Search

Background: Clinical-diffusion mismatch (CDM) and perfusion-diffusion mismatch (PDM) are used to select patients for endovascular thrombectomy (EVT) in the late-window period. As CDM well reflects true penumbra, we hypothesized that patients with CDM and PDM would respond better to EVT than those with PDM only at the late-window period. Methods: Acute ischemic stroke patients who received EVT 6–24 h after stroke onset were included. PDM (perfusion-/diffusion-weighted image (DWI) lesion volume >1.8) was used to select candidates for EVT in this time-period in our center. CDM was defined according to the DAWN trial criteria. Response to EVT was compared between patients with and without CDM. Early neurological improvement (ENI) was defined as improvement >4 points on National Institutes of Health Stroke Scale (NIHSS) score 1 day after EVT. Multivariable analysis was performed to investigate independent factors associated with ENI. The correlation between DWI lesion volume and NIHSS score was investigated in those with and without CDM. Results: Among 94 patients enrolled, all patients had PDM and 44 (46.3%) had CDM. Forty-eight patients (51.1%) showed ENI. The prevalence of hypertension, initial NIHSS score, improvement in NIHSS score after EVT, and prevalence of ENI were greater in patients with CDM than those without. ENI was independently associated with onset-to-door time (odds ratio [95% confidence interval]: 0.998 [0.997–1.000]; p = 0.042), complete recanalization (23.912 [2.238–255.489]; p = 0.009), initial NIHSS score (1.180 [1.012–1.377]; p = 0.034), and the presence of CDM (5.160 [1.448–18.386]; p = 0.011). The correlation between DWI lesion volume and initial NIHSS score was strong in patients without CDM (r = 0.731) but only moderate in patients with CDM (r = 0.355). Conclusion: Patients with both CDM and PDM had a better response to late-window EVT than those with PDM only.

PURPOSE Hereditary hemorrhagic telangiectasia (HHT), a rare genetic vascular disorder, has been rarely reported in South Korea. We investigated the current prevalence and presenting patterns of genetically confirmed HHT in South Korea. MATERIALS AND METHODS We defined HHT patients as those with proven mutations on known HHT-related genes (ENG, ACVRL1, SMAD4, and GDF2) or those fulfilling 3 or 4 of the Curacao criteria. A computerized systematic search was performed in PubMed and KoreaMed using the following search term: ("hereditary hemorrhagic telangiectasia" AND "Korea") OR ("Osler-Weber-Rendu" AND "Korea"). We also collected government health insurance data. HHT genetic testing results were collected from three tertiary hospitals in which the genetic tests were performed. We integrated patient data by analyzing each case to obtain the prevalence and presenting pattern of HHT in South Korea. RESULTS We extracted 90 cases from 52 relevant articles from PubMed and KoreaMed. An additional 22 cases were identified from the three Korean tertiary hospitals after excluding seven cases that overlapped with those in the published articles. Finally, 112 HHT patients were identified (41 males and 71 females, aged 4-82 years [mean±standard deviation, 45.3±20.6 years]). The prevalence of HHT in South Korea is about 1 in 500,000, with an almost equal prevalence among men and women. Forty-nine patients underwent genetic testing, of whom 28 had HHT1 (ENG mutation) and 19 had HHT2 (ACVRL1 mutation); the other two patients were negative for ENG, ACVRL1, and SMAD4 mutations. CONCLUSION The prevalence of HHT is underestimated in Korea. The rate of phenotypic presentation seems to be similar to that found worldwide. Korean health insurance coverage is limited to representative genetic analysis to detect ENG and ACVRL1 mutations. Further genetic analyses to detect HHT3, HHT4, and other forms of HHT should be implemented.

Although paraclinoid aneurysms do not exhibit a high risk of rupture, coil embolization is not always easy because of unstable microcatheter position. We present a technique that allows a stable microcatheter position for coil embolization of paraclinoid aneurysms. We enrolled 34 consecutive patients who underwent coil embolization for paraclinoid aneurysms. A loop of distal microcatheter was shaped based on three-dimensional rotational angiography. The basic concept is to keep the proximal loop abutting the opposite wall of the aneurysm while using the distal loop for coiling. Then, a proximal curve was made to accommodate the shape of the carotid siphon, which may decide the direction of the loop. Stent-assisted coil embolization was performed in 19 wide-necked aneurysms. Immediate radiological outcomes were analyzed with Raymond classification and clinical outcomes were evaluated with modified Rankin Scale (mRS) scores. Satisfactory occlusion of aneurysm was achieved in 94.1% (32/34) of patients with a Raymond score of 1 or 2. Packing density of ≥ 31% was achieved in 71% (24/34) of patients. No significant differences were observed between stent-assisted coiling and coiling-only groups. Follow-up magnetic resonance angiography and/or angiogram showed stable coil position, except in one patient with tiny recurrence (from Raymond scores 1 to 2) that did not require retreatment at the 6-month follow-up. mRS scores of 0–1 were obtained in all patients at 6 months. Loop microcatheter technique allowed safe and stable coil packing for paraclinoid aneurysms. The same procedural concept is also being used for aneurysms in other vascular territories.

Objective Symptomatic non–acute intracranial arterial occlusion (NAICO) is not uncommon. We report a single-center experience of the feasibility and safety of endovascular treatment of anterior circulation NAICO and summarize the outcomes of patient groups with successful or failed recanalization. Methods Patients who underwent endovascular therapy for intracranial arterial stenosis between January 2010 and May 2017 were retrospectively reviewed. Thirty-eight patients with symptomatic NAICO (symptom onset > 24 hours) in the anterior circulation were identified. Results Successful recanalization was achieved in 76.3% of patients (29/38). Intraprocedural events occurred in 10.5% (4/38), including intima dissection ( n = 1), parent artery rupture ( n = 1) and acute in-stent thrombosis ( n = 2). Mean follow-up duration after successful recanalization was 36.5 months. One patient died 68 days after the procedure because of a newly developed posterior circulation stroke. Acute reocclusion was observed in two patients (6.7%); subacute or delayed reocclusion was observed in three patients (10%). Good final outcome (modified Rankin Scale score ≤ 2) was achieved in 25 of 28 patients (89.3%) at three months. Mean follow-up duration of the nine patients with failed recanalization was 41.4 months. Three patients underwent extra–intracranial bypass for worsening symptoms. The other six patients showed stable or improved neurological status with antiplatelet medications. Good final outcome was achieved in eight of nine patients (88.9%) at three months. Conclusions Endovascular revascularization can be a viable option with an acceptable safety profile in selected patients with symptomatic NAICO in the anterior circulation. Further characterization of aborted cases would facilitate proper patient selection for endovascular treatment.