Proximal Occlusion Research Articles

Comparative analysis of the efficacy and safety of non-immunogenic staphylokinase and alteplase in bridging therapy of ischemic stroke

Introduction. Bridging therapy is the main method of treating ischemic stroke (IS) due to proximal occlusion, the effectiveness of which depends on the speed of its implementation. It is possible to increase the speed of systemic thrombolytic therapy (STT) and reduce the delay before mechanical thrombectomy (MT) by using bolus forms of thrombolytic drugs.Aim. To evaluate the efficacy and safety of using non-immunogenic staphylokinase compared to alteplase in bridging therapy of IS in real clinical practice of a regional stroke center (RSC).Materials and methods. A retrospective study of the combined use of STT and MT for the treatment of IS due to proximal occlusion was conducted from the reperfusion therapy registry of the RSC of the Tomsk Regional Clinical Hospital from 2017 to 2023. The final analysis included 49 patients who received non-immunogenic staphylokinase and 26 patients who received alteplase.Results. The time between the stages of bridging therapy was 92.0 [65.0–130.0] min in the non-immunogenic staphylokinase group and 35.0 [25.0–50.0] min in the alteplase group (p < 0.001). No intergroup differences were found in the incidence of symptomatic hemorrhagic transformation: 8.1% in the non-immunogenic staphylokinase group and 3.8% in the alteplase group (p = 0.476). Mortality in both groups did not differ significantly and was 30.6% and 26.9%, respectively. Favorable functional outcome was observed in 40.8% of patients in the non-immunogenic staphylokinase group and in 23.1% in the alteplase group (p = 0.151).Conclusion. Comparable efficacy and safety of non-immunogenic staphylokinase and alteplase in the context of staged reperfusion therapy were revealed. The use of non-immunogenic staphylokinase is associated with a decrease in the time between the stages of bridging therapy.

Evaluating Lipiodol Efficacy in Proximal Tubal Occlusion Treatment: Single-Center Experience and Literature Review

Evaluating Lipiodol Efficacy in Proximal Tubal Occlusion Treatment: Single-Center Experience and Literature Review

The effect of kaolin on postprocedural radial artery compression - randomized comparison

Abstract Background Mechanical compression is a standard method of postprocedural radial artery hemostasis. We investigated the use of this method and its combination with kaolin impragnated gauze patch as a new method of hemostasis. Methods We randomized 712 consecutive patients (pts) from our same day discharge program (age 66±8 years, 76% males) after coronary angiography (69%) and intervention (31%) from the proximal (PRA) and distal radial (DRA) approaches. Compression was performed by mechanical inflatable device with or without kaolin gauze : 241 versus (vs) 241 patients in proximal groups and 115 vs 115 pts in distal groups were compared. Postprocedural proximal radial artery patency was evaluated by reverse Barbeau test with finger oximetry testing. Time to hemostasis and access site complications were analyzed. Results Baseline characteristics were similar in all four groups - proximal with kaolin (PK+) and without kaolin (PK-), distal with kaolin (DK+) and without kaolin (DK-). Mean compression time was 57±20 min in PK+ vs 83±19 min in PK- groups (p<0.001) and 48±12 min in DK+ vs 63±12 min in DK- groups (p<0.001). In parallel, compression times were shorter in the distal groups compared to the corresponding proximal groups: (DK+ vs PK+; DK- vs PK-; both p<0.001). Postprocedural EASY grade II (<10cm) and III (> 10cm) hematomas occured more often in PRA (4,7% and 0,8%) in comparison with DRA (1,7% and 0%; p=0,03). There were no other local complications including the absence of proximal radial artery occlusion. Conclusions The use of kaolin in combination with mechanical radial artery compression was associated with shorter compression time in both PRA and DRA compared to mechanical compression alone. DRA was associated with an overall lower incidence of hematomas and also shorter compression time compared to the same PRA groups. No proximal radial artery occlusion was detected in our analysis.

Impact of the thin-walled sheath on the distal radial artery occlusion: a randomized trial

Abstract Background Distal transradial access (dTRA) has been increasingly accepted as an alternative to the transradial access (TRA) for coronary angiography (CAG) and/or percutaneous coronary intervention (PCI). Although the dTRA has been significantly associated with better patient comfort, shorter haemostasis time, and fewer vascular access-related complications, such as haematoma and proximal radial artery occlusion (pRAO), it has also been associated with an increased risk of distal radial artery occlusion (dRAO). Purpose The aim of the present study was to investigate whether the 6-Fr thin-walled sheath was superior to the conventional radial sheath with respect to the incidence of distal radial artery occlusion (dRAO) at 24 h after CAG and/or PCI via dTRA. Methods A prospective, single-centre trial of patients who were randomized to undergo CAG and/or PCI with either a 6-Fr thin-walled sheath or a 6-Fr conventional sheath. The primary endpoint was the incidence of dRAO at 24 h postoperatively, as evaluated by Doppler ultrasound. The second endpoints included the puncture success rate, puncture time, the incidence of pRAO, pain during the sheath placement, and other vascular-associated complications. Results A total of 620 patients were included in the study. The mean age of the patients was 66.6± 9.7 years (median age 69.0 years [interquartile range 60.0- 74.0 years]), and 66.3% were men. The baseline patient and procedural characteristics were similar between the two groups. For the primary endpoint, the incidence of dRAO at 24 h after the procedure was 1.0% (3/314) in the thin-walled sheath group and 3.6% (11/306) in the conventional sheath group (RR= 0.266, 95%CI= 0.075-0.943, P= 0.027) according to the intention-to-treat (ITT) analysis. For secondary endpoints, the incidence of pRAO was 0.3% (1/314) in the thin-walled sheath group and 2.3% (7/306) in the conventional sheath group (P= 0.029). No significant difference was observed between the thin-walled sheath and the conventional sheath groups regarding the puncture success rate (92.4% vs. 92.5%, P= 0.952). The severity of pain experienced during the sheath placement was similar between the two groups (VAS 2 vs. 2 P=0.426). Other secondary endpoints, including procedural outcomes and other puncture-related outcomes and access-related complications, were not significantly different between the two groups. Conclusion A thin-walled sheath can reduce the incidence of early-term dRAO in patients who underwent CAG and/or PCI via the dTRA.The primary endpoint of the trial

Assessment of coronary microvascular function with absolute coronary fl ow measurements

Abstract Background Reliable assessment of microvascular function is essential, both in research setting and clinical practice. New techniques, such as continuous coronary thermodilution, are very promising and could revolutionize the field. However, there is a need for proper validation before widespread use is possible. Purpose The goals of this study were: 1. to validate the potential of saline infusion to generate maximum hyperemia in vivo. 2. to validate absolute blood flow (ABF) measured with continuous coronary thermodilution at higher (40-50 ml/min) infusion speeds 3. To assess the safety of higher infusion speeds. Methods Fourteen closed-chest sheep underwent ABF measurements with increasing saline infusion speeds with and without adenosine. Another seven open-chest sheep underwent these measurements with epicardial doppler flow probes on both the left anterior descending artery and left circumflex coronary artery. Maximal hyperemia was defined as maximal flow after 45 seconds of proximal occlusion. The principles of laboratory animal care and all national regulations were followed. Results 20 ml/min of saline infusion induced lower hyperemic coronary flow (140 vs 191 ml/min, p=0.0165) and lower coronary flow reserve (CFR) (1.82 vs 3.21, p= <0.0001) than coronary occlusion. In contrast, 30 ml/min resulted in flow (196 vs 192 ml/min, p=0.8292) and CFR (2.77 vs 3.21, p=0.1107) that were not different from post-occlusion. There was a significant flow overestimation bias (Bland-Altman: Bias ± SD: -73.09 ± 30.52, 95% Limits of agreement: -132.9 to -13.27) with 40-50ml/min of saline. Occasionally, higher saline infusion rates resulted in ischemic ECG-changes and ventricular fibrillation (9.5% at 50 ml/min). Conclusions Continuous saline infusion of 30ml/min, but not 20 ml/min, induced maximal hyperemia. ABF measured with saline infusion speeds of 40-50 ml/min was not accurate nor safe, and should therefore be avoided.

The Prognostic Value of a Naples Score in Determining in-Hospital Mortality in Patients with Acute Ischemic Stroke Undergoing Endovascular Treatment.

Background/Objectives: The Naples prognostic score (NPS), reflecting inflammation and nutritional status, has prognostic value, especially in cancer. This study evaluated its ability to predict in-hospital mortality in acute ischemic stroke (AIS) patients undergoing endovascular treatment (EVT). Methods: We retrospectively studied 244 patients with AIS who were admitted between April 2020 and December 2023. Patients were included if they presented within 6 h of symptom onset with evidence of intracranial proximal arterial occlusion. The EVT was performed using aspiration catheters, stent retrievers, or both. The NPS was calculated based on the neutrophil-lymphocyte ratio, lymphocyte-monocyte ratio, and albumin and total cholesterol levels. Results: We found a significant association between higher NPS scores and in-hospital mortality. Patients with a high NPS (3 or 4) had a mortality rate of 41.6% compared to 21.0% in the low-NPS group (0, 1, or 2). The full model incorporating NPS showed superior predictive ability for in-hospital mortality compared with the baseline model (areas under the curve 0.881 vs. 0.808). A receiver-operating characteristic analysis at a cutoff of >2.5 for the NPS showed a sensitivity of 86.6% and specificity of 41.9%. This study demonstrated that incorporating the NPS into the predictive model improved the accuracy and calibration for predicting in-hospital mortality. A decision curve analysis showed the net benefit of using the full model incorporating NPS over the baseline model, emphasizing its potential clinical application in prognostication. Conclusions: NPS is a reliable predictor of in-hospital mortality in AIS patients undergoing EVT. Incorporating NPS into clinical practice could help to identify high-risk patients and improve outcomes through tailored interventions.

Predictors and Outcomes of Excellent Recanalization Versus Successful Recanalization After Thrombectomy in Proximal and Distal Medium Vessel Occlusion Strokes: A Multinational Study

BACKGROUND Acute ischemic stroke arising from medium vessel occlusions (MeVO) poses substantial challenges in treatment and management. This study aims to elucidate the outcomes and factors contributing to achieving excellent recanalization (modified Thrombolysis in Cerebral Infarction [mTICI] 2c–3) versus successful recanalization (mTICI 2b) in patients with MeVO stroke undergoing mechanical thrombectomy (MT). METHODS We conducted a multinational study analyzing data from the MAD‐MT (Multicenter Analysis of Distal Medium Vessel Occlusions: Effect of Mechanical Thrombectomy) registry, encompassing 37 centers across North America, Asia, and Europe, collected between September 2017 and July 2023. The study included acute ischemic stroke patients with MeVO treated with MT, with or without intravenous thrombolysis, who achieved mTICI 2b–3 post‐MT. RESULTS Among 1463 patients with successful recanalization (mTICI 2b–3), 523 achieved mTICI 2b recanalization, and 940 achieved mTICI 2c–3. Distal occlusions exhibited higher odds of excellent recanalization compared with proximal MeVO vessel occlusions (odds ratio, 1.58; 95% CI, 1.17–2.15; P = 0.003). Cardioembolic stroke pathogenesis was associated with a higher likelihood of excellent recanalization (1.67; 95% CI, 1.07–2.59; P = 0.018). Patients achieving mTICI 2c–3 recanalization demonstrated lower initial National Institutes of Health Stroke Scale scores, significant improvements in postprocedural National Institutes of Health Stroke Scale shift, and a higher percentage of favorable 90‐day outcomes compared with those with mTICI 2b. However, no significant difference in 90‐day mortality rates was observed. CONCLUSION This study underscores that among patients with MeVO stroke with successful recanalization (mTICI 2b–3) there is higher likelihood of achieving excellent recanalization (mTICI 2c–3) in distal occlusions and cardioembolic pathogenesis. mTICI 2c–3 scores post‐MT correlate with improved clinical outcomes compared with mTICI 2b, affirming the superiority of excellent recanalization over successful recanalization in patients with MeVO stroke. Further prospective studies and randomized controlled trials are warranted for validation.

Comprehensive analysis of the impact of procedure time and the ‘golden hour’ in subpopulations of stroke thrombectomy patients

ObjectiveTo evaluate the effect of procedure time on thrombectomy outcomes in different subpopulations of patients undergoing endovascular thrombectomy (EVT), given the recently expanded indications for EVT.MethodsThis multicenter study included patients...

Safe Endovascular Recanalization of Internal Carotid Artery Occlusion Using Retrograde Aspiration Angiography

ObjectsCerebral infarction, resulting from acute internal carotid artery (ICA) occlusion, typically manifests with a wide ischemic area and severe symptoms. Mechanical thrombectomy proves effective within 24 hours of disease onset and in less ischemic infarction core. However, in cases with well-developed collateral flow and mild symptoms, conservative treatment is initially selected. If symptoms worsen or ipsilateral hemisphere perfusion decreases, superficial temporal artery (STA) – middle cerebral artery (MCA) anastomosis is considered. Revascularization therapy may also be effective. Contralateral angiography allows for ipsilateral blood flow verification once complete revascularization is achieved, albeit with potential treatment-related complications. Here, we describe retrograde angiography using an intermediate catheter (IMC) and contralateral contrast injection to achieve safer revascularization. MethodsWe present ten acute ICA occlusion cases caused by thromboembolism, arteriosclerosis, carotid artery stent occlusion, or embolic stroke of undetermined source. Employing bilateral femoral artery puncture, one catheter was guided to the occluded ICA, while another was positioned for diagnostic purposes in the contralateral ICA or vertebral artery. The IMC was navigated through the occluded vessel, with contralateral imaging performed during aspiration. The catheter was gradually retracted to confirm the extent of occlusion and recognize recanalization. ResultsRecanalization was successfully achieved in all cases. Symptomatic ischemic complication and hyperperfuison was not seen in all cases. No cases were decreased modified Rankin scale after treatment. ConclusionAdvancements in IMC technology facilitate distal catheter guidance to the ICA, even in proximal occlusion. Combining this technique with contralateral imaging allows us to confirm the extent of occlusion and recanalization status without antegrade imaging, making recanalization therapy safer.

Intracoronary ECG ST-segment shift remission time during reactive myocardial hyperemia: a new method to assess hemodynamic coronary stenosis severity.

Fractional flow reserve (FFR) measurements are recommended for assessing hemodynamic coronary stenosis severity. Intracoronary ECG (icECG) is easily obtainable and highly sensitive in detecting myocardial ischemia due to its close vicinity to the myocardium. We hypothesized that the remission time of myocardial ischemia on icECG after a controlled coronary occlusion accurately detects hemodynamically relevant coronary stenosis. This retrospective, observational study included patients with chronic coronary syndrome undergoing hemodynamic coronary stenosis assessment immediately following a strictly 1-min proximal coronary artery balloon occlusion with simultaneous icECG recording. icECG was used for a beat-to-beat analysis of the ST-segment shift during reactive hyperemia immediately following balloon deflation. The time from coronary balloon deflation until the ST-segment shift reached 37% of its maximum level, i.e., icECG ST-segment shift remission time (τ-icECG in seconds), was obtained by an automatic algorithm. τ-icECG was tested against the simultaneously obtained reactive hyperemia FFR at a threshold of 0.80 as a reference parameter. From 120 patients, 139 icECGs (age, 68 ± 10 yr old) were analyzed. Receiver operating characteristic (ROC) analysis of τ-icECG for the detection of hemodynamically relevant coronary stenosis at an FFR of ≤0.80 was performed. The area under the ROC curve was equal to 0.621 (P = 0.0363) at an optimal τ-icECG threshold of 8 s (sensitivity, 61%; specificity, 67%). τ-icECG correlated inversely and linearly with FFR (P = 0.0327). This first proof-of-concept study demonstrates that τ-icECG, a measure of icECG ST segment-shift remission after a 1-min coronary artery balloon occlusion accurately detects hemodynamically relevant coronary artery stenosis according to FFR at a threshold of ≥8 s.NEW & NOTEWORTHY Invasive hemodynamic measurements are recommended by the current cardiology guidelines to guide percutaneous coronary interventions in the setting of chronic coronary syndrome. However, those pressure-derived indices demonstrate several theoretical and practical limitations. Thus, this study demonstrates the accuracy of a novel, pathophysiology-driven approach using intracoronary ECG for the identification of hemodynamically relevant coronary lesions by quantitatively assessing myocardial ischemia remission.

Preclinical evaluation of a novel endovascular thrombectomy device in a modified swine model for iliac vein thrombosis

ObjectiveTo evaluate the safety and efficacy of a novel endovascular thrombectomy device in a modified swine model of iliac vein thrombosis. MethodsA modified swine model for iliac vein thrombosis was created using proximal‒distal balloon occlusion combined with autologous venous thrombus and thrombin injections. The safety and efficacy of the newly developed Zylox endovascular thrombectomy system were evaluated in this animal model and its performance was compared with that of the AcoStream aspiration thrombectomy device. ResultsBilateral iliac vein thrombosis models were successfully created in 12 swine, with 23 iliac veins used for device testing and one for anatomical observation. The thrombus length in the Zylox group was greater than in the AcoStream group (98.42 ± 17.56 mm vs. 84.12 ± 13.30 mm), while thrombus scores were not significantly different between the two groups. Although Grade I thrombus clearance was achieved in all iliac veins in both groups, blood loss in the Zylox group was significantly less than in the AcoStream group (81.09 ± 27.26 ml vs. 162.50 ± 61.96 ml, P < 0.001). Three swine (6 iliac veins) in each group underwent repeat venography evaluations 28 days postthrombectomy, showing that all the veins were patent without any rethrombosis. Histopathologic evaluation immediately and 28 days postthrombectomy revealed no differences between the two groups. No complications or deaths occurred in the swine during the entire process. ConclusionThe current modified swine model is stable, reproducible, and appropriate for testing endovascular devices. This study preliminarily verified the safety and efficacy of the Zylox thrombectomy system for thrombus removal in this animal model and demonstrated its advantage in controlling blood loss. Future randomized controlled trials in humans are needed to further verify the safety and efficacy of the device.

Endovascular treatment for proximal middle cerebral artery occlusion due to underlying intracranial atherosclerotic disease: A retrospective single-center case series

ObjectiveTo compare treatment outcomes between patients who received a front-line stent-retriever thrombectomy (SRT) or first stenting without retrieval (FRESH) for treating proximal M1 occlusion due to underlying intracranial atherosclerotic disease (ICAD). MethodsWe retrospectively reviewed consecutive acute ischemic stroke (AIS) patients with intracranial large vessel occlusion (LVO) in the anterior circulation who underwent endovascular treatment (EVT) between January 2017 and August 2021 at Yeungnam University Medical Center. LVO in the anterior circulation was classified according to etiology as follows: Embolic group and ICAD group. Occlusion of the proximal M1 due to ICAD were enrolled in this study. The ICAD group was divided into SRT and FRESH groups according to the treatment method. ResultsAmong the 72 patients in the ICAD group, 55 patients had occlusion of the M1, and 27 had occlusion of the proximal M1 (27/55, 49.1 %). Among the 27 patients, 11 (40.7 %) underwent SRT and 16 (59.3 %) underwent FRESH. The puncture-to-recanalization time was significantly shorter in the FRESH group (28 min vs. 52 min, p = 0.023). Symptomatic ICH tended to occur more frequently in the SRT group than in the FRESH group (27.3 % vs. 0.0 %, p=0.056). There was a nonsignificant trend towards a good functional outcome in the FRESH group compared to the SRT group (81.3 % vs. 45.5 %, p=0.097). ConclusionIn the FRESH group, the puncture-to-recanalization time was significantly shorter, symptomatic ICH tended to occur less frequently, and good functional outcomes were more common.

Intracranial bypass for giant aneurysms treatment assessed by computational fluid dynamics (CFD) analysis

Unruptured giant intracranial aneurysms (GIA) are those with diameters of 25 mm or greater. As aneurysm size is correlated with rupture risk, GIA natural history is poor. Parent artery occlusion or trapping plus bypass revascularization should be considered to encourage intra-aneurysmal thrombosis when other treatment options are contraindicated. The mechanistic background of these methods is poorly studied. Thus, we assessed the potential of computational fluid dynamics (CFD) and fluid–structure interaction (FSI) analyses for clinical use in the preoperative stage. A CFD investigation in three patient-specific flexible models of whole arterial brain circulation was performed. A C6 ICA segment GIA model was created based on CT angiography. Two models were then constructed that simulated a virtual bypass in combination with proximal GIA occlusion, but with differing middle cerebral artery (MCA) recipient vessels for the anastomosis. FSI and CFD investigations were performed in three models to assess changes in flow pattern and haemodynamic parameters alternations (wall shear stress (WSS), oscillatory shear index (OSI), maximal time averaged WSS (TAWSS), and pressure). General flow splitting across the entire domain was affected by virtual bypass procedures, and any deficiency was partially compensated by a specific configuration of the circle of Willis. Following the implementation of bypass procedures, a reduction in haemodynamic parameters was observed within the aneurysm in both cases under analysis. In the case of the temporal MCA branch bypass, the decreases in the studied parameters were slightly greater than in the frontal MCA branch bypass. The reduction in the magnitude of the chosen area-averaged parameters (averaged over the aneurysm wall surface) was as follows: WSS 35.7%, OSI 19.0%, TAWSS 94.7%, and pressure 24.2%. FSI CFD investigation based on patient-specific anatomy models with subsequent stimulation of virtual proximal aneurysm occlusion in conjunction with bypass showed that this method creates a pro-thrombotic favourable environment whilst reducing intra-aneurysmal pressure leading to shrinking. MCA branch recipient selection for optimum haemodynamic conditions should be evaluated individually in the preoperative stage.

Computational fluid dynamics; a new diagnostic tool in giant intracerebral aneurysm treatment

Giant intracerebral aneurysms (GIA) comprise up to 5 % of all intracranial aneurysms. The indirect surgical strategy, which leaves the GIA untouched but reverses the blood flow by performing a bypass in combination with proximal parent artery occlusion is a useful method to achieve spontaneous aneurysm occlusion. The goal of this study was to assess the utility of computational fluid dynamics (CFD) in preoperative GIA treatment planning. We hypothesise that CFD simulations will predict treatment results.A fluid-structure interaction (FSI) CFD investigation was performed for the entire arterial brain circulation. The analyses were performed in three patient-specific CT angiogram models. The first served as the reference geometry with a C6 internal carotid artery (ICA) GIA, the second a proximal parent artery occlusion (PAO) and virtual bypass to the frontal M2 branch of the middle cerebral artery (MCA), and the third a proximal PAO in combination with a temporal M2 branch bypass. The volume of “old blood”, flow residence time (FRT), dynamic viscosity and haemodynamic changes were also analysed.The “old blood” within the aneurysm in the bypass models reached 41 % after 20 cardiac cycles while in the reference model it was fully washed out. In Bypass 2 “old blood” was also observed in the main trunk of the MCA after 20 cardiac cycles. Extrapolation of the results yielded a duration of 4 years required to replace the “old blood” inside the aneurysm after bypass revascularization. In both bypass models a 7-fold increase in mean blood viscosity in the aneurysm region was noted.Bypass revascularization combined with proximal PAO favours thrombosis. Areas prone to thrombus formation, and subsequently the treatment outcomes, were accurately identified in the preoperative model. Virtual surgical operations can give a remarkable insight into haemodynamics that could support operative decision-making.

Clinical outcomes of reperfusion therapy in patients with site-specific basilar artery occlusion

BackgroundDespite its low incidence, basilar artery occlusion (BAO) remains a major therapeutic challenge since severe disability and death occur in about 80% of patients. Specific site of BAO (proximal, middle,...

Treatment of arteriovenous fistula stenosis with proximal radial artery occlusion in 4 hemodialysis patients PTA

Percutaneous Transluminal Angioplasty PTA is an effective method for treating arteriovenous fistulas stenosis In our blood purification center we found 4 patients with poor blood flow

Early recanalization after tenecteplase versus alteplase: Experience in a large stroke network

IntroductionPreviously published data are conflicting regarding the ability of tenecteplase versus alteplase to produce early recanalization of an intracranial large vessel occlusion. We compared the performance of each thrombolytic in a stroke network. MethodsWe queried our prospectively collected code stroke registry for basilar, internal carotid, or proximal middle cerebral artery occlusion patients treated with intravenous thrombolysis from 11/17/2021-9/16/2023. The primary outcome was early recanalization, defined using angiographic or clinical criteria. Secondary and safety outcomes included 90-day functional independence and symptomatic intracranial hemorrhage. A multivariable regression analysis was performed to determine independent associations with the primary outcome. Results233 patients, with mean age 66.9 (16.6) years and median National Institutes of Health Stroke Scale score 15 (10-21), were included. One-hundred twenty-four of 233 (53.2 %) patients were treated with alteplase while 109/233 (46.8 %) were treated with tenecteplase. Endovascular thrombectomy was performed in 82 % of subjects. Early recanalization rates were similar between the groups (alteplase 22.6 %, tenecteplase 14.7 %; p = 0.14), as were rates of 90-day independent neurological function, symptomatic intracranial hemorrhage, and mortality. Patients with an internal carotid artery occlusion or with higher presenting stroke severity were less likely to achieve early recanalization. ConclusionsTenecteplase and alteplase have similar rates of early recanalization, 90-day functional independence, and safety outcomes in large vessel occlusion patients. Occlusion site and stroke severity predict response to thrombolysis. Future studies may investigate other factors associated with a positive response to thrombolytics as expanded treatment indications are explored.

The Impact of Gel Parameters on the Dispersal and Fragmentation of Hyaluronic Acid Gel Fillers within an Artificial Model of Arterial Embolism.

Accidental arterial embolization of hyaluronic acid (HA) fillers can lead to severe complications, including skin ischemia, blindness, and stroke. Currently, the intra-arterial dispersal and fragmentation behavior of HA gels is unknown but critical to our understanding of the pathomechanism of these injuries. This work introduces the Pulsatile Unit for the Laboratory Simulation of Arterio-embolic Restrictions (PULSAR) and evaluates the intravascular behavior of different HA gels. The fragmentation and dispersal behaviors of four HA gels with distinct rheological properties were evaluated via high-resolution videography and ImageJ particle size and morphology analysis. The gels' elastic modulus (G'), loss modulus (G″), tan(δ), and HA concentration were subsequently correlated with their intra-arterial behaviors. This study effectively confirms the extensive fragmentation of HA gels upon arterial inoculation, with particle sizes ranging from <50 µm to >1 mm. Gel particle size and morphology correlated most significantly with tan(δ). Conversely, arterial flow rates did not significantly influence gel fragmentation behavior, though the probability of proximal, macrovascular obstruction was affected. Overall, this study validates the PULSAR model for simulation of arterial dynamics and the testing of intravascular filler kinematics. The findings demonstrate the ability of gels to microfragment and disseminate distally, as well as induce partial proximal occlusion depending on gel rheology and arterial flow parameters.

Reliability assessment of distal occlusion eTICI scoring.

The eThrombolysis in Cerebral Infarction (eTICI) score has been validated in proximal large artery occlusion (pLAOs). Despite the growing number of distal medium vessel occlusions (DMVOs) mechanical thrombectomies (MT) and the widespread utilization of the eTICI scoring system, its reliability and standardization for more distal occlusions have not been validated. We aim to evaluate the interrater reliability of eTICI scores in primary DMVOs. This was a retrospective analysis of a prospectively maintained database for consecutive patients with pLAO and DMVO MT at a single comprehensive stroke center from 2015 to 2022. Two fellowship-trained neurointerventionalists blindly/independently assessed digital subtraction angiograms for final eTICI, followed by consensus reads for discrepancies. 59 DMVO of 2248 thrombectomies [M3:29(50%)/M4:1(2%)/A1:3(5%)/A2:12(22%)/A3: 5(9%)/P1:7(12%)/P2:1(2%)] and 124 pLAOs of 308 thrombectomies [i-ICA:13(11%)/MCA-M1: 111(90%)] were included. The distribution of final eTICI scores was comparable between pLAO vs DMVOs (p = 0.82). The pLAO final eTICI score assessment between two readers demonstrated moderate reliability with a kappa0.77 (95%CI: 0.67-0.88), while the DMVO eTICI score assessment exhibited almost-perfect agreement with kappa 0.94 (95%CI: 0.90-0.99). The agreement between the consensus read and the original report in DMVOs was 0.86 (95% CI: 0.71-1.00) while for pLAO it was 0.83(95% CI: 0.76-0.90). The performance of eTICI was comparable amongst different DMVO territories as well as for distal vs. very distal occlusions. eTICI score exhibited comparable performance for DMVO as compared to pLAO strokes. Further studies investigating DMVO eTICI grading and clinical outcomes are warranted.

An Interesting Case of Vanishing Myocardial Infarction

A 45 year old male came with complaints of chest pain since one day following alcohol intake. Patient evaluated initially at a hospital where electrocardiograph was taken which revealed ST elevation in leads V2 - V4 and loading dose was given subsequently and was subsequently refereed to our hospital. Electrocardiograph was repeated in our hospital which surprisingly showed no ST elevation. Patient was taken up for angiogram which shows proximal LAD occlusion. Achieving initial thrombolysis in myocardial infarction grade 2-3 flow in the infarct-related artery prior to primary percutaneous coronary intervention (PPCI) is commonly referred to as transient STEMI, or spontaneous reperfusion. This condition affects about 20% of patients with STEMI and is usually accompanied by a resolution or improvement of symptoms. It can delay the emergency need of angioplasty. Although there is no specific reason for spontaneous resolution of ST elevation in myocardial infarction, but there are few biomarkers, prognostic tools and potential therapeutic targets which help in spontaneous re-perfusion in a developing myocardial infarction.