Jieun Roh

Rescue Stenting for Failed Mechanical Thrombectomy in Acute Ischemic Stroke: A Multicenter Experience

Background and Purpose— Effective rescue treatment has not yet been suggested in patients with mechanical thrombectomy (MT) failure. This study aimed to test whether rescue stenting (RS) improved clinical outcomes in MT-failed patients. Methods— This is a retrospective analysis of the cohorts of the 16 comprehensive stroke centers between September 2010 and December 2015. We identified the patients who underwent MT but failed to recanalize intracranial internal carotid artery or middle cerebral artery M1 occlusion. Patients were dichotomized into 2 groups: patients with RS and without RS after MT failure. Clinical and laboratory findings and outcomes were compared between the 2 groups. It was tested whether RS is associated with functional outcome. Results— MT failed in 148 (25.0%) of the 591 patients with internal carotid artery or middle cerebral artery M1 occlusion. Of these 148 patients, 48 received RS (RS group) and 100 were left without further treatment (no stenting group). Recanalization was successful in 64.6% (31 of 48 patients) of RS group. Compared with no stenting group, RS group showed a significantly higher rate of good outcome (modified Rankin Scale score, 0–2; 39.6% versus 22.0%; P=0.031) without increasing symptomatic intracranial hemorrhage (16.7% versus 20.0%; P=0.823) or mortality (12.5% versus 19.0%; P=0.360). Of the RS group, patients who had recanalization success had 54.8% of good outcome, which is comparable to that (55.4%) of recanalization success group with MT. RS remained independently associated with good outcome after adjustment of other factors (odds ratio, 3.393; 95% confidence interval, 1.192–9.655; P=0.022). Follow-up vascular imaging was available in the 23 (74.2%) of 31 patients with recanalization success with RS. The stent was patent in 20 (87.0%) of the 23 patients. Glycoprotein IIb/IIIa inhibitor was significantly associated with stent patency but not with symptomatic intracranial hemorrhage. Conclusions— RS was independently associated with good outcomes without increasing symptomatic intracranial hemorrhage or mortality. RS seemed considered in MT-failed internal carotid artery or middle cerebral artery M1 occlusion.

Collateral status affects the onset-to-reperfusion time window for good outcome

Objective To characterise the time window in which endovascular thrombectomy (EVT) is associated with good outcome, and to test the differential relationship between functional outcome and onset-to-reperfusion time (ORT), depending on collateral status. Methods This was a retrospective analysis of clinical and imaging data of 554 consecutive patients, who had recanalisation success by EVT for anterior circulation large artery occlusion, from the prospectively maintained registries of 16 comprehensive stroke centres between September 2010 and December 2015. The patients were dichotomised into good and poor collateral groups, based on CT angiography. We tested whether the likelihood of good outcome (modified Rankin Scale, 0–2) by ORT was different between two groups. Results ORT was 298 min±113 min (range, 81–665 min), and 84.5% of patients had good collaterals. Age, diabetes mellitus, previous infarction, National Institutes of Health Stroke Scale, good collaterals (OR 40.766; 95% CI 10.668 to 155.78; p<0.001) and ORT (OR 0.926 every 30 min delay; 95% CI 0.862 to 0.995; p=0.037) were independently associated with good outcome. The drop in likelihood of good outcome associated with longer ORT was significantly faster in poor collateral group (OR 0.305 for every 30 min; 95% CI 0.113 to 0.822) than in good collateral group (OR 0.926 for every 30 min; 95% CI 0.875 to 0.980). Conclusions Earlier successful recanalisation was strongly associated with good outcome in poor collateral group; however, this association was weak during the tested time window in good collateral group. This suggests that the ORT window for good outcome can be adjusted according to collateral status.

Acoustic radiation force impulse imaging of biopsy-proven Kikuchi disease: initial experience to evaluate feasibility in a pediatric population.

Purpose This study evaluated the feasibility of acoustic radiation force impulse (ARFI) elastography and characterized the sonographic features of lymph nodes (LNs) with Kikuchi disease in pediatric patients. Methods Seventy-six cervical LN biopsies were performed for the diagnosis of cervical lymphadenopathy. ARFI imaging was performed, and the characteristic ultrasound features of the biopsied LNs and the contralateral LNs were analyzed. We also reviewed clinical and conventional ultrasonographic findings. Results On histology, 56 patients were diagnosed with Kikuchi disease. These LNs were large and elongated, with increased perinodal echogenicity and capsular thickening. In 38 of them, ARFI elastography was performed, and the median shear wave velocity (SWV) of the biopsied LNs with Kikuchi disease (2.19 m/sec; range, 1.45 to 4.57 m/sec) was higher than of the contralateral LNs (1.72 m/sec; range, 0.95 to 2.65 m/sec; P<0.001). In patients with reactive hyperplasia, the mean SWV of the biopsied LNs (2.00 m/sec; range, 1.49 to 2.26 m/sec) was higher than that of the contralateral LNs (1.55 m/sec; range, 1.21 to 2.32 m/sec; P=0.031). Conclusion The SWV of LNs with Kikuchi disease was significantly higher than that of the contralateral LNs. Morphologically, LNs with Kikuchi disease showed an enlarged, elongated, and oval shape, increased perinodal echogenicity, and capsular thickening. In addition to the conventional ultrasonographic findings, the application of ARFI is feasible even in pediatric patients for the evaluation of cervical lymphadenopathy.

A Case of Aluminum Casting in the Nasal Cavity and the Paranasal Sinus

A 32-year-old man who had aluminum casting foreign bodies in his sinonasal cavities after a molten aluminum explosion at his workplace was referred to our institution for further investigation and surgical removal. The initial computed tomography images demonstrated hyperdense foreign materials in both nasal cavities and the left anterior ethmoid sinus (Figure 1). The nasal cavity showed pale mucosa with exudates and the end of the aluminum casting. The patient underwent emergency operation. As the aluminum foreign body was impacted in the nasal cavity, the thinnest area was rotated and broken by Kelly forceps and bone-cutting scissors. The foreign material in the ethmoid sinus was removed through ethmoidectomy (Figure 2; see Video 1 in the online version of the article). Saddle nose, septal perforation, and nostril stricture were noted 2 months postoperatively. Exemption from review was obtained from the Pusan National University Yangsan Hospital Institutional Review Board. Discussion

Preliminary Study of Tirofiban Infusion in Coil Embolization of Ruptured Intracranial Aneurysms

BACKGROUND There have been some reports on the use of intra‐arterial tirofiban in ruptured intracranial aneurysms, but few studies have reported on the use of 24 h of intravenous tirofiban infusion in patients with subarachnoid hemorrhage. OBJECTIVE To present our experience with intravenous tirofiban infusion, in the form of a monotherapy as well as in addition to intra‐arterial tirofiban, as a prophylactic, and as a rescue management for thrombus in patients who have undergone embolization with coils for ruptured intracranial aneurysms. METHODS Between December 2008 and January 2015, we retrospectively reviewed 249 ruptured intracranial aneurysms that were treated with coiling at our institutions. A total of 28 patients harboring 28 ruptured and 3 unruptured intracranial aneurysms underwent intravenous tirofiban infusion during or after coil embolization of an aneurysm. Intra‐arterial infusion of tirofiban via a microcatheter was also performed in 26 patients. RESULTS Thromboembolic formation during the procedure was detected in 25 cases. Intra‐arterial tirofiban dissolved the thromboembolus under angiographic control after 10 or more minutes in 19 (76%) of 25 patients. Two intracranial hemorrhagic complications (increase in the extent of hematoma) occurred during the follow‐up period. Two cases of other complications occurred: hematuria and perioral bleeding. CONCLUSION Intravenous tirofiban, as a monotherapy or in addition to intra‐arterial tirofiban for thrombotic complications, seems to be useful as a treatment for acute aneurysm. However, alternatives to tirofiban should be considered if an associated hematoma is discovered before a patient receives a tirofiban infusion.

Distally Enlarged Feeding Artery Phenomenon in Intracranial Dural Arteriovenous Fistula: Alternative Access Route to Transarterial Intravenous Embolization

BACKGROUND Transvenous (TV) embolization is ideal for endovascular treatment of intracranial dural arteriovenous fistulas (DAVF). However, it is not always feasible because of various factors, and transarterial (TA) embolization could then be tried. We aimed to determine the incidence of distally enlarged feeding artery phenomenon and the major feeding artery in DAVF. If the TV approach is difficult and this phenomenon is observed, we could use this vessel for transarterial intravenous (TAIV) embolization as an endovascular treatment modality for DAVF. METHODS Forty-four patients with intracranial DAVF treated by the endovascular procedure between 2009 and 2016 were retrospectively reviewed. Their clinical records, angiography reports, and embolization procedure notes were studied, and their angiographies were chronologically classified into proliferative and restrictive types. RESULTS In 14 of 44 patients (32%), we observed the distally enlarged feeding artery phenomenon. The most common enlarged artery was the middle meningeal artery. The distally enlarged feeding artery group was predominantly the restrictive type, and the other group was proliferative in nature (P < 0.001). Of the 14 patients, 7 underwent TAIV embolization, and the other 7 underwent TV embolization. CONCLUSIONS Distally enlarged feeding artery phenomenon was observed in 32% of patients with intracranial DAVF. This group was predominantly the restrictive type. We conclude that this phenomenon might help determine a patients eligibility for TAIV embolization when TV embolization is difficult or impossible.