MD; for the FSR InvestigatorsBackground and Purpose-Diabetes mellitus is an established risk factor for stroke. However, it is uncertain whether prestroke glycemic control (PSGC) status affects clinical outcomes of acute ischemic stroke. The aim of this study was to elucidate the association between PSGC status and neurological or functional outcomes in patients with acute ischemic stroke. Methods-From the Fukuoka Stroke Registry (FSR), a multicenter stroke registry in Japan, 3627 patients with first-ever ischemic stroke within 24 hours after onset were included in the present analysis. The patients were categorized into 4 groups based on their PSGC status: excellent (hemoglobin [Hb] A1c on admission Ͻ6.2%), good (6.2-6.8%), fair (6.9 -8.3%) and poor (Ն8.4%). Study outcomes were neurological improvement (Ն4 points decrease in the National Institutes of Health Stroke Scale [NIHSS] score during hospitalization or 0 points on NIHSS score at discharge), neurological deterioration (Ն1 point increase in NIHSS score) and poor functional outcome (death or dependency at discharge, modified Rankin Scale 2-6). Results-The age-and sex-adjusted ORs for neurological improvement were lower, and those for neurological deterioration and a poor functional outcome were higher in patients with poorer PSGC status. After adjusting for multiple confounding factors, these trends were unchanged (all probability values for trends were Ͻ0.002). These findings were comparable in patients with noncardioembolic and cardioembolic infarctions. Conclusions-In ischemic stroke patients, HbA1c on admission was an independent significant predictor for neurological and functional outcomes. (Stroke. 2011;42:2788-2794.)
Purpose: Anatomical factors involved in the difficulty of inserting a guiding catheter (GC) into the aortic arch include marked arteriosclerosis with severe vessel tortuosity and type-3/bovine aortic arches. For patients with such factors, we have inserted a balloon guiding catheter (BGC) using the balloon-inflation anchoring technique (BIAT). In this study, we introduce the BIAT, and examine its usefulness. Subjects and Methods:The subjects were 44 patients who underwent acute mechanical thrombectomy for occlusion of the major cerebral artery in anterior circulation between January 2014 and February 2016. Of these, the BIAT was used for BGC insertion in patients, with the above anatomical factors, in whom it was difficult to insert a BGC using the standard method. The BIAT is a technique with a BGC in which an inner catheter is guided to the peripheral side by dilating/anchoring a balloon at maximum at the origin of the brachiocephalic trunk or left common carotid artery, and, subsequently, a BGC is guided to the target blood vessel by slightly deflating the balloon as a flow-guide. Results:Of the 44 patients, BGC insertion was difficult in eight patients (18%). The mean age of the other patients (control group) was 68.9 years, whereas that of the eight patients was 79.7 years, being significantly more advanced (p = 0.025). The BIAT facilitated BGC insertion in all patients, and the technical success rate was 100%. There were no procedure-related complications. The mean interval from the start of femoral artery puncture until BGC insertion was 15.7 and 20.3 minutes, respectively, in the control and BIAT groups. There was no significant difference between the two groups (p = 0.35). Conclusion:In 18% of patients who underwent acute mechanical thrombectomy, BGC insertion was difficult. In this group, the proportion of elderly patients was significantly higher. The BIAT facilitated BGC insertion in all patients. The mean interval from the start of puncture until BGC insertion was 20 minutes; a BGC could be guided in a relatively short period. This procedure may be particularly useful for acute mechanical thrombectomy, of which the duration directly contributes to the outcome.Keywords▶ balloon-inflation anchoring technique, bovine aortic arch, type-3 aortic arch, acute ischemic stroke, thrombectomy
Objective: Vertebral arteriovenous fistula is a rare entity caused primarily by trauma and is known to occur iatrogenically after penetrating trauma of the neck and surgery of the cervical spine. We present a case of iatrogenic vertebral arteriovenous fistula that was caused by erroneous jugular vein puncture and could be radically treated by target embolization after localizing the shunt points using high-resolution cone-beam computed tomography (HR-CBCT) with a review of the literature. Case Presentation:A 76-year-old woman with a history of coronary artery disease treated with percutaneous intervention underwent scheduled cardiac catheterization by the right radial artery and right internal jugular vein approaches.Following several test punctures of the right cervical region, a 6 Fr sheath was placed in the right jugular vein, but she began to note tinnitus around this time. As vascular bruit was heard in the neck, the patient was referred to our hospital.By MRI and angiography, left vertebral arteriovenous fistula was diagnosed. Two shunt points could be identified by preoperative HR-CBCT. Trans-arterial target embolization was performed on the vein side across the shunt points, resulting in the disappearance of the shunt flow with tinnitus and vascular bruit. Conclusion:A case of iatrogenic vertebral arteriovenous fistula that could be radically treated by trans-arterial target embolization was reported. HR-CBCT was useful for the localization of the shunt points.
We report a case of atrial fibrillation in a patient in whom a mobile thrombus in the left atrial appendage increased in size after low-dose dabigatran therapy. A 74-year-old man was admitted to our hospital because of sudden onset of right hemiplasia and dysarthria. On admission, his National Institutes of Health Stroke Scale score was three. Axial diffusion-weighted magnetic resonance images and magnetic resonance angiography images showed hyperintense signals in the left front-parietal cerebral cortex without any intracranial stenotic lesions, and acute cardioembolic stroke associated with nonvalvular atrial fibrillation was diagnosed. Transesophageal echocardiography revealed a mobile thrombosis (1.0 × 2.2 cm) in the left atrial appendage, and dabigatran therapy (110 mg b.i.d.) was initiated to prevent stroke recurrence. Transesophageal echocardiography performed 6 days later revealed that the size of the thrombus had increased to 1.5 × 3.0 cm. Medication was changed to warfarin, and the thrombosis subsequently decreased in size. The patient did not have a recurrent stroke and was discharged with a National Institutes of Health Stroke Scale score of zero. This case demonstrates that low-dose dabigatran may not be effective in reducing the size of a thrombus.
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