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Purpose This study aims to introduce an effective protocol for transvaginal ethanol sclerotherapy, focussing on the aspiration of viscous cystic content and the amount of ethanol instilled in the cystic cavity according to cyst size. Methods We retrospectively reviewed the medical records of 90 women who underwent transvaginal ethanol sclerotherapy from 2015 to 2022 at Good Moonhwa Hospital, Busan, Republic of Korea. The volume of ethanol used for sclerotherapy was determined based on the initial volume of aspirated cystic content, with a target limit of 30 cc, and the injected alcohol was retained within the cystic cavity. All patients were followed up on postoperative days 1 and 2, at 2 weeks, 4 weeks, 3 months, 6 months, 12 months, and every 6 months thereafter to assess the ovary, AMH level, complications, recurrence, and pregnancy outcome. Results The cyst size was 5.07 ± 1.56 cm. AMH levels increased in 22 cases (27.4%) and decreased in 68 cases (75.6%). Among the 68 cases that decreased, 38 cases (55.9%) showed a mild decrease of less than 30%. The change rates in AMH levels did not significantly correlate with cyst size, aspirated cyst volume, alcohol instillation volume, operation time, recurrence rate, or pregnancy outcome. The volume of alcohol instilled significantly correlated with operation time. Of the 44 patients (78.9%) who wished to conceive, 17 (38.6%) became pregnant (12 spontaneously and 5 via IVF-ET). Recurrence occurred in 6 cases (6.67%). Conclusion This study demonstrates that our protocol for ethanol sclerotherapy not only significantly reduces the recurrence rate but also preserves ovarian reserve, as reflected by the minimal impact on AMH.

ObjectiveAcute ischemic stroke in the territory of anterior cerebral artery (ACA) is uncommon. Therefore, large population studies evaluating ACA infarction are scarce. We sought to evaluate epidemiological and etiological characteristics of ACA infarction compared to other territorial infarctions.MethodsWe analyzed a prospectively collected stroke registry of all acute ischemic stroke patients for 19 years at two tertiary hospitals. We included patients with acute ischemic stroke caused by large vessel stenosis or occlusion including ACA, middle cerebral artery (MCA), posterior cerebral artery (PCA), and vertebrobasilar artery (VBA).ResultsA total of 4171 patients were enrolled. Patients with ACA infarction (N = 288) were significantly older with more females than those with MCA, PCA, or VBA infarction. There were more patients with history of prior ischemic stroke in the ACA infarction group than in other groups. The etiology of the ACA infarction was similar to those of the MCA, PCA and also the total population (66.7–71.8% of LAA and 17.9–20.9% of CE). When patients had prior ischemic stroke history, ACA infarction was more likely to be caused by LAA than MCA or PCA infarction (OR = 6.2, 95% CI 2.0–19.2, p = 0.002 and OR = 4.0, 95% CI 1.1–14.6, p = 0.038, respectively).ConclusionsPatients with ACA infarction had significantly more prior ischemic stroke than those with MCA, PCA, or VBA infarction. The etiology of ACA infarction in patients with prior ischemic stroke showed significantly more LAA than that of MCA or PCA infarction.

The optic nerve sheath diameter (ONSD) can predict intracranial pressure and outcomes in neurological disease, but it remains unclear whether a small ONSD can be accurately measured on routine CT images with a slice thickness of approximately 4–5 mm. We measured the ONSD and ONSD/eyeball transverse diameter (ETD) ratio on routine-slice (4 mm) and thin-slice (0.6–0.75 mm) brain CT images from initial scans of acute ischemic stroke (AIS) patients. ONSD-related variables, National Institutes of Health Stroke Scale (NIHSS) scores, and age were compared between good (modified Rankin Scale [mRS] ≤ 2) and poor (mRS > 2) outcomes at discharge. Among 155 patients, 38 had poor outcomes. The thin-slice ONSD was different between outcome groups (p = 0.047), while the routine-slice ONSD showed no difference. The area under the curve (AUC) values for the ONSD and ONSD/ETD were 0.58 (95% CI, 0.49–0.66) and 0.58 (95% CI, 0.50–0.66) on the routine-slice CT, and 0.60 (95% CI, 0.52–0.68) and 0.62 (95% CI, 0.54–0.69) on the thin-slice CT. The thin-slice ONSD/ETD ratio correlated with initial NIHSS scores (r = 0.225, p = 0.005). After adjusting for NIHSS scores and age, ONSD-related variables were not associated with outcomes, and adding them to a model with NIHSS scores and age did not improve performance (all p-values > 0.05). Although ONSD measurements were not an independent outcome predictor, they correlated with stroke severity, and the thin-slice ONSD provided a slightly better prognostic performance than the routine-slice ONSD.

This study aimed to describe patterns of long-term antithrombotic use in acute ischemic stroke (AIS) patients with non-valvular atrial fibrillation (NVAF) in Korea and their impacts on clinical events before introduction of non-vitamin K antagonist oral anticoagulants (NOAC) into practice in 2015. Patients with NVAF who were admitted due to the AIS and discharged no later than 2008 were enrolled retrospectively. Data were collected at 11 time points during the first 3 years of follow-up. The primary outcome event was a composite of stroke recurrence, major bleeding, and death. Vitamin K antagonist (VKA) users were categorized into a well-controlled INR group and a poorly-controlled INR group (modified TTR ≥47.0% vs <47.0%). Of 1,350 patients enrolled in this study, 95% were on antithrombotic medications at discharge. The rate of VKA usage decreased over time (77% and 40% at discharge and 3 years, respectively). The cumulative event rates of the primary outcome differed by treatment patterns. Among the 10 most frequent treatment types, the highest outcome rate was observed in patients who started with VKA-only therapy but discontinued VKAs during follow-up without restarting (70.2%); this was followed by those starting with antiplatelet-only therapy and stopping it without restart (66.7%). Among VKA users, the 3-year cumulative primary outcome rates were higher in the poorly-controlled INR group than the well-controlled INR group (24.5% vs 15.7%; p = 0.015). Our study revealed that, in pre-NOAC era, there was a wide spectrum of long-term antithrombotic use. The incidence of the composite outcome also varied by patterns of antithrombotic use.

Background: The radiologic diagnosis of vertebral artery dissection (VAD) depends on characteristic intraluminal findings on angiography and intramural hematoma or a double-lumen sign on high-resolution vessel wall imaging. We aimed to evaluate the accuracy of intramural hematoma sign on susceptibility-weighted imaging (SWI) in VAD. Methods: We retrospectively analyzed SWI, phase map images and brain computed tomography (CT) of the consecutive patients who suffered an ischemic stroke in the vertebral artery territory from August 2010 to July 2012. We divided the patients into 2 groups: the VAD group and the nondissection group. VAD was diagnosed by conventional catheter angiographic findings (aneurysmal dilatation, pearl-and-string or tapered steno-occlusion) and pathognomonic findings such as intramural hematoma or a double-lumen sign on the source images of TOF-MRA, high-resolution T 1 -weighted MRI or high-resolution T 2 -weighted MRI. Intramural hematoma sign was considered positive if the patient had an eccentric or concentric hypointense signal lesion in the vertebral artery on SWI, a corresponding hyperintense signal on phase map and no evidence of calcification on the brain CT, suggesting blood products other than calcification. Two experienced neuroradiologists blinded to clinical information and angiographic findings were asked to judge for the presence of intramural hematoma sign on SWI. The accuracy of intramural hematoma sign on SWI was evaluated. Phase value, demographic and clinical data were compared between the VAD and the nondissection groups. Results: Thirty-nine patients were included: 10 in the VAD group and 29 in the non-dissection group. Among the VAD group cases, intramural hematoma sign on SWI was positive in 9 of the 10 VAD cases and in 1 out of the 29 cases in the nondissection group. The intramural hematoma sign on SWI was significantly associated with VAD (p < 0.001), and showed sensitivity of 90% and specificity of 96.6%. Mean phase values of intramural hematomas (n = 9) were all positive and those of calcified lesions (n = 13) were all negative (0.45 radian vs. -0.42 radian, p < 0.001). Conclusions: The intramural hematoma sign on SWI was significantly associated with VAD and the phase map values were higher in intramural hematomas when compared with atherosclerotic calcifications.

Background: Aspirin is a proven antiplatelet agent in acute ischemic stroke, and there are no current guidelines for other antiplatelet treatments. We aimed to compare the efficacy and safety of cilostazol with aspirin in acute stroke. Methods: Patients with measurable neurological deficits (NIHSS score ≤15) within 48 h of onset were randomly assigned to cilostazol (200 mg/day) or aspirin (300 mg/day) for 90 days. The primary endpoint was a modified Rankin Scale (mRS) score of 0–2 at 90 days. Cardiovascular events, bleeding complications, and other functional outcomes were also assessed. Statistical analysis was carried out by intention-to-treat and per-protocol bases. This trial is registered with ClinicalTrials.gov (NCT00272454). Results: In total, 458 patients were enrolled (mean age of 63 years, median NIHSS of 3), and mRS at 90 days was obtained in 447 patients. The primary endpoint was achieved in 76% (173/228) of those randomized to cilostazol and in 75% (165/219) assigned to aspirin, which supported the pre-specified non-inferiority of cilostazol to aspirin (95% CI of proportion difference: –6.15 to 7.22%, p = 0.0004). These results were also supported by per-protocol analysis (p = 0.045). Cardiovascular events occurred in 6 patients (3%) treated with cilostazol, and in 9 patients (4%) treated with aspirin (p = 0.41). Adverse events were more common in cilostazol-treated patients during the trial (91 vs. 85%, p = 0.055), while the frequencies of bleeding complications (cilostazol 11%, aspirin 13%, p = 0.43) or drug discontinuation (cilostazol 10%, aspirin 7%, p = 0.32) were not different. Conclusion: Cilostazol is feasible in acute ischemic stroke, and comparable to aspirin in its efficacy and safety.

Introduction: Eccentric vessel wall enhancement (EVWE) and high-sensitivity C-reactive protein (hs-CRP) are inflammatory biomarkers associated with atherosclerotic disease. We investigated their prognostic value in patients with acute ischemic stroke receiving guideline-adherent medical treatment. Patients and methods: In this prospective observational cohort study, patients with acute ischemic stroke attributed to intracranial arterial disease (ICAD) underwent vessel wall MRI and hs-CRP testing. The study included intracranial cases of both large artery atherosclerosis (LAA) and small vessel occlusion (SVO). The primary outcome was subsequent ischemic stroke during the follow-up period. The median follow-up duration was 21 months. Kaplan-Meier survival and Cox regression analysis was used to determine the associations between EVWE, hs-CRP levels, and subsequent ischemic stroke. Results: Among 191 patients, 81 (42.4%) had EVWE. EVWE positivity showed a trend toward a lower risk of subsequent ischemic stroke compared to EVWE negativity (HR 0.32, 95% CI 0.12–0.87; p = 0.061). Hs-CRP levels were not associated with recurrent stroke risk. The combination of EVWE positivity and low hs-CRP levels (<1.25 mg/l) was associated with a favorable outcome, while EVWE negativity and high hs-CRP levels (⩾1.25 mg/l) were associated with an unfavorable outcome (HR 0.143, 95% CI 0.04–0.50; p = 0.031). Discussion: In this observational study of patients with intracranial atherosclerotic stroke receiving optimal medical therapy, EVWE positivity appeared to be associated with a trend toward lower risk of recurrent stroke, though this relationship requires further validation. Conclusion: The combination of EVWE and hs-CRP status might potentially offer prognostic information, with preliminary data suggesting that EVWE positivity and low hs-CRP levels could be associated with more favorable outcomes in patients receiving guideline-adherent medical treatment. These preliminary findings suggest a possible role for combining imaging and serum inflammatory biomarkers in risk stratification, though larger prospective studies are needed to confirm these associations. Graphical abstract

IntroductionThis study is to explore the long-term functional outcome of antihypertensive medication-naïve, untreated hypertension (HTN) patients with acute ischemic stroke compared to those with no prior HTN and those with treated HTN.Patients and methodsWe analyzed a prospectively collected stroke registry of all patients with acute ischemic stroke consecutively admitted to Incheon St. Mary’s Hospital. Patients who received reperfusion therapy were excluded. Long-term functional outcomes were assessed at a 3-month follow-up visit using the modified Rankin Scale.ResultsA total of 1044 patients was enrolled. Compared to patients with no or treated HTN, those with untreated HTN had higher odds for more favorable outcomes (adjusted odds ratio (OR): 1.7 [95% CI: 1.0–2.7, p = 0.050*] and 1.7 [95% CI: 1.0–2.8, p = 0.047*], respectively) when the stroke was large vessel atherosclerosis (LAA)/cardioembolic (CE) with large vessel occlusion/stenosis. However, no such association was observed when there was no large vessel occlusion or stenosis, in total patients, or if the index stroke was related to SVO.In untreated HTN patients with LAA/CE and large vessel occlusion/stenosis compared to patients in the lowest mean arterial pressure quartile (< 96.7 mmHg), patients in the second and third highest quartiles had higher odds of favorable outcomes.ConclusionsPatients with untreated HTN had significantly more favorable outcomes at 3 months after ischemic stroke compared to those with no or treated HTN when the stroke was LAA/CE with large vessel occlusion/stenosis. Untreated HTN patients also showed an association between higher MAP and favorable outcomes.

Abstract IntroductionStudies regarding multiple chronic lacunes (MCLs) and clinical outcome according to stroke etiology are scarce. We sought to evaluate the association between MCL and short-term/long-term clinical outcomes according to stroke etiology.Patients and methodsWe analyzed a prospectively collected stroke registry of acute ischemic stroke patients over 4 years. The enrolled patients were classified as having large artery atherosclerosis (LAA), small vessel occlusion (SVO), cardioembolic (CE) stroke, and other etiology. The early neurological deterioration (END) and favorable outcome at 3 months were assessed.ResultsA total of 1070 patients were enrolled. Patients with MCL had significantly more END compared to those without MCL both in total population (adjusted odds ratio (OR), 1.7; 95% confidence interval [CI], 1.1–2.5; p = 0.013*) and in the LAA group (adjusted OR, 2.3; 95% CI, 1.3–4.2, p < 0.006). Patients with MCL had a significantly lower OR for favorable outcome at 3 months compared to those without MCL both in total population (adjusted OR, 0.7; 95% CI, 0.5–1.0, p = 0.035) and in the LAA group (adjusted OR, 0.6; 95% CI, 0.3–1.0, p = 0.043). However, MCL was not associated with END or long-term functional outcome in patients with SVO, CE, or other etiology.ConclusionsThe presence of MCL was an independent predictive factor for END as well as long-term poor functional outcome in acute ischemic stroke patients. These associations were only observed in patients with LAA, not in those with SVO, CE, or other etiology.

Hemorrhagic transformation (HT) is one of the most feared complications of acute recanalization therapies. The aim of this study was to evaluate whether blood-brain barrier permeability (BBBP) imaging can predict HT in the setting of acute recanalization therapy and to determine the sensitivity and specificity of BBBP for the prediction of HT according to the type of reperfusion therapy. We assessed a total of 46 patients who received recanalization therapy (intravenous (IV) recombinant tissue plasminogen activator (tPA), mechanical thrombectomy with a stent retriever or both) for acute ischemic stroke within the internal carotid artery or middle cerebral artery. BBBP above the threshold was significantly associated with HT after adjustment for confounding factors in all patients (OR 45.4, 95% CI 2.9~711.2, p = 0.007), patients who received IV tPA (OR 20.1, 95% CI 1.2–336.7, p = 0.037), and patients who received endovascular therapy (OR 47.2, 95% CI 1.9–1252.5, p = 0.022). The sensitivity and specificity of the initial BBBP measurement as a predictor of HT in the overall 46 patients were 80 and 71%, respectively. These values were 75 and 64% in only IV tPA group, 100 and 80% in only endovascular group, 77 and 67% in IV tPA with or without endovascular therapy group, and 86 and 76% in endovascular therapy with or without bridging IV tPA therapy group. Increased pretreatment BBBP values were significantly associated with HT after acute recanalization therapy. This correlation with HT was stronger in patients receiving endovascular mechanical thrombectomy than in patients receiving IV rtPA.