aimed to examine the influences of age on appearance of DWI abnormal lesion, and on its enlargement after successful recanalization by mechanical thrombectomy for large-vessel occlusion.

Methods: This study included 94 acute cardioembolic stroke patients who successful recanalization (TICI2b or 3) was obtained with mechanical thrombectomy for large-vessel occlusion in our hospital from 2010 to 2018. Patients were classified into 3 groups depending on age, under 69 years old (Young group, n=20), 70 to 84 (Intermediate group, n=50), and over 85(Elderly group, n=24). DWI abnormal lesion volume was assessed before and within24hours after treatment for each group.

Results: There was no difference in time from onset to recanalization between three groups. Initial DWI abnormal lesion volume in Young group was larger than that in Elderly group (51.0ml vs 10.8ml P<0.05). A similar tendency was observed regardless of the occluded blood vessel site and MRI imaging time and baseline NIHSS. The proportion of patients with the volume of DWI abnormal lesion enlarged 1.5 times or more in 24 hours after treatment in the elderly group was higher than in young group (45% VS 70.8%). In multivariate analysis, the elderly age and the time to reperfusion were related to expansion of DWI abnormal lesion, and this tendency was remarkable in ICA, MCA occlusion.

Conclusions: Young age was associated with the appearance of larger initial DWI abnormal lesions.And old age was associated with the expansion of DWI abnormal lesions after successful recanalization by mechanical thrombectomy of large vessel occlusion.

Abstract WP26: Factors Related to Acute Brain Swelling After Successful Recanalization With Mechanical Thrombectomy

Background and Purpose: We have experienced acute ischemic stroke patients who had poor outcome due to acute brain swelling after successful recanalization with mechanical thrombectomy. The aim of this study was to investigate factors related to acute brain swelling.

Methods: The study included 89 patients who obtained successful recanalization (TICI 2b or 3) after mechanical thrombectomy for occlusions of the internal carotid artery (ICA) or middle cerebral artery from 2013 to June 2016. We classified by the distance of midline shift on FLAIR image including the lens nucleus and thalamus within 24 hours after treatment into 2 groups; more than 5 mm (Swelling group; the S group, n=16), and less than 5 mm (Non-Swelling; the N group, n=73). We compared demographic data, radiological characteristics, and outcomes between both groups. We also measured flow transit time (FTT) from intracranial artery to cortical vein with the use of automated software (syngo iflow, Siemens Healthcare, Germany).

Results: Regarding mean time of onset-to-reperfusion time, medical history, treatment with IV-rtPA, there were no significant differences between both groups. Increase rate of the brain swelling area before and after treatment on FLAIR image was higher in the S group (20.9%) than in the N group (3.0%). The median FTT of the S group was 7.0 sec (IQR 4.5-7.5), the N group was 6.0 sec (5.2-6.5). The S group included more patients of ICA occlusion (80% vs. 46%, p=0.023), longer FTT (>7.0 sec, 60% vs. 13%, p<0.001), and lower DWI-ASPECTS (median 3 vs. 7, p<0.001). Parenchymal hematoma was equivalent in each group. Modified Rankin Scale score 0-2 at 90 days was significantly lower in the S group (0% vs. 37%, p=0.004). Logistic regression analysis showed FTT of more than 7 seconds was a significant independent predictor [OR 9.77 (2.13-54), p=0.003] of acute brain swelling.

Conclusion: Important factors related to acute brain swelling after successful thrombectomy were ICA occlusion, lower DWI-ASPECTS, and longer FTT. Particularly FTT was a significant independent predictor of acute brain swelling.

Contrast-enhanced transoral carotid ultrasonography for the evaluation of plaque protrusion after carotid artery stenting

A 67 year-old man was admitted to our hospital because of mild left hemiparesis and was diagnosed with cerebral infarction caused by right internal carotid artery stenosis. He was treated with dual antiplatelet therapy and scheduled for carotid artery stenting 14 days after onset. The preoperative right carotid angiogram showed 60% stenosis by the NASCET criteria, with an ulcer. The postoperative angiogram suggested protrusion in the stent, which could not be seen on conventional carotid ultrasonography because of its high location. On transoral carotid ultrasonography, clear delineation of the lesion was not possible due to color blurs. Contrast-enhanced transoral carotid ultrasonography (CETOCU) clearly demonstrated the protrusion and delineated the lumen within the stent.