Intracranial Hemorrhagic Complications Research Articles

Temporal trends in endovascular therapy for acute stroke in the era of modern mechanical thrombectomy: The JR-NET4 study

ObjectivesThis study aimed to examine nationwide trends in acute stroke endovascular thrombectomy (EVT) following five pivotal trials in 2015 that established it as the ‘standard of care’. MethodsThe Japanese Registry of NeuroEndovascular Therapy 4 was a nationwide retrospective study registering consecutive patients who underwent neurointervention by specialists certified by the Japanese Society for Neuroendovascular Therapy at 166 centers from January 2015 to December 2019. We extracted patients who underwent EVT, and analyzed the annual trends in baseline characteristics, revascularization procedures and outcomes. ResultsA total of 13,090 patients (75.3 ± 12.2 years, 5637 women) were included. Analyses revealed an annual increase in patient age and treatments beyond 6 h after onset. However, there was an annual decline in premorbidly independent patients and those with large vessel occlusion. The frequency of stent-aspiration techniques and rate of successful reperfusions significantly increased from 19.9 % to 51.0 % and from 81.4 % to 83.9 %, respectively through the study period. Trends in patients achieving a favorable (modified Rankin Scale score of 0-2 at 30 days) or fatal outcome, or experiencing intracranial hemorrhagic complications remained unchanged. However, calendar time was associated with favorable outcomes after adjusting for clinical and treatment characteristics (odds ratio, 1.040; P = 0.015). ConclusionsDuring the study period, EVT indications expanded for patients with characteristics linked to worse outcomes. However, factors such as advancements in techniques, have led to modest but significant improvements in reperfusion status, leading to maintenance of the post-EVT clinical outcomes. RegistrationURL: https://www.umin.ac.jp/ctr/; Unique identifier: UMIN000038869

Cost-effectiveness analysis of transthoracic echocardiographic assessment in patients with ischemic stroke or TIA of undetermined cause

BackgroundThe multicenter ATTEST study recently assessed 1084 patients with ischemic stroke or transient ischemic attack (TIA) of undetermined cause and found that routine transthoracic echocardiography (TTE) detects abnormalities with treatment implications (i.e., major cardiac sources of embolism) in only 1 % of patients, of whom most (91 %) also had major electrocardiographic (ECG)-abnormalities. In this study, we performed a cost-effectiveness analysis of different TTE strategies. MethodsWe compared the cost-effectiveness of three strategies of TTE assessment: (1) TTE in all patients; (2) TTE only in patients with major ECG-abnormalities; and (3) TTE not performed. Input data were derived from ATTEST and systematic literature reviews. A Markov model was developed that simulated recurrent ischemic stroke or TIA and intracranial and gastro-intestinal bleeding complications in patients with ischemic stroke or TIA of undetermined cause. Primary outcome was the additional costs per additional quality-adjusted life-year (QALY) from a Dutch societal perspective. ResultsPerforming TTE only in patients with major ECG-abnormalities led to 0.0083 additional QALYs and €108 additional costs per patient as compared with not performing TTE (€12,987/QALY). Performing TTE in all patients resulted in 0.0005 additional QALYs and €422 additional costs per patient as compared with performing TTE only in case of major ECG-abnormalities (€805,336/QALY). ConclusionsIn patients with ischemic stroke or TIA of undetermined cause, a strategy of performing TTE only in patients who also had major ECG-abnormalities resulted in the most favorable ratio of additional costs per additional QALY. This supports performing TTE only in patients, who also have major ECG-abnormalities.

Iatrogenic arterial vasospasm during mechanical thrombectomy requiring treatment with intra-arterial nimodipine might be associated with worse outcomes.

Vasospasm is a common iatrogenic event during mechanical thrombectomy (MT). In such circumstances, intra-arterial nimodipine administration is occasionally considered. However, its use in the treatment of iatrogenic vasospasm during MT has been poorly studied. We investigated the impact of iatrogenic vasospasm treated with intra-arterial nimodipine on outcomes after MT for large vessel occlusion stroke. We conducted a retrospective analysis of the multicenter observational registry Endovascular Treatment in Ischemic Stroke (ETIS). Consecutive patients treated with MT between January 2015 and December 2022 were included. Patients treated with medical treatment alone, without MT, were excluded. We also excluded patients who received another insitu vasodilator molecule during the procedure. Outcomes were compared according to the occurrence of cervical and/or intracranial arterial vasospasm requiring intraoperative use of insitu nimodipine based on operator's decision, using a propensity score approach. The primary outcome was a modified Rankin Scale (mRS) score of 0-2 at 90 days. Secondary outcomes included excellent outcome (mRS score 0-1), final recanalization, mortality, intracranial hemorrhage and procedural complications. Secondary analyses were performed according to the vasospasm location (intracranial or cervical). Among 13,678 patients in the registry during the study period, 434 received intra-arterial nimodipine for the treatment of MT-related vasospasm. In the main analysis, comparable odds of favorable outcome were observed, whereas excellent outcome was significantly less frequent in the group with vasospasm requiring nimodipine (adjusted odds ratio [aOR] 0.78, 95% confidence interval [CI] 0.63-0.97). Perfect recanalization, defined as a final modified Thrombolysis In Cerebral Infarction score of 3 (aOR 0.63, 95% CI 0.42-0.93), was also rarer in the vasospasm group. Intracranial vasospasm treated with nimodipine was significantly associated with worse clinical outcome (aOR 0.64, 95% CI 0.45-0.92), in contrast to the cervical location (aOR 1.37, 95% CI 0.54-3.08). Arterial vasospasm occurring during the MT procedure and requiring intra-arterial nimodipine administration was associated with worse outcomes, especially in case of intracranial vasospasm. Although this study cannot formally differentiate whether the negative consequences were due to the vasospasm itself, or nimodipine administration or both, there might be an important signal toward a substantial clinical impact of iatrogenic vasospasm during MT.

Transplacental delivery of factor IX Fc-fusion protein ameliorates bleeding phenotype of newborn hemophilia B mice

Hemophilia B is an inherited hemorrhagic disorder characterized by a deficiency of blood coagulation factor IX (FIX) that results in abnormal blood coagulation. The blood coagulation is already evident in hemophiliacs at the fetal stage, and thus intracranial hemorrhage and other bleeding complications can occur at birth, leading to sequelae. Therefore, it is important to develop effective treatments for hemophiliacs in utero. In this study, in order to transplacentally deliver FIX from pregnant mice to their fetuses, an improved adenovirus (Ad) vector expressing human FIX fused with the IgG Fc domain (FIX Fc fusion protein), which plays a crucial role in neonatal Fc receptor (FcRn)-mediated transcytosis across the placenta, was intravenously administered to E13.5 pregnant mice. Significant levels of FIX Fc fusion protein were detected in 0-day-old newborn mice whose mothers were administered an Ad vector expressing FIX Fc fusion protein. Wild-type FIX overexpressed in the pregnant mice was not delivered to the fetuses. Plasma FIX levels in the newborn mice were relatively well correlated with those in their mothers, although transplacental delivery efficiencies of FIX Fc fusion protein were slightly reduced when the FIX Fc fusion protein was highly expressed in the mother mice. Plasma FIX levels in the newborn mice were about 3.6–6.4% of those in their mothers, Transplacental delivery of FIX Fc fusion protein to their fetuses successfully improved the blood clotting ability in the newborn mice.

Ischemic stroke in cancer patients: possibilities of reperfusion therapy in elderly patients

Globally, stroke and malignancies represent a major public health burden. Cancer and stroke are two clinical manifestations that are related: cancer patients have twice the risk of stroke than the general population [1]. Types of cancer most commonly associated with ischemic stroke are lung cancer, pancreatic cancer, breast cancer and prostate cancer [2]. An analysis of patients with ischemic stroke and concomitant cancer who underwent inpatient treatment at the regional vascular center in Botkin Hospital. A total of 199 patients with ischemic stroke and malignancy were analyzed. 68 patients received reperfusion therapy and 131 patients did not receive reperfusion therapy. As a result of the analysis, it was concluded that reperfusion therapy is possible and necessary for patients with malignant tumors. The risk of developing extracranial hemorrhages associated with the oncological process is extremely low, and the development of intracranial hemorrhagic complications does not significantly worsen the outcome of the disease. The severity of stroke in the presence of cancer was for the most part due to the stroke itself, its size and location, and depended less on the stage of cancer.

Optimizing thrombectomy in medium vessel occlusion: Focus on vessel diameter.

Mechanical thrombectomy for medium vessel occlusion (MeVO) is a challenging field with limited results. In this study, we aimed at evaluating the efficacy and safety of a procedural strategy beginning with occluded vessel diameter measurement and matched aspiration catheter selection. We retrospectively analyzed all sequentially treated patients by mechanical thrombectomy at two comprehensive stroke centers between May 2020 and April 2023, focusing on the occluded vessel diameter. We included patients who underwent thrombectomy for MeVO based on the matching strategy (a procedural approach involving vessel diameter assessment, matching aspiration catheter selection, and firm clot engagement with or without a stent retriever). We evaluated efficacy and safety using the modified Thrombolysis in the Cerebral Infarction Scale (mTICI) and intracranial hemorrhage (ICH) and procedure-related complications. Seventy patients fulfilled the final inclusion criteria. The median occluded vessel diameter was 1.71 mm. We achieved mTICI 2b/2c/3 in 82.9% and mTICI 2c/3 in 51.4% of the cases and did not observe any symptomatic ICH. We detected asymptomatic subarachnoid hemorrhage (SAH) in 24.3% of the cases, that is, 5.6%, 20.0%, and 45.5% in the vessel diameter groups ≥2.0, 1.5-2.0, and ≤1.5 mm, respectively. The SAH incidence was significantly higher in narrower vessel groups. The occluded vessel diameter and the contact method with clots predicted clinical outcomes. Matching strategy-based thrombectomy yields acceptable efficiency and safety results. In narrower vessels, it is optimal to engage matched aspiration catheters and clots without the assistance of conventional stent retrievers.

Neurological Outcomes Following Craniotomy for Extracorporeal Membrane Oxygenation-Associated Intracranial Hemorrhage: Case Series and Literature Review

BackgroundIntracranial hemorrhage (ICH) is a potential complication associated with extracorporeal membrane oxygenation (ECMO), which has been increasingly utilized in recent years. A paucity of data exists describing patient outcomes following invasive neurosurgical interventions in patients receiving ECMO therapy. The purpose of this study was to assess the clinical and functional outcomes in patients who underwent cranial neurosurgery for the management of an ECMO-associated intracranial complication. MethodsThis was a single-institution retrospective review of adult patients who underwent craniotomy or craniectomy after sustaining an intracranial hemorrhagic complication of ECMO therapy from 2008-2023. Anticoagulation status, operative indication, surgical details, post-operative course, and functional outcome were recorded. A systematic review of the prior literature was performed to contextualize our institutional results within previous reports. ResultsFour adult patients were identified at our institution who underwent craniotomy or craniectomy for the neurosurgical management of an ECMO-associated ICH. One patient (25%) ultimately made a satisfactory recovery (mRS 3 at one year). The surviving patient had a notably higher GCS (7T vs 3T), had not received anticoagulation at the time of surgery, and did not experience post-operative re-accumulation or expansion of their hemorrhage, distinguishing factors from the other three included. Review of the existing literature identified 15 adult patients who underwent craniotomy while receiving ECMO therapy, of which four (26.7%) had a long-term favorable neurologic outcome. ConclusionsThe overall prognosis following neurosurgical intervention for the management of ECMO-associated intracranial complications was poor in our case series, which was corroborated by our literature review.

MCA Parallel Anatomic Scanning MR Imaging-Guided Recanalization of a Chronic Occluded MCA by Endovascular Treatment.

Basi-parallel anatomic scanning has been widely used for assessing the vascular morphology of vertebral basilar arteries. Previous studies have demonstrated its efficacy in evaluating the morphology of the MCA, which we refer to as MCA parallel anatomic scanning MR imaging (MCPAS). In this study, we present our experience with the application of MCPAS in patients with MCA occlusion. Endovascular treatment was performed on the patients with intact MCA morphology visible in on MCPAS, with no intracranial hemorrhage, occlusion, or other complications observed. No severe stenosis or re-occlusion was observed at the 12-month postoperative follow-up. In conclusion, MCPAS is an effective method for assessing the outer contour of an occlusive MCA. Endovascular treatment can be considered a safe and efficient option for patients who show a favorable MCA through MCPAS assessment.

'X' marks the spot! Utilising factor Xa inhibitors to optimise thromboprophylaxis in multiple myeloma.

Venous thromboembolism (VTE) remains a significant cause of morbidity and mortality among multiple myeloma patients. Chang and colleagues' findings indicate that factor Xa inhibitors are as effective as warfarin in preventing VTE without raising the risk of gastrointestinal or intracranial bleeding complications. Commentary on: Chang etal. The comparative efficacy and safety of factor Xa inhibitors and warfarin for primary thromboprophylaxis in multiple myeloma patients undergoing immunomodulatory therapy. Br J Haematol 2024;205:473-477.

Endovascular treatment to improve outcomes for medium vessel occlusions: The ESCAPE-MeVO trial.

Clinical outcomes in acute ischemic stroke due to medium vessel occlusion (MeVO) are often poor when treated with best medical management. Data from non-randomized studies suggest that endovascular treatment (EVT) may improve outcomes in MeVO stroke, but randomized data on potential benefits and risks are hitherto lacking. Thus, there is insufficient evidence to guide EVT decision-making in MeVO stroke. The primary aim of the ESCAPE-MeVO trial is to demonstrate that acute, rapid EVT in patients with acute ischemic stroke due to MeVO results in better clinical outcomes compared to best medical management. Secondary outcomes are to demonstrate the safety of EVT, its impact on self-reported health-related quality of life, and cost-effectiveness. Based on previously published data, we estimate a sample size of 500 subjects to achieve a power of 85% with a two-sided alpha of 0.05. To account for potential loss to follow-up, 530 subjects will be recruited. ESCAPE-MeVO is a multicenter, prospective, randomized, open-label study with blinded endpoint evaluation (PROBE design), clinicaltrials.gov: NCT05151172. Subjects with acute ischemic stroke due to MeVO meeting the trial eligibility criteria will be allocated in a 1:1 ratio to best medical care plus EVT versus best medical care only. Patients will be screened only at comprehensive stroke centers to determine if they are eligible for the trial, regardless of whether they were previously treated at a primary care center. Key eligibility criteria are (1) acute ischemic stroke due to MeVO that is clinically and technically eligible for EVT, (2) last-known well within the last 12 h, (3) National Institutes of Health Stroke Scale > 5 or 3-5 with disabling deficit, (4) high likelihood of salvageable tissue on non-invasive neuroimaging. The primary outcome is the modified Rankin scale 90 days after randomization (shift analysis), whereby modified Rankin Score 5 and 6 will be collapsed into one category. Secondary outcomes include dichotomizations of the modified Rankin Score at 90 days, 24 h National Institutes of Health Stroke Score, difference between 24 h and baseline National Institutes of Health Stroke Score, mortality at 90 days, health-related quality of life (EQ-5D-5 L), Lawton scale of instrumental activities of daily living score, reperfusion quality (MeVO expanded Thrombolysis in Cerebral Infarction Score) and infarct volume at 24 h, and cost-effectiveness of endovascular recanalization. Safety outcomes include symptomatic and asymptomatic intracranial hemorrhage and procedural complications. The ESCAPE-MeVO trial will demonstrate the effect of endovascular thrombectomy in addition to best medical management vis-à-vis best medical management in patients with acute ischemic stroke due to MeVO and provide data for evidence-based treatment decision-making in acute MeVO stroke. The raw data discussed in this mansucript will be made available by the corresponding author upon reasonable request.

Efficacy and safety of microvascular decompression with or without partial sensory rhizotomy: a comprehensive meta-analysis and systematic review in treating trigeminal neuralgia.

Classical trigeminal neuralgia (TN), caused by vascular compression of the nerve root, is a severe cause of pain with a considerable impact on a patient's quality of life. While microvascular decompression (MVD) has lower recurrence rates when compared with partial sensory rhizotomy (PSR) alone, refractoriness can still be as high as 47%. We aimed to assess the efficacy and safety profile of MVD + PSR when compared to standalone MVD for TN. We searched Medline, Embase, and Web of Science following PRISMA guidelines. Eligible studies included those with ≥ 4 patients, in English, published between January 1980 and December 2023, comparing MVD vs. MVD + PSR for TN. Endpoints were pain cure, immediate post-operative pain improvement, long-term effectiveness, long-term recurrence, and complications (facial numbness, hearing loss, and intracranial bleeding). We pooled odds ratios (OR) with 95% confidence intervals with a random-effects model. I2 was used to assess heterogeneity, and sensitivity and Baujat analysis were conducted to address high heterogeneity. Eight studies were included, comprising a total of 1,338 patients, of whom 1,011 were treated with MVD and 327 with MVD + PSR. Pain cure analysis revealed a lower likelihood of pain cure in patients treated with MVD when compared to patients treated with MVD + PSR (OR = 0.30, 95% CI: 0.13 to 0.72). Immediate postoperative pain improvement assessment revealed a lower likelihood of improvement in the MVD group when compared with the MVD + PSR group (OR = 0.31, 95% CI: 0.10 to 0.95). Facial numbness assessment revealed a lower likelihood of occurrence in MVD alone when compared to MVD + PSR (OR = 0.08, 95% CI: 0.04 to 0.15). Long-term effectiveness, long-term recurrence, hearing loss, and intracranial bleeding analyses revealed no difference between both approaches. Our meta-analysis identified that MVD + PSR was superior to MVD for pain cure and immediate postoperative pain improvement for treating TN. However, MVD + PSR demonstrated a higher likelihood of facial numbness complications. Furthermore, identified that hearing loss and intracranial bleeding complications appear comparable between the two treatments, and no difference between long-term effectiveness and recurrence.

Cerebral Revascularization: Boom or Doom for Neurosurgeons

Cerebral revascularization which was once commonly used technique became outdated and emerged in a new avatar. Fisher was the first person who promoted that most strokes were not due to vasospasm but due to CA disease. Improvement of various microsurgical methods and techniques are resulting in excellent outcomes. With the advent of modern techniques, cerebral revascularization has taken a back seat. However many diseases like moyamoya disease, complex intracranial aneurysms and skull based tumours, traditional cerebral revascularization methods play a very important role. Although an important method to treat strokes but is also associated with dreaded complication of intracranial haemorrhage. Cerebral collateral circulation channels are restored by cerebral revascularization. Although very commonly used treatment but underwent various modifications, implementations, expanding the horizons of diseases involved. All these innovations in the use of endovascular technique resulted in the decline of cerebral revascularization surgeries. New endovascular surgical approaches lead to shorter recovery times and the patients whose conditions are not indicated for the traditional cerebrovascular approaches can also be managed. One of the major and important drawback of Cerebral Revascularization is the intraoperative thrombosis which can result in severe motor and sensory disturbances. This article aims to weigh the pros and cons of cerebral revascularization.

Defining light transmission aggregometry cutoff values for clopidogrel and aspirin resistance in flow diversion treatment of intracranial aneurysms.

Concern about thromboembolic events after flow diversion (FD) warrants dual antiplatelet therapy for 3 to 6 months. Platelet function tests are routinely performed prior to the procedure to detect clopidogrel responsiveness, as resistance is associated with CYP2C19 gene polymorphisms. This study aimed to identify optimal cutoff values in light transmission aggregometry (LTA) for clopidogrel and aspirin as predictive indicators of thromboembolic complications. The authors conducted a retrospective analysis of aneurysms treated with FD between 2013 and 2023 at a single academic institution. Patients with LTA data for adenosine diphosphate (ADP) and arachidonic acid (ARA) were included, excluding those with aborted procedures. Receiver operating characteristic curves were plotted for ADP and ARA assays to determine optimal cutoff values. A total of 442 patients harboring 552 aneurysms treated in 485 procedures were selected for this analysis. Complete and near-complete aneurysm occlusion on the last radiological follow-up was achieved in 81.8% of aneurysms in a median last imaging follow-up of 13.9 months. A good functional outcome (modified Rankin Scale score ≤ 2) was achieved in 96.3% of patients on the last follow-up. Thromboembolic complications occurred in 4.9% of procedures, and intracranial hemorrhagic complications in 1.9%. For the ADP assay, a value ≥ 40% reached a sensitivity of 82.1% and a specificity of 42.9% with a positive likelihood ratio (LR) of 1.50. For the ARA assay, a value ≥ 13.5% reached a sensitivity of 82.1% and a specificity of 45.6% with a positive LR of 1.51. This study analyzed the largest FD-treated cohort in which optimal LTA platelet function thresholds for clopidogrel were evaluated and is the first to assess LTA values for aspirin. The authors found that values ≥ 40% for clopidogrel and ≥ 13.5% for aspirin were optimal for predicting thromboembolic complications after FD in treating aneurysms.

295 High Volume Centers Provide Superior Value of Care in the Surgical Treatment of Malignant Brain Tumor

INTRODUCTION: Improved outcomes in surgical patients have been associated with increasing volume of cases. This has led to the development of centers that facilitate care for a specific patient population. METHODS: The 2016-2020 National Inpatient Sample (NIS) was queried for patients undergoing resection of malignant brain tumors. Teaching hospitals with high case load (greater than two standrad deviations above the mean, or >140 cases) were categorized as high-volume centers (HVC). Value of care was computed by adding one point for each of the following variables: lower length of stay, lower total charges, discharge to home, and lack of major comorbidity or complication, as defined per DRG codes. RESULTS: A total of 118,390 patients underwent resection of malignant brain tumors in 3,009 hospitals. HVC criteria was met by 91 (3%) hospitals, which represented 20,230 (17.1%) of total cases. The Mid-Atlantic and South Atlantic regions had the highest percentage of cases (22.7% and 20.2%, respectively) and number of HVC (21 and 17, respectively). Value of care was higher at HVC (OR = 1.35 95%CI 1.31-1.39 p < 0.01). After controlling for baseline risk factors and high risk admissions, HVC was associated with decreased complications of intracranial hemorrhage, deep venous thrombosis, aspiration pneumonitis, acute kidney injury, and external ventricular drain requirement (p < 0.01 for all). HVC was also associated with decreased length of stay and increased rate of discharge to home (p < 0.01 for both). CONCLUSIONS: Patients undergoing craniotomy for malignant brain neoplasms have superior outcomes in HVC. Trends of centralization are likely a reflection of the benefits of multidisciplinary treatment for these patients. Improvement of access to care at these institutions may improve the efficiency of the delivery of care for these patients.

The Effect of Out-of-Hours Admission on Mortality in Patients Who Underwent Thrombectomy Due to Ischemic Stroke.

It is important to investigate the factors that may delay the diagnosis and treatment process of ischemic stroke. The aim of this study was to investigate whether in-hospital mortality increased in patients who presented to the emergency department out-of-hours and underwent thrombectomy. A total of 59 patients who applied to the emergency department between January 1, 2018 and November 1, 2021 and underwent thrombectomy due to ischemic stroke were included in the study. Patient age, gender, thrombectomy success (successful recanalization), in-hospital mortality status, intracranial hemorrhage status after thrombectomy, and out-of-hours admission status were recorded and compared according to out-of-hours admission status. Twenty-seven (45.8%) patients were male, and the median age was 74 (61-81) years. Forty-two (71.2%) patients applied to the emergency department out-of-hours. In-hospital mortality occurred in 27 (45.8%) patients. There was no statistically significant difference in out-of-hours admission status between the non-survivor group and the survivor group (non-survivor: 24 [75%]; survivor: 18 [66.7%], p = 0.481). Nor was a statistically significant difference found in the intracranial hemorrhage complication rate of the patients admitted out-of-hours compared to the patients admitted during working hours (out-of-hours: 17 [40.5%]; during working hours: 6 [35.3%], p = 0.712). No statistically significant difference was found in the rate of in-hospital mortality and intracranial bleeding complications in patients who underwent thrombectomy out of working hours compared to during working hours.

Safety and efficacy of acute stent implantation during endovascular treatment for patients with emergent large vessel occlusion due to intracranial atherosclerotic stenosis

Objective: To investigate the efficacy and safety of acute stent implantation during endovascular treatment for patients with emergent large vessel occlusion due to intracranial atherosclerotic stenosis. Methods: A retrospective analysis was carried out on 46 patients with emergent large vessel occlusion due to intracranial atherosclerotic stenosis who received endovascular treatment at the Strategic Support Force Medical Center from January 2015 to August 2022. Twenty-seven patients underwent balloon angioplasty alone and 19 patients underwent acute stent implantation. The baseline characteristics, modified thrombolysis in cerebral infarction (mTICI) score of the responsible vessels, modified Rankin scale (mRS) score 90 days after operation, incidence of symptomatic intracranial hemorrhage and mortality of the two groups were evaluated. Results: The proportion of effective recanalization of the offending vessels (mTICI≥2b) in the acute stenting group was slightly higher than that in the balloon angioplasty group (16/19 vs. 81.5%), but the difference was not statistically significant (P>0.05). Besides, there was no significant difference in the median of mRS between the acute stenting group [3.0(0, 4.0)] and the balloon angioplasty group [4.0(1.0, 5.0)] 90 days after operation (P>0.05). In terms of safety, the incidence of symptomatic intracranial hemorrhage and mortality were comparable between the two groups (P>0.05). Conclusions: The effect of acute stent implantation during endovascular treatment for patients with emergent large vessel occlusion due to intracranial atherosclerotic stenosis is not inferior to that of balloon angioplasty, and it does not increase the risk of intracranial bleeding complications.

Clinical Safety and Efficiency of the H-Port for Treatment of Leptomeningeal Metastasis.

To evaluate the usefulness of a cranial implantable chemoport, the H-port, as an alternative to the Ommaya reservoir for intraventricular chemotherapy/cerebrospinal fluid (CSF) access in patients with leptomeningeal metastasis (LM). One hundred fifty-two consecutive patients with a diagnosis of LM and who underwent H-port installation between 2015 and 2021 were evaluated. Adverse events associated with installation and intraventricular chemotherapy, and the rate of increased intracranial pressure (ICP) control via the port were evaluated for safety and efficacy. These indices were compared with published data of Ommaya (n=89), from our institution. Time-to-install and installation-related complications of intracranial hemorrhage (n=2) and catheter malposition (n=5) were not significantly different between the two groups. Intraventricular chemotherapy-related complications of CSF leakage occurred more frequently in the Ommaya than in the H-port group (13/89 vs. 3/152, respectively, p<0.001). Intracranial hemorrhage during chemotherapy occurred only in the Ommaya group (n=4). The CSF infection rate was not statistically different between groups (14/152 vs. 12/89, respectively). The ICP control rate according to reservoir type revealed a significantly higher ICP control rate with the H-port (40/67), compared with the Ommaya result (12/58, p<0.001). Analyzing the ICP control rate based on the CSF drainage method, continuous extraventricular drainage (implemented only with the H-port), found a significantly higher ICP control rate than with intermittent CSF drainage (33/40 vs. 6/56, respectively, p<0.0001). The H-port for intraventricular chemotherapy in patients with LM was superior for ICP control; it had equal or lower complication rates than the Ommaya reservoir.

Incidence of intracranial hemorrhagic complications after anterior circulation endovascular thrombectomy in relation to occlusion site: a nationwide observational register study

BackgroundIntracranial hemorrhage (ICH) is a potentially severe complication of endovascular thrombectomy (EVT). However, the relationship between the incidence and severity of ICH and vascular occlusion location is not well described.ObjectiveTo...

Symptomatic subdural hemorrhage following heart valve surgery: a retrospective cohort study.

Subdural hemorrhage (SDH) has been reported to be the most frequent intracranial hemorrhagic complication following open heart surgery; however, its clinical features and pathophysiology remain unclear. The aim of this retrospective study was to elucidate the incidence, clinical course, and factors associated with the development of symptomatic SDH following heart valve surgery. A retrospective review of medical records on the development of symptomatic SDH after heart valve surgery involving cardiopulmonary bypass (CPB) from April 2011 to March 2016 was performed. Patients who had undergone preoperative cranial computed tomography (CT) or brain magnetic resonance imaging (MRI) were included in this study, and factors associated with SDH following heart valve surgery were analyzed. When neurological symptoms developed after heart valve surgery, cranial CT or brain MRI was performed. A total of 556 patients who had undergone heart valve surgery were analyzed. Among these patients, symptomatic SDH occurred in 11 (2.0%). The mean duration of symptomatic onset was 10.1 days (range 2-37 days). Ten of 11 patients (90.9%) developed SDH in the posterior fossa or occipital convexity. Logistic regression analysis revealed longer aortic clamp time (95% CI 1.00-1.10, p = 0.04), higher dose of heparin after surgery (95% CI 1.00-1.02, p = 0.001), and higher pulmonary artery pressure (PAP) just before disconnection of the CPB (95% CI 1.01-1.37, p = 0.04) as significantly associated with the development of SDH. The incidence of symptomatic SDH following heart valve surgery was 2.0%. Symptoms due to SDH usually developed a few days to 1 month after surgery. Surprisingly, most SDHs developed in the posterior fossa or occipital convexity following heart valve surgery. A longer aortic clamp time, higher dose of heparin after surgery, and higher PAP just before disconnection of the CPB were related to the development of symptomatic SDH following heart valve surgery.

Prominent Vessel Signs After Endovascular Thrombectomy Corelates with Unexplained Neurological Deterioration and is a More Reliable Imaging Predictor of Prognosis in Anterior Large Vessel Occlusion Stroke

Fifty percent of patients who undergo endovascular thrombectomy (EVT) for large-vessel occlusion exhibit unfavorable outcomes. The primary factor is attributed to persistent brain impairment even after successful EVT. The prominent vessel sign (PVS) on magnetic resonance susceptibility-weighted imaging reflects the territory of dysmetabolism and may facilitate an expeditious assessment for prognostication. We aimed to examine the relationship between PVS after EVT and the occurrence of early neurological deterioration (END) and 3-month outcomes. Patients who underwent EVT and multimodal magnetic resonance imaging were included. END was defined as an increase of ≥2 in the National Institutes of Health Stroke Scale within 72 hours after EVT. Symptomatic intracranial hemorrhage, malignant edema, and surgical complications were defined as definite END, whereas the other symptoms were categorized as unexplained END (ux-END). The PVS-Alberta Stroke Program Early CT Score (ASPECTS) score was used to evaluate the asymmetric cerebral venous signal on the susceptibility-weighted imaging sequences semiquantitatively. A total of 116 eligible patients were included, 18 (15.5%) of whom presented with ux-END. The 72hour National Institutes of Health Stroke Scale was strongly correlated with diffusion-weighted imaging infarct volume and PVS-ASPECTS and was significantly higher in the ux-END group (16 ± 6 vs. 5 ± 4, P= 0.001). The PVS-ASPECTS score was significantly associated with poor outcomes (odds ratio 2.551, 95% confidence interval (CI) 1.722-3.780, P＜0.001), and PVS-ASPECTS (area under the curve 0.884, 95% CI 0.815-0.953, P<0.001) was superior to diffusion-weighted imaging infarct volume (area under the cure 0.720, 95% CI 0.620-0.820, P= 0.001) in predicting 3-month poor outcome. At the optimal cut-off of 2, the PVS-ASPECT predicted poor outcomes with a sensitivity of 89.7% and a specificity of 78.2%. PVS 72 hours after EVT correlated with ux-END. The PVS-ASPECTS is a more reliable predictor of stroke prognosis and provides valuable information regarding post-EVT management.