Intravenous thrombolysis (IVT) and endovascular treatment (EVT) are currently the main treatments for reperfusion in acute ischemic stroke. Although the EVT recanalization rate has increased, unsuccessful recanalization is still observed in 10-30% cases. Superficial temporal artery-middle cerebral artery (STA-MCA) bypass is considered a rescue therapy in such cases, but in most centers it is not usually performed for acute ischemic stroke. Graft occlusion is rare following STA-MCA bypass, but it might lead to recurrent ischemic stroke. We hereby report on a patient with right MCA infarction and in whom EVT failed due to complete proximal internal carotid artery occlusion. He underwent an emergency STA-MCA bypass, resulting in a full recovery of his motor weakness. However, six months later, the patient experienced recurrent acute ischemic stroke due to bypass graft occlusion. His EVT failed again but revision bypass surgery, using STA remnant branch, was successful with full motor weakness recovery. We recommend a revision bypass surgery as a feasible therapeutic option for recurrent cerebral infarction caused by delayed STA graft occlusion. Keywords: Stroke, Cerebral revascularization, Vascular graft occlusion, Reoperation
Intrahospital delay is the most serious obstacle in thrombolysis in acute ischaemic stroke (AIS). We implemented the pre-hospital notification system from the emergency medical information system in our metropolitan area to reduce intrahospital delay.From October 2007, we implemented a 24-h hotline system between our stroke center and the Korean Emergency Medical Information System in Busan. We compared processing times and clinical outcomes amongst patients after using intravenous tissue type plasminogen activator (iv t-PA) with and without the hotline system.After the pre-hospital notification system was implemented, the rate of iv t-PA use increased from 6.5% to 14.3%. Time of onset in patients with pre-hospital notification was much longer than in patients without (121.5 +/- 34.8 min vs. 74.7 +/- 38.5 min, P < 0.01) notification but door-to-needle time was significantly reduced (28.9 +/- 11.4 min vs. 47.7 +/- 22.8 min, P < 0.01). However, there were no significant differences in 90-day clinical outcomes between the two groups.The pre-hospital notification system reduced intrahospital processing times which led to increased iv t-PA use after AIS. However, the improvement of clinical outcomes in thrombolysis might require organization of not only intrahospital processes but of outside processes such as the early recognition and rapid dispatch of patients with suspected AIS.
It has been suggested that AF-related ischemic stroke (IS) that is accompanied by atherosclerotic burden have poorer outcomes. The aim of this study was to investigate the importance of pre-stroke glycemic control (PSGC) on the early neurologic deterioration (END) of patients with acute AF-related IS.We retrospectively recruited 121 patients with AF-related IS who also had Diabetes mellitus (DM). The HbA1C level was measured in all subjects. END was defined as an increase in the National Institute of Health Stroke Scale (NIHSS) score of 4 NIHSS points within 7 days of symptom onset compared to the initial NIHSS score.In this study, 20.7% (25 patients) were classified as having a poor PSGC status with a HbA1C level above 8.0%. In the univariate analysis, a poor PSGC status (p < 0.01), smoking (p = 0.01), severe neurologic deficits at admission (p = 0.01), and a larger size of ischemic lesions on DWI (p < 0.01) were associated with the occurrence of END. In the multivariate model, a poor PSGC status (p = 0.02) and larger size of ischemic lesions on MRI (p < 0.01) were independent predictors of END in acute AF-related IS.The HbA1c level upon admission was independently associated with significant prediction of END in acute AF-related IS.
Follow-up with MRA for intracranial aneurysms after stent-assisted coiling is complicated by imaging artifacts. We evaluated the usefulness of an alternative method: vessel wall MR imaging.
MATERIALS AND METHODS:
We conducted a single-center, retrospective review of medical records of 47 patients who underwent 3D TOF-MRA, vessel wall MRI, and DSA after stent-assisted coiling between March 2016 and January 2018. We evaluated the mean value of the signal intensity in the stented artery and the contralateral normal artery on vessel wall MRI. The quality of visualization was further compared between TOF-MRA and vessel wall MRI. Furthermore, we evaluated the diagnostic accuracy and concordance rate of TOF-MRA and vessel wall MRI for assessing the patency of the stented parent artery. DSA was used as a reference test.
RESULTS:
The mean signal intensities of the stented and normal arteries on vessel wall MRI were not significantly different (P = .133). The mean scores for the visualization of the stented parent artery on vessel wall MRI were significantly superior to those of TOF-MRA images (P < .001). Vessel wall MRI reached an excellent positive predictive value (100%). However, TOF-MRA had a poor positive predictive value (11%; 95% CI, 9%–12%). The likelihood ratios of vessel wall MRI and TOF-MRA were 27.36 (P < .001) and 2.98 (P = .225), respectively. The concordance rate of vessel wall MRI and TOF-MRA with DSA for evaluating the state of the stented artery was 100% (κ = 1) and 28% (κ = 0.038), respectively.
CONCLUSIONS:
Vessel wall MRI may be useful in evaluating the patency of stented arteries after stent-assisted coil embolization for intracranial aneurysms.
We hypothesized that the relative regional cerebral blood volume (rCBV) ratio could help predict the risk of infarct growth on follow-up magnetic resonance imaging (MRI) in patients with diffusion perfusion mismatch (DPM) on the time-to-peak (TTP) map. We recruited 60 patients with acute middle cerebral arterial (MCA) infarction who had been evaluated by perfusion MRI within 24 h of initial ischemic events, and assessed the predictive role of the rCBV ratio on infarct growth in patients with DPM. Among 60 patients with acute MCA ischemic stroke, 41 (68.3%) patients had DPM on the initial MRI. Follow-up MRI revealed ischemic lesion enlargement in 19 (31.7%) of these 41 patients. The presence of DPM had no effect on the rate of lesion enlargement. Patients with ischemic lesion growth in follow-up images had a significantly lower rCBV ratio than patients without (0.81 +/- 0.22 vs. 1.08 +/- 0.20, p < 0.01). In this study, the decreased rCBV ratio on perfusion MRI has a predictive value for the growth of ischemic lesions after acute ischemic stroke with DPM on the TTP map.
Purpose: To assess the utility cerebral perfusion MR in the identification of changes in the findings before and after a stent-assisted angioplasty in cases of severe symptomatic carotid stenosis. Materials and Methods: Twenty-three patients with symptomatic high grade ICA stenosis underwent cerebral perfusion MR imaging before and after carotid stent placement. The time to peak (TTP) and cerebral blood volume (%CBV) were retrospectively calculated before and after stenting in each hemisphere, as well as between the vascular enhancing group and non-vascular enhancing group on contrast-enhanced T1-weighted images before stenting. As well, the prestent TTP was compared with the stenosis degree for each case. Results: The value of TTP decreased significantly after stenting, while the difference of the prestent TTP between the vascular enhancing group and non-vascular enhancing group was also statistically significant (pTTP before stenting was positively correlated (r=0.472) to the degree of carotid stenosis (p
Meningioma is a common neoplasm of the central nervous system; however, primary extracranial meningioma of the paranasal sinus, especially the maxillary sinus, is rare. We report a case of primary extracranial meningioma (fibrous type) of the maxillary sinus and present a literature review of the imaging features that correlate with fibrous meningioma.수막종은 중추신경계에서 흔한 종양이지만, 부비동, 특히 상악동에 위치한 일차성 두개외 수막종은 매우 드물다. 본 연구에서는 상악동에서 발생한 일차성 섬유질형 수막종의 증례를 보고하고, 문헌의 섬유질형 수막종의 영상 소견과 함께 고찰하고자 한다.
Abstract Background Distal embolic protection devices have been widely used to reduce the incidence of embolic events during carotid artery stenting. Entrapment of an embolic protection device is an extremely rare complication, and most cases are resolved by surgical removal. Case presentation A 67-year-old male underwent carotid artery stenting with an embolic protection device. During the procedure, the embolic protection filter became entrapped within the stent. The complication was resolved endovascularly without sequelae. Conclusion The most important step in stenting is to be careful until the procedure is completed. However, if complications occur during the operation, in-depth knowledge of the catheters, wires, and devices will help the operator resolve the problem using endovascular techniques.
Thromboembolic complications during stent-assisted coiling of ruptured intracranial aneurysms are major complications that can cause serious neurological deficits. Management strategies include medical thrombolysis, mechanical thrombectomy with suction aspiration or stent retrieval, and rescue stenting. The existing literature suggests that tissue plasminogen activator agents should be used cautiously because of the high risk of severe bleeding at the aneurysm. We present the case of a ruptured anterior communicating artery aneurysm. Acute in-stent thrombosis occurred during the stent-assisted coiling of the aneurysm. Rescue therapy with tirofiban, suction aspiration, and rescue stenting was attempted; however, these methods failed. Finally, tissue plasminogen activator infusion was performed, which successfully dissolved the thrombus and restored blood flow. Follow-up brain computed tomography revealed no increase in hemorrhage volume.
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