Objectives
Thrombi in cerebral large vessel occlusion associated with active cancer are often fibrin and platelet-rich white thrombi. However, evaluating the thrombus composition in a short time ...before thrombectomy is often ineffective. We sought to determine factors related to white thrombi in acute ischemic stroke due to large vessel occlusion in cancer patients.
Methods
Consecutive cancer patients undergoing thrombectomy for acute ischemic stroke due to large vessel occlusion between January 2018 and May 2022 were retrospectively reviewed. The patients were classified into white thrombus and red thrombus groups on the basis of the pathological findings of retrieved thrombi. Patient characteristics and laboratory findings were compared between the two groups.
Results
There were 12 patients in the white thrombus group and 11 patients in the red thrombus group. Active cancer was significantly more in the white thrombus group than in the red thrombus group (91.7% vs. 36.3%, p = 0.0094). Internal carotid artery occlusion was significantly less in the white thrombus group than in the red thrombus group (0% vs. 36.4%, p = 0.037). Among laboratory findings, D-dimer levels were an independent factor associated with white thrombi (odds ratio 8.97 95% confidence interval 1.71–368.99, p < 0.0001). The cutoff value of D-dimer levels for predicting white thrombi was 3.5 μg/mL (83.3% sensitivity and 100% specificity).
Conclusions
In acute ischemic stroke in cancer patients, active cancer, no internal carotid artery occlusion, and higher D-dimer levels (≥3.5 μg/mL) may be associated with occlusion with fibrin and platelet-rich white thrombi.
A 78-year-old woman was diagnosed with cerebral infarction due to left hemiplegia by her family physician and was transferred to our hospital. On arrival, she had the NIHSS score of 15, right M1 ...occlusion on head MRA taken by her family physician, and a DWI-Alberta stroke program early CT score (DWI-ASPECTS) of 8. A white thrombus was retrieved by thrombectomy, and recanalization of thrombolysis in cerebral infarction (TICI) grade 3 was obtained, but the left hemiplegia did not resolve. On day 2, there was progression of impaired consciousness, the NIHSS score was 19, right M1 occlusion was observed again on head MRA, and the DWI-ASPECTS was 5. A white thrombus was retrieved again by the second thrombectomy, leading to TICI grade 2b recanalization. Postoperative contrast-enhanced CT of the trunk showed advanced pancreatic cancer. Based on elevated D-dimer levels and characteristics of the thrombi, we determined that the mechanism of the first M1 occlusions was cancer-associated embolism. The patient died of the primary disease on day 39. Cancer-associated occlusion of the major cerebral artery requires careful follow-up because of the possibility of reocclusion of recanalized sites with vascular endothelial damage due to hypercoagulable conditions in a short time period after mechanical thrombectomy.
Correspondence to Dr Hiroki Matsuura, Department of General Internal Medicine, Okayama City Hospital, Okayama 700-0962, Japan; superonewex0506@yahoo.co.jp A 31-year-old woman presented to the ...emergency department with an acute onset of severe abdominal pain, vomiting and abdominal distension 2 hours after binge eating at buffet-style restaurant. The causes of acute gastric dilation included postoperative complications, anorexia nervosa, bulimia nervosa, diabetes mellitus, electrolyte abnormalities, trauma, gastric volvulus, acute pancreatitis and SMA syndrome, as in this current case.1 2 Several cases have been reported following radiofrequency catheter ablation for supraventricular arrhythmia.3 Severe complications of acute gastric dilation include gastric infarction, necrosis, perforation and compression of the aorta.4 5 Early diagnosis and appropriate gastrointestinal decompression can prevent these severe complications. Two cases of acute gastric dilation after radiofrequency catheter ablation for supraventricular arrhythmia.
We retrospectively examined the initial experience and learning curve after the introduction of thrombectomy with the combined technique using an aspiration catheter and a stent retriever as ...first-line attempt for acute ischemic stroke.
Consecutive patients undergoing thrombectomy for acute ischemic stroke at our institution between January 2020 and December 2022 were divided into 3 groups according to the year of thrombectomy. Patient characteristics and procedural, safety, and clinical outcomes were compared between the three year periods to determine predictors of favorable clinical outcome.
In 2020, 2021, and 2022, the numbers of patients were 74, 70, and 90, respectively, with similar patient characteristics across the three years; successful recanalization rates were 79.7%, 97.1%, and 93.3%, respectively (P < 0.01 for the first 2 years); median procedure times were 67, 43, and 32 minutes, respectively (P < 0.01 for the first 2 years and P = 0.018 for the last 2 years); first pass effect rates were 20.3%, 41.4%, and 44.4%, respectively (P < 0.01 for the first 2 years); symptomatic intracranial hemorrhage rates were 14.9%, 2.9%, and 1.1%, respectively (P = 0.018 for the first 2 years); and percentages of modified Rankin Scale score 0–2 at 90 days were 24.3%, 42.9%, and 41.1%, respectively (P = 0.022 for the first 2 years). Procedure time (P = 0.038) and successful recanalization (P = 0.041) were independent predictors of favorable clinical outcome.
The learning curve effect of the combined technique may be associated with better clinical outcome due to increased successful recanalization rates, shortened procedure time, and reduced symptomatic intracranial hemorrhage.
BACKGROUND The main feeding artery of an anterior condylar arteriovenous fistula (AC-AVF) is the ascending pharyngeal artery and rarely the internal maxillary artery. OBSERVATIONS A 58-year-old male ...with a history of sinusitis since adolescence presented with a 5-year history of bilateral pulsatile tinnitus and a 2-month history of right ocular symptoms. Angiography showed that the peripheral branches of the bilateral internal maxillary arteries were the main feeding arteries of the AC-AVF and that they gathered in the clivus with a relatively large shunted pouch in the left jugular tubercle. Shunt flow drained to the right external jugular vein via the right superior ophthalmic vein. A sheath was placed in the right external jugular vein, and a small distal access catheter was guided to the right superior ophthalmic vein to allow the microcatheter to reach the shunted pouch. Selective angiography of the contralateral sphenopalatine artery allowed us to confirm the gathering site of the feeding arteries and the shunted pouch and archive the complete occlusion. LESSONS Selective angiography of the contralateral sphenopalatine artery may be useful to confirm the gathering site of the peripheral branches of the bilateral internal maxillary arteries in an AC-AVF.
Objective
Pseudoaneurysms are a serious complication of neuroendovascular therapy with femoral artery puncture, for which ultrasound-guided compression repair (UGCR) is often the first choice of ...radical therapy. We sought to retrospectively investigate the factors for failure of UGCR for pseudoaneurysm at the femoral artery puncture site.
Methods
Among patients undergoing neuroendovascular therapy with femoral artery puncture at our hospital between January 2018 and April 2021, those who received a diagnosis of pseudoaneurysm and underwent UGCR were enrolled. They were classified into two groups according to whether UGCR was successful (UGCR group) or was converted to surgical repair (SR group). Patient and procedural characteristics were compared between the two groups.
Results
During the study period, 577 patients underwent neuroendovascular therapy with femoral artery puncture, 10 of whom (1.7%) received a diagnosis of pseudoaneurysm and underwent UGCR. There were seven patients in the UGCR group and three patients in the SR group. The sheath diameter tended to be larger in the SR group than in the UGCR group (p = 0.16). The modified Rankin scale score when a diagnosis of pseudoaneurysm was made was significantly lower in the SR group than in the UGCR group (1 0–2 vs. 3 2–5, p = 0.037).
Conclusions
Physical activity may be associated with failure of UGCR. In patients with high physical activity, the use of sedatives and analgesics to keep them at rest during puncture site compression after UGCR may lead to successful UGCR.
A 78-year-old woman was diagnosed with cerebral infarction due to left hemiplegia by her family physician and was transferred to our hospital. On arrival, she had the NIHSS score of 15, right M1 ...occlusion on head MRA taken by her family physician, and a DWI-Alberta stroke program early CT score (DWI-ASPECTS) of 8. A white thrombus was retrieved by thrombectomy, and recanalization of thrombolysis in cerebral infarction (TICI) grade 3 was obtained, but the left hemiplegia did not resolve. On day 2, there was progression of impaired consciousness, the NIHSS score was 19, right M1 occlusion was observed again on head MRA, and the DWI-ASPECTS was 5. A white thrombus was retrieved again by the second thrombectomy, leading to TICI grade 2b recanalization. Postoperative contrast-enhanced CT of the trunk showed advanced pancreatic cancer. Based on elevated D-dimer levels and characteristics of the thrombi, we determined that the mechanism of the first M1 occlusions was cancer-associated embolism. The patient died of the primary disease on day 39. Cancer-associated occlusion of the major cerebral artery requires careful follow-up because of the possibility of reocclusion of recanalized sites with vascular endothelial damage due to hypercoagulable conditions in a short time period after mechanical thrombectomy.
Differential methylation between the two alleles of a gene has been observed in imprinted regions, where the methylation of one allele occurs on a parent-of-origin basis, the inactive X-chromosome in ...females, and at those loci whose methylation is driven by genetic variants. We have extensively characterized imprinted methylation in a substantial range of normal human tissues, reciprocal genome-wide uniparental disomies, and hydatidiform moles, using a combination of whole-genome bisulfite sequencing and high-density methylation microarrays. This approach allowed us to define methylation profiles at known imprinted domains at base-pair resolution, as well as to identify 21 novel loci harboring parent-of-origin methylation, 15 of which are restricted to the placenta. We observe that the extent of imprinted differentially methylated regions (DMRs) is extremely similar between tissues, with the exception of the placenta. This extra-embryonic tissue often adopts a different methylation profile compared to somatic tissues. Further, we profiled all imprinted DMRs in sperm and embryonic stem cells derived from parthenogenetically activated oocytes, individual blastomeres, and blastocysts, in order to identify primary DMRs and reveal the extent of reprogramming during preimplantation development. Intriguingly, we find that in contrast to ubiquitous imprints, the majority of placenta-specific imprinted DMRs are unmethylated in sperm and all human embryonic stem cells. Therefore, placental-specific imprinting provides evidence for an inheritable epigenetic state that is independent of DNA methylation and the existence of a novel imprinting mechanism at these loci.
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