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We report a case of acquired tracheoinnominate artery fistula TIF at 6 months after tracheostomy in a 78 year old woman. She had massive hemorrhage from the stoma when the tracheostomy tube cuff was deflated. The hemorrhage was temporarily controlled by hyperinflating the cuff. Contrast enhanced computed tomography CT angiography revealed TIF. The patient died the next day because of massive rebleeding.TIF, a highly fatal complication of tracheostomy incidence rate, 0.1 4 , mostly occurs within 48 h to 4 weeks after tracheostomy. TIF usually results from erosion of the tracheal and innominate arterial walls by the tracheostomy tube cuff or tube tip. The risk factors for this condition include high intracuff pressure, mucosal trauma caused by malpositioned cannula tip, low tracheostomy, and deformity and shifting of the trachea and major blood vessels. Although the complication cannot be completely prevented, it may be avoided by creating the stoma at the second to third tracheal cartilage or appropriate management of intracuff pressure. Minor tracheal bleeding, also called sentinel bleeding, is an early sign of TIF if noted, the cause of bleeding should be immediately confirmed by bronchoscopy or CT, and suitable interventions should be initiated. Thus, TIF is a life threatening condition and is a risk that should be considered in tracheostomy management.

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Background Endovascular treatment (EVT) for acute large vessel occlusion has proven to be effective in randomized controlled trials. We conducted a prospective cohort study to evaluate the real-world efficacy of EVT in a metropolitan area with a large number of comprehensive stroke centers and to compare it with the results of other registries and RCTs. Methods We analyzed the Kanagawa Intravenous and Endovascular Treatment of Acute Ischemic Stroke registry, a prospective, multicenter observational study of patients treated by EVT and/or intravenous tissue-type plasminogen activator (tPA). Of the 2488 patients enrolled from January 2018 to June 2020, 1764 patients treated with EVT were included. The primary outcome was a good outcome, which was defined as a modified Rankin Scale (mRS) of 0 to 2 at 90 days. Secondary analysis included predicting a good outcome using multivariate logistic regression analysis. Results The median age was 77 years and the median National Institute of Health Stroke Scale (NIHSS) score was 18. Pretreatment mRS score 0-2 was 87%, and direct transport was 92%. The rate of occlusion in anterior circulation was 90.3%. Successful recanalization was observed in 88.7%. The median time from onset to recanalization was 193 minutes. Good outcomes at 90 days were 43.3% in anterior circulation and 41.9% in posterior circulation. Overall mortality was 12.6%. Significant predictors for a good outcome were: age, male, direct transfer, NIHSS score, Alberta Stroke Program Early Computed Tomography Score, intravenous tPA, and successful recanalization. Conclusions EVT in routine clinical use in a metropolitan area showed comparable good outcomes and lower mortality compared to previous studies, despite the high proportion of patients with older age, pretreatment mRS score of > 2, posterior circulation occlusion, and higher NIHSS. Those results may have been associated with more direct transport and faster onset-to-recanalization times.

Background: Endovascular treatment (EVT) for acute large vessel occlusion has been found to be effective in several randomized controlled trials. We conducted a prospective cohort study to evaluate the real-world efficacy of EVT in patients with acute ischemic stroke in a metropolitan area with a high population density and a large number of comprehensive stroke centers. Methods: We analyzed the Kanagawa Intravenous and Endovascular Treatment of Acute Ischemic Stroke registry, a prospective, multicenter observational study of patients treated by EVT and/or intravenous tissue-type plasminogen activator (tPA), in Kanagawa, Japan. Of the 2488 patients enrolled from January 2018 to June 2020, 1764 patients treated with EVT were included. The primary outcome was a good outcome, which was defined as a modified Rankin Scale (mRS) of 0 to 2 at 90 days. Secondary analysis included predicting a good outcome using multivariate logistic regression analysis. Results: The median age was 77 years and the median National Institute of Health Stroke Scale (NIHSS) score was 18. Pretreatment mRS score 0-2 was 87%, and direct transport was 92%. The rate of occlusion in anterior circulation was 90.3%. Successful recanalization was observed in 88.7%. The median time from onset to recanalization was 193 minutes. Good outcomes at 90 days were 43.3% in anterior circulation and 41.9% in posterior circulation. Furthermore, 49.3% of patients with anterior circulation obstruction who had pre-stroke mRS 0-2 had good outcome, which was higher than the HERMES trial. Overall mortality was 12.6%. Significant predictors for a good outcome were: age, male, direct transfer, NIHSS score, Alberta Stroke Program Early Computed Tomography Score, intravenous tPA, and successful recanalization. Conclusions: EVT in routine clinical use in a metropolitan area showed comparable good outcomes and lower mortality compared to previous registries and RCTs, despite the high proportion of patients with older age, pretreatment mRS score of > 2, posterior circulation occlusion, and higher NIHSS. Those results may have been associated with more direct transport and faster onset-to-recanalization times.