Absence of susceptibility vessel sign with cancer- associated hypercoagulability-related stroke.

BACKGROUND AND PURPOSE: Susceptibility vessel sign (SVS), a hypointense signal on MR T2-weighted gradient-recalled echo images, is associated with erythrocyte-predominant thrombi, which are often present in cardioembolism (CE). In contrast, cancer-associated hypercoagulability (CAH)-related stroke, which is presumably caused by fibrin-predominant thrombi, is associated with the absence of SVS. We hypothesized that the prevalence of SVS may be of help in distinguishing CAH-related stroke from CE. This study attempted to validate this hypothesis and investigated the usefulness of SVS in differentiating CAH-related stroke from CE. MATERIALS AND METHODS: We retrospectively studied both CAH-related stroke patients (CAH group) and CE patients (CE group), who had major cerebral artery occlusion on MR angiography that was performed within 6 hours of stroke onset. All patients visited our department from 2015 to 2021. CAH-related stroke was defined as 1) complication of active cancer, 2) pre-treatment D-dimer value >3 µg/mL, 3) multiple vascular territories infarctions, and 4) lack of any other specifically identified causes of stroke. We compared SVS positivity rates within each group. Multivariable logistic regression analysis was used to assess the association between the absence of SVS and CAH-related stroke. RESULTS: Of 691 patients with CAH-related stroke or CE, major cerebral artery occlusion was observed in 10 patients in the CAH group and 198 patients in the CE group. The absence of SVS was identified in 55 of 208 patients and was significantly more frequent in the CAH versus the CE group (90% versus 24%, p < 0.05). For predicting CAH-related stroke, absence of SVS demonstrated a sensitivity of 90% (95% confidence interval [95%CI] 59-99), specificity of 78% (95%CI 71-83), positive predictive value of 18 (95%CI 10- 31), negative predictive value of 99% (95%CI 96-99), and a likelihood ratio of 4.06. Multivariable logistic regression analysis revealed that the absent of SVS was independently associated with CAH-related stroke (odds ratio 43, 95% [CI] 6.8-863; p < 0.01). CONCLUSIONS: The absence of SVS was more frequent in CAH-related stroke versus that found for CE. These findings could potentially be helpful for clinical management and differentiating between CE and CAH-related stroke. ABBREVIATIONS: CAH, cancer-associated hypercoagulability; CE, cardioembolism; SVS, susceptibility vessel sign; GRE, gradient recalled echo.

Influence of single pass recanalization in acute ischemic stroke with large vessel occlusion in patients of Asian ethnicity.

BACKGROUND AND PURPOSE: A previous report revealed single pass recanalization was associated with better functional outcome for patients with acute ischemic stroke with large vessel occlusion in real-world settings. However, the effect of single pass recanalization in acute large vessel occlusion based on the largest registry in real-world settings in Asian population are not well scrutinized. MATERIALS AND METHODS: RESCUE-Japan Registry-2 was a physician-initiated prospective multicenter registry that enrolled consecutive patients with acute large vessel occlusion who were admitted within 24 h of onset. We compared patients who underwent endovascular therapy and achieved good recanalization in single or multiple device passes (single-pass group and multiple-passes group, respectively) in terms of the good outcome defined as modified Rankin Scale of 0-2 at 90 days after onset. We estimated the odds ratios, safety and mortality adjusting for confounders. RESULTS: Among 2420 patients registered, 1281 patients treated with endovascular therapy. 829 patients were analyzed (557 patients in single-pass and 272 patients in multiple-passes group). Patient characteristics were almost similar between two groups. The good outcome was more observed of patients in the single groups (51.5% vs 39.3%). The adjusted odds ratio of single pass of good outcome was 1.92 (95% confidence interval, 1.37-2.69). The frequencies of symptomatic intracranial hemorrhage were similar between the two groups. CONCLUSION: Single pass recanalization was associated with good clinical outcome on real-world settings in Asian population.

Diffusion-Weighted Imaging-Fluid-Attenuated Inversion Recovery Mismatch Is Associated with 90-Day Functional Outcomes in Patients Undergoing Mechanical Thrombectomy.

BACKGROUND AND PURPOSE: Diffusion-weighted imaging-fluid-attenuated inversion recovery (DWI-FLAIR) mismatch is an early sign of acute ischemic stroke. DWI-FLAIR mismatch was reported to be valuable to select patients with unknown onset stroke who are eligible to receive intravenous thrombolysis (IVT), but its utility is less studied in patients undergoing mechanical thrombectomy (MT) for acute large vessel occlusion (LVO). We thus investigated the functional outcomes at 90 days between patients with DWI-FLAIR mismatch and those with match who underwent MT for LVO. METHODS: We conducted a historical cohort study in consecutive patients who were evaluated by magnetic resonance imaging for suspected stroke at a single center. We enrolled patients with occlusion of internal carotid artery or horizontal or vertical segment of middle cerebral artery who underwent MT within 24 h after they were last known to be well. DWI-FLAIR mismatch was defined when a visible acute ischemic lesion was present on DWI without traceable parenchymal hyperintensity on FLAIR. Image analysis was done by 2 stroke neurologists independently. We estimated the adjusted odds ratio (OR) of DWI-FLAIR mismatch relative to DWI-FLAIR match for moderate outcome defined as modified Rankin Scale (mRS) 0-3, favorable outcome defined as mRS 0-2 and mortality at 90 days after the onset, and symptomatic intracranial hemorrhage (sICH) within 72 h after the onset. RESULTS: Of the 380 patients who received MT, 202 were included. Patients with DWI-FLAIR mismatch (146 [72%]) had significantly higher baseline National Institutes of Health Stroke Scale (median 16 vs. 13, p = 0.01), more transferred-in (78 vs. 63%, p = 0.02), more IVT (45 vs. 18%, p = 0.0003), more cardioembolism (69 vs. 54%, p = 0.03), and shorter onset-to-hospital door times (median 175 vs. 371 min, p < 0.0001) than patients with DWI-FLAIR match. Patients with DWI-FLAIR mismatch had more moderate outcome than those with DWI-FLAIR match (61 vs. 52%, p = 0.24), and the adjusted OR was 3.12 (95% confidence interval [CI]: 1.35-7.19, p = 0.008). sICH within 72 h was less frequent in the DWI-FLAIR mismatch group (10 vs. 20%, p = 0.06), with an adjusted OR of 0.36 (95% CI: 0.13-0.97, p = 0.044). The adjusted ORs for favorable outcome and mortality were 0.87 (95% CI: 0.39-1.94, p = 0.73) and 0.63 (95% CI: 0.20-2.05, p = 0.44), respectively. CONCLUSIONS: DWI-FLAIR mismatch was associated with more moderate outcome and less sICH in the adjusted analysis in patients receiving MT for acute LVO. DWI-FLAIR mismatch could be useful to select patients with unknown onset stroke who are eligible to receive MT for acute LVO.

An Adult Case of Anti-Myelin Oligodendrocyte Glycoprotein (MOG) Antibody-associated Multiphasic Acute Disseminated Encephalomyelitis at 33-year Intervals.

Acute disseminated encephalomyelitis (ADEM) followed by optic neuritis (ON) has been reported as a distinct phenotype associated with anti-myelin oligodendrocyte protein (MOG) antibody. We herein report the case of a 37-year-old woman who was diagnosed with ADEM at 4 years old of age and who subsequently developed ON followed by recurrent ADEM 33 years after the initial onset. A serum analysis showed anti-MOG antibody positivity. This phenotype has only previously been reported in pediatric cases. Neurologists thus need to be aware that the phenotype may occur in adult patients, in whom it may be assumed to be atypical multiple sclerosis.