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Background and purposeThis study aimed to evaluate the efficacy of intra-arterial thrombectomy (IAT) and prognosis for acute ischaemic stroke patients with active cancer.MethodsWe retrospectively reviewed 253 patients who underwent IAT within 24 h after stroke onset between January 2012 and August 2017. We classified the patients into active cancer (n = 26) and control groups (n = 227) and compared clinical data. Primary outcome was a modified Rankin scale score at 3 months with ordinal logistic regression (shift analysis).ResultsInitial National Institutes of Health Stroke Scale (NIHSS) and rate of successful recanalisation did not differ between groups, but the active cancer group showed poor outcomes at 3 months on shift analysis (P = 0.001). The independent predictors of poor prognosis were age [adjusted common odds ratio (aOR) 1.03, 95% confidence interval (CI) 1.01–1.05], baseline NIHSS (aOR 1.14, 95% CI 1.09–1.19), baseline C-reactive protein level (aOR 1.14, 95% CI 1.03–1.25), any cerebral haemorrhage (aOR 1.92, 95% CI 1.21–3.06), and active cancer (aOR 2.35, 95% CI 1.05–5.25). Mortality at 90 days was 30.8% in the cancer group and 8.8% in the control group (P = 0.003).ConclusionsAlthough baseline characteristics and recanalisation rate after IAT up to 24 h after stroke onset were similar between acute ischaemic stroke patients with active cancer and without any cancer, stroke-related death and short-term outcome were significantly poorer in patients with active cancer than the controls. Post-procedural haemorrhage and active cancer itself were independent predictors of a decrease in functional independence at 3 months.

Purpose Endovascular reperfusion therapy (ERT) in patients with intracranial atherosclerosis (ICAS)-related acute large vessel occlusion (ALVO) may require different strategies based on the underlying culprit plaque lesion. This study investigated the effectiveness and safety of direct stent placement in ICAS-related ALVO compared with initially attempted mechanical thrombectomy (MT) with or without rescue treatment. Methods Direct stenting for ICAS-related ALVO was performed in 30 consecutive patients between January 1, 2012, and December 31, 2018. As a control for comparison, MT with or without rescue stenting for patients with ICAS-related ALVO was performed in 73 consecutive patients during the same period. Clinical outcomes were assessed by measuring modified Rankin Scale (mRS) at 90 days. Results Patients who underwent direct stenting and those who underwent MT with or without rescue stenting showed no significant differences in baseline characteristics. There was a higher proportion of patients with mRS 0–2 at 90 days in the direct stenting group than in the MT with or without rescue stenting group [24 (80.0%) vs. 34 (46.6%); p  = 0.004]. Successful recanalization to modified thrombolysis in cerebral infarction category 2b or 3 was achieved in 93.3% of patients who underwent direct stenting, and in 90.4% of patients who underwent MT with or without rescue stenting. Conclusion Direct stenting is an effective and safe option for ICAS-related ALVO. Further studies are needed to confirm that endovascular treatments are effective and safe in patients with ALVO and underlying ICAS.

Changes in cerebral blood flow (CBF) immediately after cigarette smoking (CS) are still unclear. Our purpose was to evaluate the hemodynamic changes in each intracranial vessel after CS by using quantitative magnetic resonance angiography (MRA). Fifteen healthy male smokers less than 45 years old with more than 3 pack-year smoking history were enrolled in this study. The hemodynamic change in the vessels, represented by cerebral flow rate (CFR, ml/s) and flow velocity (FV, cm/s), was quantitatively measured in eleven vascular segments of the brain using phase-contrast MRA. Two sets of data at each vessel before and after CS were statistically analyzed by paired t-test. Three of 15 participants, as a control group, followed all the procedures but did not smoke. Total CFR of the distal intracranial vessels (anterior, middle, and posterior cerebral arteries; ACA, MCA, and PCA) was significantly reduced after CS by 7.3% (847 vs. 785 ml/s, p = 0.024). Such flow changes were statistically more significant in the anterior circulation (ACA and MCA) compared to the posterior circulation (PCA). All distal intracranial vessels did not have significant FV change while peak systolic velocity and mean velocity dropped 7.4 and 4.3% and pulsatility index decreased 10.9% in the internal carotid artery. Regarding cross-sectional areas, all distal intracranial vessels showed diminished, and only MCA had a statistical significance (9.9 vs. 9.3 mm2, p = 0.016). There was a significant decrease of CFR after CS especially in the anterior circulation of twelve young male smokers. Considering the changes of FV and cross-sectional area all together, it can be suggested that cerebrovascular impedance increased after CS especially at the main trunk level of the distal intracranial vessels (ACA, MCA, and PCA).

The Alpha stent (CGBio), a new intracranial stent featuring a re-sheathable mesh design with improved wall apposition at the curved segment, was clinically evaluated. We report the 6-month follow-up results from a prospective, single-center study in which the stent was used for coiling of wide-necked distal internal carotid artery (ICA) aneurysms. Between April 2016 and 2018, 50 patients (mean age, 56.5 years, 45 females [90%]) with 54 unruptured distal ICA aneurysms (average diameter: 5.6 ± 1.7 mm) were enrolled. The primary endpoint for effectiveness was successful coil embolization with the Alpha stent, and subsequent complete or near-complete occlusion at the 6-month magnetic resonance angiography assessment. The primary safety endpoint was the absence of serious adverse events (SAEs) up to 6 months from the procedure. The primary effectiveness endpoint was observed in 94.4% (51/54) aneurysms. In one patient with technical failure, the stent could not be deployed because of parent artery tortuosity; therefore, a different type of stent was used. Of the 53 aneurysms treated with the Alpha stent, complete occlusion was achieved in 64.1% (34/53) cases, and near-complete occlusion was achieved in 32.0% (17/53) cases by the 6-month follow-up. Two cases (3.7%) required retreatment because of major recurrence. In 4% (2/50) patients, SAEs, i.e., retinal artery thromboembolism and corona radiata lacunar infarction, were reported after the procedure. For endovascular treatment of unruptured, wide-necked, distal ICA aneurysms, coil embolization using the newly developed Alpha stent showed excellent procedural and mid-term clinical follow-up results in terms of effectiveness and safety.

To identify clinical, laboratory, and magnetic resonance imaging (MRI) features in predicting incident stroke and dementia in Korean patients with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). We enrolled 87 Korean CADASIL patients who had undergone baseline clinical, laboratory, and MRI examinations between March 2012 and February 2015. The primary outcome of this study is the occurrence of stroke and dementia during the study period. The occurrence of incident stroke was confirmed by neuroimaging study, and dementia was defined by the diagnostic and statistical manual of mental disorders, fourth edition, criteria. Of the 87 patients, 57.5% were men, and the mean age was 63 ± 13 years (range 34-90 years), and 82 patients (94.3%) had p.Arg544Cys mutation. During an average follow-up of 67 months (interquartile range: 53-69 months), incident stroke occurred in 14 of 87 patients (16.1%) and incident dementia in 7 of 70 non-demented patients (10.0%). In adjusted analysis, increased systolic blood pressure was associated with increased risk of incident stroke [for every 10-mmHg increase; hazard ratio, 1.44 (1.02-2.03)]. Apolipoprotein E ε4 genotype was associated with an increased risk of incident dementia [hazard ratio, 10.70 (1.27-89.88)]. In this study, apolipoprotein E ε4 genotype was associated with the development of incident dementia, and higher blood pressure was associated with increased risk of incident stroke in CADASIL patients with predominant p.Arg544Cys mutation.

BackgroundAlthough 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.MethodsWe 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.ResultsSatisfactory 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.ConclusionsLoop 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.

Background Evidence supporting the use of statin therapy to reduce stroke recurrence and cardiovascular events in acute cardioembolic stroke (CES) patients without atherosclerosis is limited. Past observational studies have been hampered by selection bias and unmeasured confounding factors. This study aims to investigate the potential benefits of statin therapy in acute CES patients without established indications through a registry-based, randomized clinical trial. Methods This is a registry-based, multicenter, prospective, randomized, open-label, blinded endpoint (PROBE) study designed to evaluate the efficacy and safety of statin therapy in acute CES patients without established indications for statin use. Patients will be randomly assigned (1:1) to either statin users or non-users, with statin users receiving atorvastatin at a dose of 10 mg or higher throughout the study period. We plan to recruit 1036 participants to detect a relative risk reduction of 43% with 80% power and a two-sided alpha error of 0.05, accounting for a 10% loss to follow-up. The primary outcome is the occurrence of a major clinical event, defined as a composite of stroke recurrence, myocardial infarction, and all-cause mortality within 3 months after the index stroke. The secondary efficacy outcomes include (1) stroke recurrence, (2) all-cause mortality, (3) vascular death, and (4) major vascular events. Discussion This study will assist stroke physicians in determining the appropriate use of statin therapy for acute CES patients who do not have guideline-based indications. Trial registration CRIS Registration Number: KCT0006806. Registered on November 29, 2021. URL: https://cris.nih.go.kr/cris

There is currently no validated risk prediction model for recurrent events among patients with acute ischemic stroke (AIS) and atrial fibrillation (AF). Considering that the application of conventional risk scores has contextual limitations, new strategies are needed to develop such a model. Here, we set out to develop and validate a comprehensive risk prediction model for stroke recurrence in AIS patients with AF. AIS patients with AF were collected from multicenter registries in South Korea and Japan. A developmental dataset was constructed with 5648 registered cases from both countries for the period 2011‒2014. An external validation dataset was also created, consisting of Korean AIS subjects with AF registered between 2015 and 2018. Event outcomes were collected during 1 year after the index stroke. A multivariable prediction model was developed using the Fine-Gray subdistribution hazard model with non-stroke mortality as a competing risk. The model incorporated 21 clinical variables and was further validated, calibrated, and revised using the external validation dataset. The developmental dataset consisted of 4483 Korean and 1165 Japanese patients (mean age, 74.3 ± 10.2 years; male 53%); 338 patients (6%) had recurrent stroke and 903 (16%) died. The clinical profiles of the external validation set (n = 3668) were comparable to those of the developmental dataset. The c-statistics of the final model was 0.68 (95% confidence interval, 0.66 ‒0.71). The developed prediction model did not show better discriminative ability for predicting stroke recurrence than the conventional risk prediction tools (CHADS2, CHA2DS2-VASc, and ATRIA). Neither conventional risk stratification tools nor our newly developed comprehensive prediction model using available clinical factors seemed to be suitable for identifying patients at high risk of recurrent ischemic stroke among AIS patients with AF in this modern direct oral anticoagulant era. Detailed individual information, including imaging, may be warranted to build a more robust and precise risk prediction model for stroke survivors with AF.

Using data from the real world to solve clinical questions that cannot be answered using data from clinical trials is attracting more attention. Clinical outcomes for patients with esophageal cancer in a real-world setting might be different from data in randomized controlled trials. This study aimed to provide real world data on treatment and prognosis in Korean patients with esophageal cancer. This retrospective cancer cohort included newly diagnosed cases of esophageal cancer at 19 tertiary hospitals between January 1, 2005 and December 31, 2017. Cancer staging was defined according to the 7th edition of the American Joint Committee on Cancer criteria. We identified 6,354 patients with newly diagnosed esophageal cancer (mean age: 64.9 ± 9.0 years, 96.9% squamous cell carcinoma). The proportion of early esophageal cancer increased from 24.7% in 2005 to 37.2% in 2015 (p<0.001). Among all cases, surgery alone was 31.3%, followed by definitive concurrent chemoradiotherapy (CCRT) (27.0%), neoadjuvant therapy (12.4%), adjuvant therapy (11.1%), and endoscopic resection (5.8%). The 5-year overall survival rate was 45.7 ± 0.7%. Endoscopic resection provided similar median survival relative to surgery for stage Ia cases. Among stage II-III cases, definitive CCRT was associated with poorer survival than neoadjuvant or adjuvant therapy, although there was no survival difference between neo-adjuvant and adjuvant therapy. Early esophageal cancer is gradually becoming more common and endoscopic resection provided similar long-term survival relative to surgery. Surgery with combined therapy provided better survival in locally advanced esophageal cancer, relative to definitive CCRT.

Background Although endoscopic submucosal dissection (ESD) is standard therapy for early gastric cancer, the complication rate is unsatisfactory, with perforation as the major complication during ESD. There have been several reports regarding the complications of ESD for gastric tumor especially perforation; however, little is known about the predictors for complications in patients undergoing ESD. The purpose of this retrospective study was to determine the risk factors for perforation in patients with early gastric cancer during ESD. Methods Between February 2003 and May 2010, we performed ESD for 1,289 lesions in 1,246 patients at six tertiary academic hospitals in Daegu, Kyungpook, Korea. Patient-related variables (age, sex, and underlying disease), endoscopic-related variables (indication of ESD, lesion size, location, type, and mucosal ulceration), procedure-related variables (operation time, complete resection, and invasion of submucosa/vessel/lymph node), and the pathologic diagnosis were evaluated as potential risk factors. Results The mean age of the patients was 64 years. The mean size of the endoscopic lesion was 19.4 mm. The overall en bloc resection rate was 93.3 %. Perforation (microperforation and macroperforation) was seen in 35 lesions. The location of the lesion (long axis: body/short axis: greater and lesser curvature) and piecemeal resection were associated with perforation ( p  = 0.01/0.047 and p  = 0.049). Upon multivariate analysis, the location (body vs. antrum) of the lesion (odds ratio (OR) 2.636; 95 % confidence interval (CI) 1.319–5.267; p  = 0.006) and piecemeal resection (OR 2.651; 95 % CI 1.056–6.656; p  = 0.038) were significant predictive factors for perforation. Conclusions The result of this study demonstrated that the location of the lesion (body) and piecemeal resection were related to perforation during ESD.