Effect of Mechanical Thrombectomy Without vs With Intravenous Thrombolysis on Functional Outcome Among Patients With Acute Ischemic Stroke: The SKIP Randomized Clinical Trial

IMPORTANCE

Whether intravenous thrombolysis is needed in combination with mechanical thrombectomy in patients with acute large vessel occlusion stroke is unclear.

OBJECTIVE

To examine whether mechanical thrombectomy alone is noninferior to combined intravenous thrombolysis plus mechanical thrombectomy for favorable poststroke outcome.

DESIGN, SETTING, AND PARTICIPANTS

Investigator-initiated, multicenter, randomized, open-label, noninferiority clinical trial in 204 patients with acute ischemic stroke due to large vessel occlusion enrolled at 23 hospital networks in Japan from January 1, 2017, to July 31, 2019, with final follow-up on October 31, 2019.

INTERVENTIONS

Patients were randomly assigned to mechanical thrombectomy alone (n = 101) or combined intravenous thrombolysis (alteplase at a 0.6-mg/kg dose) plus mechanical thrombectomy (n = 103).

MAIN OUTCOMES AND MEASURES

The primary efficacy end point was a favorable outcome defined as a modified Rankin Scale score (range, 0 [no symptoms] to 6 [death]) of 0 to 2 at 90 days, with a noninferiority margin odds ratio of 0.74, assessed using a 1-sided significance threshold of .025 (97.5% CI). There were 7 prespecified secondary efficacy end points, including mortality by day 90. There were 4 prespecified safety end points, including any intracerebral hemorrhage and symptomatic intracerebral hemorrhage within 36 hours.

RESULTS

Among 204 patients (median age, 74 years; 62.7% men; median National Institutes of Health Stroke Scale score, 18), all patients completed the trial. Favorable outcome occurred in 60 patients (59.4%) in the mechanical thrombectomy alone group and 59 patients (57.3%) in the combined intravenous thrombolysis plus mechanical thrombectomy group, with no significant between-group difference (difference, 2.1% [1-sided 97.5% CI, -11.4% to ∞]; odds ratio, 1.09 [1-sided 97.5% CI, 0.63 to ∞]; P = .18 for noninferiority). Among the 7 secondary efficacy end points and 4 safety end points, 10 were not significantly different, including mortality at 90 days (8 [7.9%] vs 9 [8.7%]; difference, -0.8% [95% CI, -9.5% to 7.8%]; odds ratio, 0.90 [95% CI, 0.33 to 2.43]; P > .99). Any intracerebral hemorrhage was observed less frequently in the mechanical thrombectomy alone group than in the combined group (34 [33.7%] vs 52 [50.5%]; difference, -16.8% [95% CI, -32.1% to -1.6%]; odds ratio, 0.50 [95% CI, 0.28 to 0.88]; P = .02). Symptomatic intracerebral hemorrhage was not significantly different between groups (6 [5.9%] vs 8 [7.7%]; difference, -1.8% [95% CI, -9.7% to 6.1%]; odds ratio, 0.75 [95% CI, 0.25 to 2.24]; P = .78).

CONCLUSIONS AND RELEVANCE

Among patients with acute large vessel occlusion stroke, mechanical thrombectomy alone, compared with combined intravenous thrombolysis plus mechanical thrombectomy, failed to demonstrate noninferiority regarding favorable functional outcome. However, the wide confidence intervals around the effect estimate also did not allow a conclusion of inferiority.

TRIAL REGISTRATION

umin.ac.jp/ctr Identifier: UMIN000021488.

Efficacy of holmium laser enucleation in patients with a small (less than 30 mL) prostate volume

Purpose

To evaluate the efficacy of holmium laser enucleation of the prostate (HoLEP) in patients with a small prostate volume (≤30 mL).

Materials and Methods

We retrospectively evaluated 1,135 patients who underwent HoLEP at two institutions between July 2007 and March 2020. Patients who were not evaluated for the International Prostate Symptom Score (IPSS) before or after HoLEP were excluded. We divided patients into two groups according to estimated prostate volume (ePV): ≤30 (n=198) and >30 mL (n=539). The patient characteristics, IPSS, peak urinary flow rate (Qmax), postvoid residual urine volume (PVR), and other data were compared before and after surgery in each group and between the two groups. Multivariate analysis was performed to identify the factors associated with the efficacy of HoLEP in the group with ePV ≤30 mL.

Results

A total of 737 patients were included in this retrospective study. ePV (23.4 mL vs. 50 mL; p<0.001) and PVR differed significantly between the two groups. The IPSS, IPSS-quality of life, PVR, and Qmax significantly improved after HoLEP in both groups. Improvements in the IPSS, IPSS-quality of life, Qmax, and PVR were greater in the >30 mL group (p<0.001), whereas operation time and morcellation time were significantly shorter in the ≤30 mL group. In the multivariate analysis, age <70 years was independently associated with improvement by HoLEP.

Conclusions

HoLEP is an effective treatment for patients with a small prostate, even though the extent of improvement after HoLEP was greater in those with a larger prostate.

"Computed Tomography Perihematomal Rims": A Perihematomal Low-Density Area Is a Part of an Acute Brain Hemorrhage

Objective Computed tomography (CT) can be used for visualizing acute intracerebral hemorrhages (ICHs) as distinct hyperdense areas and cerebral edema as perihematomal low-density areas (LDAs). We observed a perihematomal LDA on CT, which appeared to be part of a hemorrhage on magnetic resonance imaging (MRI) in acute ICH. We named this "CT perihematomal rim" and evaluated its characteristics and clinical significance. Methods We stratified patients with acute ICH according to the presence or absence of a CT perihematomal rim and then compared their radiologic findings. Logistic regression analyses were performed to assess whether the CT findings can predict the presence of a CT perihematomal rim. Patients Patients within 24 hours of ICH onset who were admitted between September 1, 2014, and October 31, 2018, were registered. Results Overall, 139 patients (91 men; mean age, 66 years) were investigated. CT perihematomal rims were observed in 40 patients (29%). ICH volumes on CT were 30% smaller than those on MRI in patients with CT perihematomal rims. On a multivariate analysis, the presence of a CT perihematomal rim was independently associated with the maximum diameter of the perihematomal LDA. According to a receiver operating characteristic analysis, the maximum LDA diameter threshold was 7.5 mm (sensitivity, 85%; specificity, 83%). Conclusion CT perihematomal rims were observed in 29% of the patients with acute ICH. A perihematomal LDA (>7.5 mm) in acute ICH cases should be considered a CT perihematomal rim. Clinicians should be aware that the ICH volume on CT may be underestimated by 30%.

Biphasic nucleophilic aromatic substitution using a microreactor under droplet formation conditions

Biphasic nucleophilic aromatic substitution of 4-fluoronitrobenzene proceeded efficiently using a packed bed reactor.

[A case of neurogenic pulmonary edema due to left internal carotid artery occlusion]

A 79-year-old woman developed consciousness disturbance, left eye deviation, right hemiplegia and aphasia with hypoxemia. Chest X-ray showed bilateral pulmonary edema. MRI revealed the left internal carotid artery occlusion and entire left middle cerebral artery infarct including insular cortex. We performed mechanical thrombectomy therapy and TICI3 recanalization was obtained. During operation, the respiratory condition deteriorated and the ventilator was started after mechanical thrombectomy therapy. Chest X-ray showed butterfly shadow, which indicated pulmonary edema. Pulmonary edema improved on the 2nd day of onset, and disappeared on the 3rd day. There was no heart diseases such as Takotsubo myocardiopathy, acute cardiac failure and cardiomyopathy on echocardiography and electrocardiography. Therefore, we diagnosed her as having neurogenic pulmonary edema due to cerebral infarction including insular cortex. We consider that left insular cortex infarction was a trigger of neurogenic pulmonary edema. If hypoxemia associated with infarction including the insular cortex, neurogenic pulmonary edema should be considered for medical treatment.

Stenting for Common Carotid Artery Stenosis Using the Sheath Pull-Through Technique

Objective

We report the "sheath pull-through technique" for stenting of common carotid artery stenosis (CCAS).

Case Presentations

In this technique, an 8-10 Fr super-long sheath (SLS) 55-65 cm is inserted into the femoral artery and the brachiofemoral pull-through technique is subsequently used, improving the support of the sheath itself. We pulled both ends of a pull-through wire to further improve the support of SLS, stabilizing guiding catheter (GC) during the procedure in two cases.

Conclusion

This technique stabilizes GC during CCAS stenting.

Urinary biomarkers of kidney tubule injury, risk of acute kidney injury, and mortality in patients with acute ischaemic stroke treated at a stroke care unit

BACKGROUND AND PURPOSE

Urinary liver-type fatty-acid binding protein (L-FABP), which is a biomarker of kidney tubule injury, has been studied extensively and established as a risk marker of acute kidney injury (AKI). The aim of this study was to investigate whether kidney tubule injury is associated with the development of AKI and mortality in patients with acute ischaemic stroke.

METHODS

Acute ischaemic stroke patients hospitalized in the stroke care unit (SCU) within 24 h after symptom onset were prospectively investigated. AKI was defined on the basis of Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Baseline urinary L-FABP was measured on admission. We evaluated the associations among urinary L-FABP, incidence of AKI, and 90-day mortality adjusted for renal function, albuminuria and other potentially predictive variables, using multivariable analysis.

RESULTS

In total, 527 acute ischaemic stroke patients (342 men, median age 74 years) were enrolled in the study. Twenty-seven patients (5.1%) experienced AKI within 7 days of admission. In the univariate analysis, high urinary L-FABP level had positive associations with AKI [53.8 μg/g creatinine (Cr) vs. 3.9 μg/g Cr; P < 0.001] and 90-day mortality (15.5 μg/g Cr vs. 4.0 μg/g Cr; P < 0.001). In the multivariate analysis, elevated urinary L-FABP level (per 10-μg/g Cr increase) was independently associated with AKI (odds ratio 1.225, 95% confidence interval (CI) 1.083-1.454; P = 0.003) and 90-day mortality (hazard ratio 1.091, 95% CI 1.045-1.138; P < 0.001).

CONCLUSION

Urinary biomarkers of kidney tubule injury are independently associated with the development of AKI and 90-day mortality in patients with acute ischaemic stroke treated at the SCU.

Thrombectomy for Upper Extremity Artery Occlusion with Major Cerebral Artery Occlusion Using Mechanical Thrombectomy Devices for Acute Ischemic Stroke

Objective

We report two cases of thrombectomy for upper extremity artery occlusion with major cerebral artery occlusion using mechanical thrombectomy devices for acute ischemic stroke.

Case Presentations

Case 1 was a 79-year-old woman admitted for left internal carotid artery occlusion and left upper extremity artery occlusion. Case 2 was an 87-year-old woman admitted for left middle cerebral artery occlusion and bilateral upper extremity artery occlusion. After performing mechanical thrombectomy for the cerebral artery, we achieved good recanalization of the brachial artery using the same devices in Case 1 and Case 2.

Conclusions

Thrombectomy using acute ischemic stroke mechanical thrombectomy devices for upper extremity artery occlusion is useful for recanalization.

Cholesterol Crystal in Thrombus Removed by Mechanical Thrombectomy Should be a Strong Marker for Aortogenic Embolic Stroke

Aortogenic embolic stroke (AES) is an important stroke mechanism. However, as many stroke patients have aortic atheromatous lesions, it is unclear whether these lesions are the cause of these strokes. Cholesterol crystals are the solid, crystalline form of cholesterol that is found in atherosclerosis, but not in cardiac diseases such as atrial fibrillation, valvular diseases, and cardiomyopathy. Therefore, if a cholesterol crystal is found in a thrombus removed by mechanical thrombectomy (MT), this makes it possible to diagnose a patient as having an atheromatous lesion. Here, we report an AES case with a cholesterol crystal found in a thrombus removed by MT. A 67-year-old man was admitted due to consciousness disturbance, aphasia, and right hemiplegia. Diffusion-weighted imaging (DWI) showed a hyperintense area in the left frontal lobe, and magnetic resonance angiography demonstrated a branch occlusion of the left middle cerebral artery (MCA). MT was performed 1.5 h after stroke onset, with the thrombus removed and a left occluded MCA completely recanalized. Carotid duplex ultrasonography did not reveal any plaque in the carotid artery. Echocardiography did not show any abnormal function or findings, including thrombus. Transesophageal echocardiography showed a 4.9 mm atheromatous lesion at the aortic arch. Therefore, we suspected this patient as having an AES due to the embolic source of atheromatous lesion at the aortic arch. Pathological examination of the embolus revealed a cholesterol crystal cleft in the thrombus. Therefore, we diagnosed this patient as having AES caused by an atheromatous lesion at the aortic arch.

Association between mitral regurgitation and clinical outcome after endovascular thrombectomy in stroke patients

OBJECTIVE

Some hyperacute stroke patients have unfavorable outcomes after endovascular thrombectomy (EVT) despite successful recanalization. We hypothesized that a cardiac parameter, moderate-to-severe mitral regurgitation (MR), might decrease the rate of favorable clinical outcome after EVT in patients with atrial fibrillation (AF).

METHOD

From our prospective EVT registry, AF patients who underwent transthoracic echocardiography (TTE) were retrospectively analyzed. Based on the presence of moderate-to-severe MR, patients were assigned to either significant MR or nonsignificant MR group. The severity of MR was determined by the ratio of the color Doppler jet area to the left atrial area in mid-systole. Moderate-to-severe MR was estimated to be at a ratio of >20%. Favorable outcome was defined as having a modified Rankin Scale score of 0-1 at 3 months.

RESULT

127 patients with AF who underwent TTE were included in the study. TTE results found that 25 (20%) patients had significant MR. Patients with significant MR were older (p = 0.051) and had enlarged left (p = 0.015) and right (p = 0.002) atria. Tricuspid and aortic regurgitation (p = 0.007 and 0.043, respectively) were more severe in significant MR group. At 3 months, favorable outcomes were 11% in the significant MR group and 26% in the non-significant MR group (p = 0.031). Multivariate regression analysis reported that moderate-to-severe MR was a negative predictor of favorable outcome (odds ratio = 0.14; 95% confidence interval = 0.02, 0.84; p = 0.031).

CONCLUSIONS

Significant MR might prevent the clinical recovery of AF patients.

Impact of complete recanalization on clinical recovery in cardioembolic stroke patients with M2 occlusion

BACKGROUND AND PURPOSE

We investigated the impact of complete recanalization beyond partial recanalization in distal (M2) middle cerebral artery (MCA) occlusion.

METHODS

Data regarding M2 occlusion patients treated with endovascular thrombectomy (EVT) and/or intravenous thrombolysis (tPA) were reviewed from our prospective EVT registry and multicenter tPA (YAMATO study) data bank. Complete recanalization was modified thrombolysis with cerebral infarction score (TICI) of 3 at the end of EVT or similar appearances of both MCAs on magnetic resonance angiography (MRA) within 1.5 h after tPA. Partial recanalization was defined as TICI ≥2b or > 50% recanalization on MRA. At 3 months, favorable outcome was defined as a modified Rankin Scale score ≤ 2.

RESULT

Data on 121 patients were analyzed. EVT-alone was in 38 patients; combined EVT and tPA in 28; and tPA-alone in 55. Complete recanalization was achieved in 27 (22%), partial recanalization in 48 (40%), and no-to-limited recanalization in 46 (38%). At 3 months, 51% of patients had favorable outcomes, and this rate was significantly higher in the complete recanalization group than in the partial and no-to-limited recanalization groups (75% vs. 41% vs. 49%, p = .043). Multivariate regression analysis showed that complete recanalization was an independent parameter related to favorable outcomes (odds ratio 4.78, 95% CI: 1.16-19.73, p = .030). However, combined complete and partial recanalization was not associated with favorable outcomes (odds ratio 1.49, 95% CI 0.53-4.22, p = .449).

CONCLUSION

Complete recanalization, but not partial recanalization, at the end of EVT and tPA therapy is associated with favorable outcomes in patients with M2 occlusion.

[A fungus in a thrombus by mechanical thrombectomy in acute cerebral infarction: a case report]

A 88-year-old man suddenly presented with aphasia and right hemiparesis. The diffusion-weighted image of MRI showed ischemic lesions on the left middle cerebral artery area, and MRA showed the left intracranial artery (ICA) occlusion. Therefore, we diagnosed him as having acute ischemic stroke and treated with mechanical thrombectomy (MT). The DWI of MRI showed ischemic lesions on the left middle cerebral artery area, and MRA showed the left ICA occlusion. Therefore, we performed MT and continued best medical treatment, but ICA was reoccluded. Six day later, aspergillus was found in the thrombus from ICA. Then, we considered that ICA occlusion was caused by aspergillus. We experienced a patient specified the cause by thrombus pathology. The pathological diagnosis of the thrombus getting by MT is usefulness for stroke etiology.

Early Cognitive Impairment after Minor Stroke: Associated Factors and Functional Outcome

OBJECTIVES

Evaluation of cognitive status is not performed routinely in the acute stroke setting. This study aimed to evaluate the frequency of early cognitive impairment in patients with minor ischemic stroke, analyze the factors associated with early cognitive impairment, and assess functional outcomes.

METHODS

In this prospective study, 112 consecutive patients with acute minor ischemic stroke were enrolled. Neuroimages were assessed for semiquantitative evaluation of brain atrophy and small vessel disease (SVD) markers. Cognitive performance was measured within 5 days of onset using Montreal Cognitive Assessment (MoCA) scores. Functional outcome analyses were adjusted for demographic variables, premorbid cognitive status, education level, vascular risk factors, neuroimaging characteristics, stroke severity, and MoCA scores.

RESULTS

The median MoCA score was 22, and 63% of patients had cognitive impairment. Factors independently associated with cognitive impairment were education (odds ratios [OR], .79; confidence intervals [CI], .63-.99), smoking (OR, .26; 95%CI, .073-.89), and temporal horn atrophy (OR, 4.73; 95% CI, 1.66-13.49). Factors independently associated with poor functional outcome were total MoCA score (OR, .78; 95%CI, .62-.95) and the sum of 4 MoCA subscores (visuospatial/executive, attention, language, and orientation; OR, .72; 95%CI, .53-.92). The cutoff value of the sum of 4 MoCA subscores for predicting poor outcome was 13 points with 76.5% sensitivity and 81.1% specificity.

CONCLUSIONS

Early cognitive impairment was common after minor ischemic stroke and was associated with preexisting temporal horn atrophy but not SVD markers. The sum of 4 MoCA subscores was useful in predicting the functional outcome.

Early Cognitive Assessment Following Acute Stroke: Feasibility and Comparison between Mini-Mental State Examination and Montreal Cognitive Assessment

OBJECTIVES

Cognitive assessment is not performed routinely in the acute stroke setting. We investigated factors associated with cognitive impairment and the differences between the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) scores in patients with acute stroke.

METHODS

In this prospective study, 881 consecutive patients (median age, 73 years) with acute stroke were enrolled. Clinical characteristics, such as education, vascular risk factors, premorbid cognitive status using the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), and stroke severity, were assessed. Cognitive performance was measured using MMSE and MoCA within 5 days of stroke onset.

RESULTS

Both MMSE and MoCA were feasible in 621 (70.5%) patients. Factors independently associated with nonfeasibility were age (odds ratio [OR]: 1.05; 95% confidence interval [CI]: 1.02-1.08), IQCODE score (OR: 1.02; 95%CI: 1.00-1.04), and National Institutes of Health Stroke Scale (NIHSS) score (OR, 1.16; 95%CI, 1.12-1.20). Impaired MoCA (with a cut-off <26/30) performance was observed in 544 of 621 (87.6%) patients. Factors independently associated with cognitive impairment were age (OR: 1.06; 95%CI: 1.03-1.10) and NIHSS score (OR: 1.34; 95%CI: 1.14-1.57). Eighty percent of patients with normal MMSE scores had an impaired MoCA score (MMSE-MoCA mismatch). The differences were highest in the visuospatial (94.8% versus 65.3%; P < .0001), recall (76.6% versus 35.6%; P < .0001), abstraction (82.5% versus 49.8%; P < .0001), and language (72.3% versus 65.9%; P < .0001) domains between the normal MMSE and MoCA group and MMSE-MoCA mismatch group.

CONCLUSIONS

The MoCA can be particularly useful in patients with cognitive deficits undetectable on the MMSE in the acute stroke phase.

Reducing door-to-reperfusion time in acute stroke endovascular therapy using magnetic resonance imaging as a screening modality

Background

The feasibility of performing MRI first for patients with suspected hyperacute stroke in real-world practice has not been fully examined. Moreover, most past studies of reducing door-to-reperfusion time (DRT) in endovascular treatment (EVT) were conducted using CT. The aim of this study was to evaluate the feasibility of an MRI-first policy and to examine the effects of a quality improvement (QI) process for reducing DRT using MRI.

Methods

From January 2013 to December 2018, consecutive patients with acute stroke who came to hospital directly and were treated with emergent EVT were prospectively enrolled into the present study. In principle, MRI was performed first for patients with suspected acute stroke. A step-by-step QI process for decreasing DRT was adopted during this period. Time metrics for EVT were compared between specific time periods.

Results

A total of 180 patients (71 women; median age 76 years (range 69–64); National Institutes of Health Stroke Scale score 17 (range 10–23)) were included in the present study. More patients in the late phase were managed with the MRI-first policy (p<0.001). DRT (199 min in Phase 1, 135 min in Phase 2, 129 min in Phase 3, and 121 min in Phase 4, p<0.001) was significantly reduced across the phases. The percentage of patients with DRT <120 min increased significantly across time periods (p<0.001). Symptomatic intracerebral hemorrhage did not increase across phases (p=0.575).

Conclusion

An MRI-first policy was feasible, and DRT decreased considerably with a step-by-step QI process. This process may be applicable to other hospitals.

Abstract TP195: Pre-Stroke Cognitive Impairment is Associated With Poor Outcome in Acute Ischemic Stroke Patients Treated With Mechanical Thrombectomy

Background: It is reported that pre-stroke cognitive impairment is associated with poor functional outcome after stroke associated with small vessel disease. However, it is not clear that pre-stroke cognitive impairment is associated with poor outcome in patients treated with mechanical thrombectomy.

Method: We enrolled 127 consecutive patients treated with mechanical thrombectomy for acute ischemic stroke from December 2016 to November 2018. Pre-stroke cognitive function was evaluated using the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). We retrospectively compared poor outcome (a score of 3 to 6 on the modified Rankin Scale at 90 days) group (n=75) with good outcome (a score of 0, 1, or 2 on the modified Rankin Scale at 90 days) group (n=52) and examined that IQCODE could be the predictor of PO.

Result: IQCODE was significantly higher in poor outcome group than in good outcome group (89 vs. 82, P=0.0012). Moreover, age (77.2 years old vs. 71.6 years old, P= 0.0009), the percentage of female (42.7% vs. 17.3%, P= 0.0021), complication of hypertension (HT, 68.0% vs. 44.2%, P=0.0076), National Institutes of Health Stroke Scale (NIHSS) at admission (20 vs. 11, P<0.0001), the percentage of postoperative intracerebral hemorrhage (ICH, 33.3% vs. 15.4%, P=0.0233) were higher in poor outcome group than in good outcome group, too. However, there was no significant difference between poor outcome and good outcome groups in occlusion site (P= 0.1229), DWI-ASPECTS (P= 0.2839), the duration from onset to recanalization (P=0.4871) and other risk factors. Multivariable logistic regression analysis demonstrated that IQCODE, HT and NIHSS at admission were associated with poor outcome (P= 0.0128, P=0.0061 and P<0.0001, respectively).

Conclusion: Cognitive impairment could be associated with poor outcome in patients treated with mechanical thrombectomy.

Abstract WP240: Urinary Biomarker of Kidney Tubular Function, Risk of Acute Kidney Injury, and Mortality in Acute Stroke Patients

Background and Purpose: Urinary liver-type fatty-acid binding protein (L-FABP), which is a biomarker of kidney tubule injury, has been studied extensively and established as a risk marker of acute kidney injury (AKI) and cardiovascular disease outcomes. However, no evidence to date has indicated whether kidney tubule injury has any potential for predictor of AKI and mortality in acute stroke patients. The aim of the present study was to accurately determine the prevalence of AKI and effect on clinical outcome of acute stroke patients assessed by urinary L-FABP.

Methods: Acute ischemic stroke and intracerebral hemorrhage patients hospitalized in the stroke care unit (SCU) within 24 h after symptom onset were prospectively investigated. AKI was defined on the basis of Kidney Disease: Improving Global Outcomes (KDIGO) criteria. We evaluated the association among urinary L-FABP, AKI, and 3-months mortality using multivariate logistic analysis adjusted for baseline estimated glomerular filtration rate (eGFR), albuminuria, stroke risk factors, and neurological severity.

Results: In total, 601 acute stroke patients (390 males; median age 72 years, ischemic stroke 476 cases and intracranial hemorrhage 125 cases) were enrolled to the study. AKI occurred in 32 acute stroke patients (5.3%). In the univariate analysis, high urinary L-FABP level had positive associations with AKI (25.4 μg/g Cr vs. 3.6 μg/g Cr, P<0.001) and 3 months mortality (13.4 μg/g Cr vs. 3.8 μg/g Cr, P<0.001). In the multivariate analysis, elevated urinary L-FABP level was independently associated with AKI (OR 1.015; 95% CI, 1.008-1.023, P<0.001) and 3-months mortality (OR 1.012; 95% CI, 1.001-1.023, P=0.032). Moreover, AKI also increased the risk of 3-months mortality after stroke (OR 7.053, 95% CI, 1.771-28.087, P=0.006).

Conclusion: Biomarker of tubular dysfunction is independent predictor of AKI and mortality in acute stroke patients.

Abstract TP47: Mitral Regurgitation Might Prevent the Neurological Recovery After Endovascular Thrombectomy in Patients With Atrial Fibrillation

Hypothesis: Some of hyperacute stroke patients had unfavorable outcome even when the occlusive artery was successfully opened. We hypothesized that moderate-to-sever mitral regurgitation (significant MR) might inhibit cerebral reperfusion, and thus decrease the rate of good clinical outcome after endovascular thrombectomy (EVT) in patients with atrial fibrillation (AF).

Method: From our prospective EVT registry, patients received transthoracic echocardiography (TTE), were retrospectively analyzed. Only patients with AF were included. Based on the presence of the moderate-to-sever MR, all patient were divided into group with and without significant MR (MR group, and non-MR group). Clinical background, laboratory findings, and TTE parameters were compared between the 2 groups. Favorable outcome was defined as mRS 0-1 at 3 months.

Result: From 2014 September to 2018 December, 316 patients treated with EVT, and 246 received TTE. Among them, data on 127 patients with AF were analyzed. TTE found 25 (20%) patients had significant MR. Patients in MR group were older (p=0.05) and had higher plasma level of brain natriuretic peptide (p=0.05). NIHSS, DWI-APSECTS, TICI ≥2b reperfusion, onset-to-reperfusion time, ICA occlusion (p=0.96, 0.26, 0.52, 0.33, and 0.80) were similar between the 2 groups. Regarding TTE parameters, although ejection fraction was similar (p=0.28), left atrial area (p=0.02), right atrial area (p<0.01), and tricuspid regurgitation area (p<0.01) were elevated in the MR group. At 3 months, favorable outcome was seen in only 9% in the MR group, while 26% had it in the non-MR group (p=0.04), Group with favorable outcome had higher rate of TICI ≥2b reperfusion (p=0.04), lower NIHSS score (p=0.04), however, above mentioned TTE parameter except significant MR, were not associated favorable outcome. When we conduct multivariate regression analysis, moderate-to-sever MR the negative independent parameter of favorable outcome (odds ratio 0.17, 95%CI [0.03-0.89], p=0.04).

Conclusion: The presence significant MR was related to the unfavorable outcome independent of the neurological symptom and reperfusion status on cerebral angiography.MR might prevent the clinical recovery in patients with atrial fibrillation.

Abstract TP27: Time-window of Endovascular Therapy for Elvo Patients Will be Extended Beyond 24 Hours After Onset ?

Background and Purpose: Eendovascular thrombectomy(EVT) had a clinical benefit when it was performed within 6 hours after onset symptom in the emergent large vessel occlusion(ELVO) patients. Recently, it is proved that EVT 6 to 24 hours after stroke onset with mismatch between deficit and infarct is benefit. However, it is not unclear whether EVT is effective more than 24 hours after stroke onset.

Method: We enrolled ELVO patients treated with EVT more than 24 hours after stroke onset from our prospective registry. We investigated clinical background including onset to puncture time, clinical stroke type, and recanalization rate. We evaluated patient outcome at 3 months after onset and classified patients into two group; good outcome group as modified Rankin Scale (mRS) 0-2 and poor outcome group as mRS 3-6, respectively. We compared clinical background between two groups.

Result: In our stroke registry, 443 patients were treated with EVT from January 2011 to July 2019. Among them, 21 patients(5.4%, age was 69(55-72) years old, and male was 16(76%)) were treated with EVT more than 24 hours after stroke onset. All patients had ELVO and clinical and DWI mismatch, which might be thought to be benefit from EVT. Onset to puncture time was median 2632 (1605-6116) minutes and NIHSS scale was 6(2.5-15), and DWI-ASPECTS were 9(7-10). ICA, M1 and BA occlusion were 8(38%), 4 (19%), and 1(4%) patients, respectively. Symptomatic hemorrhage was none. Regarding to patient outcome at 3 months, good and poor outcome were 14(66.7%) and 7(33.3%) patients, respectively. Among the 19 patients with premorbid mRS 0-2, 14(73%) patients achieved good outcome at 3 months. Age, gender, onset to puncture time, DWI-ASPECTS, and ICA occlusion were not different between good and poor outcome groups. However, good outcome patients less frequently had NIHSS score (3.5(2-7) vs. 15(12-23), P=0.006), and cardioembolic stroke (0% vs. 14%, P=0.333).

Conclusion: More than a half of ELVO patients with clinical DWI mismatch more than 24 hours after stroke onset had good outcome from EVT. There is possibility that time window of EVT for ELVO patients is extended beyond 24 hours after stroke onset.

Abstract WP497: Investigation of Cognitive Impairment in Ischemic Stroke Patients After Endovascular Treatment in Acute Phase and at 6 Months Follow-Up

Purpose and Objective: There have been limited reports that focused on cognitive impairment in acute ischemic stroke after endovascular treatment. The aim of this study, therefore, was to investigate cognitive function in patient after endovascular treatment in acute phase and at 6 months follow-up.

Method: In this prospective study, from December 2016 to November 2018, the patients who were diagnosed as ischemic stroke with occlusion of the internal carotid artery and of the middle cerebral artery and treated with endovascular treatment were enrolled. Cognitive function was assessed with the Montreal Cognitive Assessment (MoCA-J) test within 5 days of onset and at 6 months follow-up. We defined cognitive impairment as a score of <24 in MoCA-J.

Results: 150 patients were enrolled. MoCA-J was feasible in 69 patients (median 76 years; 49 female) (46%), in acute phase (Figure A). 63 patients (91%) had cognitive impairment and no significant differences were found in the naming and the abstraction domains between MoCA-J <24 group and ≧24 group. At 6 months follow-up, 48 patients (median 72 years; 12 female) were assessed with MoCA-J and 35 patients (73%) had cognitive impairment. However, only one patient scored less at 6 months follow-up than in acute phase (Figure B), which resulted in the significant increase in the median MoCA-J score (7 vs. 21, P<0.05) (Figure C) and in all the domains except for the language (P=0.078) (Figure D).

Conclusion: In acute phase of ischemic stroke after endovascular treatment, MoCA-J was feasible in about 45%, in which 91% had cognitive impairment. However, at 6 months follow-up, the median MoCA-J score was significantly higher and less number of patients had cognitive impairment. The present results suggest that cognition recovers with time after endovascular treatment in ischemic stroke.

Abstract TP204: Intima-Media Thickness in the Carotid Bifurcation, But Not Cardio-Ankle Vascular Index or Ankle-Brachial Index, is Related to Silent Brain Infarct on Magnetic Resonance Imaging in Healthy, Middle-Aged Japanese Individuals

Background: Carotid ultrasonography is currently the principal noninvasive tool for evaluating subclinical atherosclerosis and carotid artery disease. Increased carotid intima-media thickness (IMT) may precede the development of atherosclerotic plaques. Several studies have shown that increased IMT is associated with increased incidence of stroke. Silent brain infarct (SBI) has been proposed as a strong subclinical risk marker for future symptomatic stroke onset. However, the relationship between SBI and elevated IMT in healthy, middle-aged Japanese individuals has not been adequately examined.

Methods: We examined 280 Japanese adults (92 women; mean age, 52.9 ± 5 years) with no history of cardiocerebrovascular disease. We assessed all participants’ periventricular hyperintensities, deep subcortical white matter hyperintensities, SBI on magnetic resonance imaging, cardio-ankle vascular index (CAVI)/ankle-brachial index (ABI), and various vascular risk factors. In addition, we measured intima-media thickness at the common carotid artery (CCA), carotid bifurcation (CB), and internal carotid artery (ICA).

Results: Participants were categorized into two groups according to the presence or absence of SBIs, and we then compared the clinical characteristics of the two groups. Age, hypertension, increased HbA1c level, and decreased estimated glomerular filtration rate were found to be significantly associated with the SBI group. The odds ratio (OR) of the maximum IMT at the CB for the presence of SBI was 4.016 (95% confidence interval [CI], 1.565-10.304), even after adjusting for potential confounding factors. In contrast, the ORs of maximum IMT at the ICA and CCA as well as CAVI and ABI were not significant. Participants with IMTs ≥2 mm at the CB had a higher probability of the presence of SBI (OR, 26.451; 95% CI, 2.404-291.00).

Conclusion: The maximum IMT at the CB was significantly correlated with the presence of SBI on MRI, but ABI or CAVI did not show significant correlation. Thus, compared to CAVI or ABI, carotid ultrasonography appears to be a very useful tool for noninvasively detecting SBI. In particular, IMTs ≥2 mm at the CB on carotid ultrasonography may be practical for identifying SBIs among middle-aged Japanese individuals.