Reocclusion after endovascular thrombectomy in tandem occlusions may contribute to disability, but its mechanism and the role of emergent carotid artery stenting remain unclear. We conducted a meta-analysis to evaluate the impact of cervical internal carotid artery (c-ICA) reocclusion on functional outcomes, recurrent ischemic stroke, and the potential benefit of emergent stenting. We systematically searched Medline, EMBASE, and Scopus for studies reporting c-ICA reocclusion after endovascular thrombectomy for tandem occlusions. The primary outcome was c-ICA reocclusion incidence; secondary outcomes included recurrent ischemic stroke and 90-day functional outcome (modified Rankin Scale score, 0-2). Random-effects models were used. Metaregression, sensitivity, and power analyses were performed. Fifty-one studies (4998 patients: 3444 received emergent carotid artery stenting and 1554 did not) were included. Overall, c-ICA reocclusion incidence was 10.8% (95% CI, 8.0%-14.3%). In patients treated with emergent carotid artery stenting, reocclusion occurred in 10.9% versus 28.2% without stenting (risk difference, -14.7% [95% CI, -20.2 to -9.2]). c-ICA treatment approach was not associated with recurrent ischemic stroke (odds ratio, 1.00 [95% CI, 0.33-3.01]), whereas c-ICA reocclusion was associated with worse functional outcome (odds ratio, 0.45 [95% CI, 0.28-0.71]). Metaregression identified no significant moderators. Sensitivity analyses confirmed adequate power to detect moderate associations. c-ICA reocclusion after endovascular thrombectomy in tandem occlusions is common and associated with worse functional outcome, likely due to infarct progression. Emergent carotid artery stenting reduces reocclusion rates but does not modify the risk of ischemic stroke. Future studies should refine procedural strategies and integrate physiological markers to better characterize the risk of reocclusion and outcomes.
Detection of large vessel occlusions using a deep learning (DL) algorithm for the anterior circulation has shown promising results. However, the role of DL algorithms in detecting posterior circulation large vessel occlusion (PC-LVO) remains uncertain. We aimed to evaluate the diagnostic performance of a DL algorithm (Methinks PC-LVO) for detecting PC-LVO using noncontrast computed tomography. This is a retrospective, multicenter, observational cohort study that included patients with PC-LVO who underwent both noncontrast computed tomography and computed tomography angiography. The diagnostic performance of the DL algorithm was assessed by analyzing sensitivity, specificity, and area under the curve for PC-LVO detection of consecutive PC-LVO strokes. For comparative analysis, the area under the curve of the DL algorithm was also evaluated against the performance of a neuroradiologist interpreting noncontrast computed tomography. Ground truth labels were established through consensus readings by expert neuroradiologists. Subgroup analyses were performed according to clot location (proximal posterior cerebral artery and basilar artery) and National Institutes of Health Stroke Scale (NIHSS) score (NIHSS score ≥6, NIHSS score ≥8, and NIHSS score ≥10). A total of 196 patients were included, of whom 74 patients had PC-LVO. Among these, 43 had basilar artery occlusions, and 34 had proximal posterior cerebral artery occlusions. The overall sensitivity and specificity of the software were 55.4% and 80.9%, respectively, with an area under the curve of 0.72. The neuroradiologist achieved a sensitivity of 27.4% and specificity of 91.8%. Among patients with proximal posterior cerebral artery occlusion, sensitivity was 55.9%, whereas for basilar artery occlusion, it was 53.5%. When stratified by NIHSS score ≥10, sensitivity in the proximal posterior cerebral artery was 56.2%, and for the basilar artery with NIHSS score ≥10, it increased to 61.5%. Our initial experience with a DL algorithm for the detection of PC-LVO showed promising results. However, further improvements are required before the algorithm can be implemented in clinical practice.
Mechanical thrombectomy (MT) is the recommended therapy based on Grade A evidence for acute ischemic stroke due to large vessel occlusion (LVO). However, acute intracranial atherosclerotic stenosis-related LVO (ICAS-LVO), which is prevalent in East Asian populations, including the Japanese, represents a distinct clinical entity characterized by progressive hemodynamic compromise, a high risk of reocclusion, and unique technical challenges during endovascular treatment (EVT) for this condition. Unlike typical embolic LVO, the efficacy of MT alone in ICAS-LVO has not been firmly established, and optimal treatment strategies remain controversial. This review presents a practical, stepwise EVT strategy for ICAS-LVO based on published reports and the authors' clinical experience. The proposed strategy consists of 4 key components: 1) comprehensive diagnosis; 2) early antithrombotic management; 3) stage- and lesion-specific EVT techniques; and 4) meticulous postprocedural management. Because preprocedural diagnosis of ICAS-LVO is often difficult, diagnosis should be established dynamically by integrating information on atherosclerotic risk factors, the clinical course, the presence or absence of characteristic imaging findings, and intraprocedural observations such as guidewire behavior, residual stenosis after recanalization, and early reocclusion. As the initial EVT approach, MT is recommended as the first-pass strategy, similar to embolic LVO, given its diagnostic and therapeutic utility, with prompt initiation of antiplatelet therapy when indicated. When immediate flow restoration is achieved after stent retriever (SR) deployment, the degree of stent expansion provides critical information regarding the presence and location of underlying ICAS. In such cases, prolonging the SR deployment, referred to as SR angioplasty, may be considered a vessel-sparing adjunctive technique to enhance the effects of circulating antiplatelet agents while achieving gentle vessel dilation. If recanalization cannot be achieved with MT alone, or if severe residual stenosis or early reocclusion is observed, timely escalation to percutaneous transluminal cerebral balloon angioplasty, with or without intracranial stent placement, should be considered. Postprocedural management focuses on continuation of antiplatelet therapy, careful blood pressure control, and close clinical and imaging surveillance to detect early reocclusion. Preparedness for urgent retreatment in cases of acute reocclusion, as well as elective angioplasty for residual stenosis, is essential. This strategy-oriented approach highlights the importance of adaptive decision-making throughout EVT and may help optimize outcomes in patients with ICAS-LVO.
Pediatric acute ischemic stroke is a rare entity, and mechanical thrombectomy (MT) in this population can be technically challenging. We aim to discuss key technical aspects of pediatric MT and report our experience in this population. Pediatric patients were identified from our prospectively maintained database of MT patients. Inclusion criteria were pediatric patients' age >28 days and <18 years undergoing MT for large vessel occlusion at a single center between 2012 and 2023. Seven patients were included in this case series. Patient age ranged from ≈1 to 17 (10.0±6.2) years. Causes of large vessel occlusion included hypercoagulability disorders, cardiac disorders, and iatrogenic during neurointerventions. Most patients (n=5, 71.4%) had middle cerebral artery or internal carotid artery occlusions. Six patients (85.7%) were successfully treated with MT, achieving modified Thrombolysis in Cerebral Infarction grade 2C or above. Five patients were treated with stent retriever MT and the other 2 patients with aspiration MT alone, with an average of 2.3±1.5 passes total. Five patients (71.4%) made an excellent clinical recovery with a pediatric modified Rankin Scale score ≤2 at last outpatient follow-up (pediatric modified Rankin Scale score, 1.8±1.2). Average follow-up duration was 2.7±2.4 years. Recent advancements in catheter technology have facilitated MT in pediatric patients. Pediatric MT appears to be safe and effective for treating cerebral large vessel occlusions; however, technical limitations can arise secondary to small vessel diameters. A technical guide based on patient age and femoral artery diameter is provided.
The balloon guide catheter (BGC) is widely used in endovascular thrombectomy, but evidence of its effect in intracranial internal carotid artery embolic occlusion is limited, and recent randomized trials have reported contradictory outcomes. We aimed to explore the potential association between BGC use and outcomes of thrombectomy in intracranial internal carotid artery embolic occlusion. Patients with acute intracranial internal carotid artery occlusion from a prospectively maintained 2-center stroke registry were classified according to BGC use. Propensity score matching and overlap weighting were used to balance baseline differences. The primary outcome was functional independence at 90 days (modified Rankin Scale score, 0-2). Secondary outcomes included first-pass complete reperfusion (expanded Thrombolysis in Cerebral Infarction grade 3), distal emboli, and 90-day modified Rankin Scale score shift. Among 397 patients (median age, 72 years; 45.1% men), 90 (22.7%) underwent BGC-assisted endovascular thrombectomy. After 1:2 propensity score matching (84 BGC versus 168 non-BGC), the groups were well balanced. BGC use was associated with higher odds of 90-day functional independence (propensity score matching odds ratio [OR], 2.24 [95% CI, 1.07-4.72]; overlap weighting OR, 1.97 [95% CI, 1.07-3.62]), higher rates of first-pass expanded Thrombolysis in Cerebral Infarction 3 reperfusion (propensity score matching OR, 1.98 [95% CI, 1.09-3.60]; overlap weighting OR, 1.74 [95% CI, 1.05-2.89]), and fewer distal emboli (overlap weighting OR, 0.49 [95% CI, 0.25-0.97]). The 90-day modified Rankin Scale score distribution favored BGC use, but was not statistically significant (P=0.20). In acute intracranial internal carotid artery embolic occlusion, BGC use was associated with better functional outcomes, higher first-pass reperfusion rates, and fewer distal emboli. These findings suggest that BGC may be a beneficial adjunct in this population and warrant validation in prospective trials.
Endovascular thrombectomy for medium-vessel occlusion (MeVO) stroke has emerged as a major area of clinical and research uncertainty. Unlike large-vessel occlusions, MeVO stroke encompasses substantial heterogeneity in neurological severity, occlusion location, and vessel caliber, complicating both bedside decision-making and trial design. Recent randomized trials of endovascular thrombectomy for MeVO stroke have produced heterogeneous and sometimes conflicting results, leaving clinicians uncertain about patient selection and equipoise. In this review, we examine how differences in occlusion location, vessel size, and baseline National Institutes of Health Stroke Scale across recent MeVO trials may influence observed treatment effects, safety signals, and interpretation of trial results. We review how procedural risk varies across anatomic and clinical phenotypes and summarize subgroup findings that highlight important limitations of treating MeVO stroke as a uniform entity. We then propose a pragmatic, anatomy- and severity-informed framework to guide clinical decision-making and trial design, delineating scenarios where endovascular thrombectomy is beneficial, those where harm likely outweighs benefit, and a broad intermediate group requiring individualized approaches. Lastly, we discuss implications for future trials, including the need for explicit stratification, reconsideration of outcome measures, and exploration of alternative reperfusion strategies in select MeVO populations.
Tear drainage dysfunction, presenting as epiphora or dry eye symptoms, significantly affects quality of life. Punctal occlusion, using temporary or permanent techniques, aims to retain tears and improve ocular surface health. However, the overall efficacy and safety of these techniques remain variably reported across studies. This systematic review and meta-analysis followed PRISMA 2020 guidelines and was registered on PROSPERO (CRD42024607753). A comprehensive search of PubMed, MedLine, ScienceDirect, and the Cochrane Library yielded 1550 studies. After screening and eligibility assessment, 14 studies were included. Data extraction covered study design, plug type, follow-up duration, and clinical outcomes. Meta-analyses were performed using Review Manager 5.4. Fourteen studies involving 1537 patients (1155 eyes) were analyzed. Punctal occlusion techniques included silicone, collagen, SmartPlugs, and thermal cautery. Meta-analysis revealed no significant improvements in tear film break-up time (WMD = 0.37; 95% CI: -0.94 to 1.67; p = 0.58), Schirmer scores (WMD = 0.61; 95% CI: -0.96 to 2.18; p = 0.45), or fluorescein staining (WMD = -0.38; 95% CI: -0.92 to 0.16; p = 0.17) compared to controls. However, within group analysis based on follow up period of Schirmer test demonstrated significant improvement (p= 0.01). Reported adverse events were minor and self-limiting. Punctal occlusion techniques offer consistent ocular surface benefits with minimal risks. While current evidence highlights positive clinical outcomes, high-quality randomized controlled trials with standardized metrics are necessary to establish definitive efficacy.
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an established adjunct treatment of hemorrhagic shock caused by subdiaphragmatic bleeding. However, evidence for its use in prehospital settings and long-distance transportation in remote locations remains limited. Herein, we report a case of hemorrhagic shock secondary to traumatic liver injury, for which prehospital REBOA was successfully employed. A 41-year-old man sustained multiple traumatic injuries after being run over by heavy machinery. The patient was diagnosed with hemorrhagic shock resulting from a grade IIIb liver injury. Owing to limited local resources and the anticipated clinical deterioration during long-distance transportation to an emergency medical center, a physician-staffed ground ambulance was dispatched. During which the hemodynamic status of the patient deteriorated, tracheal intubation and REBOA were performed in the ambulance. Partial aortic occlusion was initially applied, followed by complete occlusion when cardiac arrest was imminent. On arrival in the operating room, the patient underwent massive blood transfusion, damage-control laparotomy with perihepatic packing, and subsequent transcatheter arterial embolization. No REBOA-related complications occurred. The patient was discharged from the intensive care unit on hospital day seven. Prehospital REBOA may serve as an effective bridge for definitive hemorrhage control during long-distance transportation in resource-limited regions. Successful implementation requires experienced trauma teams and coordinated system-level management.
Basilar artery occlusion (BAO) accounts for 10% of all ischemic strokes due to largevessel occlusion (LVO) and is associated with highest mortality and disability rate. The aim ofthis study is to propose a specific basilar artery reperfusion score based on digital subtraction angiography (DSA) to evaluate the efficacyof mechanical thrombectomy in patients with acute BAO. We conducted a retrospective analysis of a prospective database of consecutivepatients with acute BAO treated with mechanical thrombectomy within 24 h from symptomonset at a comprehensive stroke center between January-2014 and December-2023. BasilarThrombolysis In Cerebral Infarction (bTICI) scale was made using PC ASPECTS grading scoreas reference. Primary outcome was defined by a modified Rankin scale score of 0-3 (goodfunctional status) at 90-days. A total of 98 patients were included (median age 70 years, 56 men). bTICI score of 10was achieved in 46 patients (46.9%), bTICI 9 in 8 patients (8.2%), bTICI 8 in 16 patients (16.3%), bTICI 7 in 4 patients (4.1%) and bTICI 0-6 in 24 patients (24.5%). On multivariable analysis, mTICI 3 was independently associated with 90-day goodfunctional status [OR 4.48 (95% CI 1.64-18.27)], while mTICI 2b-3 was not. Regarding bTICI scale, a bTICI ≥ 7 remained as independentpredictors of 90-day good functional status [OR 9.45 (95% CI 2.68-33.30)]. In our study, bTICI ≥ 7 or ≥8 is an independent predictor of 90-day good functional status (mRS 0-3) in patientswith Acute BAO treated with mechanical thrombectomy. The Basilar Thrombolysis In Cerebral Infarction (bTICI) scale identified meaningful distinctions in clinical outcomes in our single-center study, showing better performance thanmTICI scale. This new scale, specific to posterior circulation stroke, may be useful in futurestudies and routine practice but this needs to be confirmed in multicenter.
The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke from distal- and medium-vessel occlusion (DMVO) for endovascular thrombectomy (EVT). The intended audiences are prehospital care providers, physicians, and allied health professionals. The Society of Vascular and Interventional Neurology Guidelines and Practice Standards committee formed a writing group to conduct a structured literature review on EVT for DMVO-related acute ischemic stroke and to draft practice recommendations in accordance with the Society of Vascular and Interventional Neurology Guidelines and Practice Algorithm. A structured literature search was conducted across PubMed, MEDLINE, and the Cochrane Library from January 2015 through February 2026, supplemented by manual review of reference lists from key studies and conferences. Recommendations were developed with consensus from an expert panel and the Guidelines and Practice Standards committee, with final approval by the Society of Vascular and Interventional Neurology Board of Directors. Data from all randomized controlled trials, prior meta-analyses, and subgroup analyses were extracted to evaluate the latest evidence on the safety and efficacy of EVT in patients presenting with DMVO acute ischemic stroke. The guideline outlines practical considerations for patient selection, procedural technique, and systems of care. These guidelines provide focused practical recommendations based on recent evidence regarding patient selection and decision-making for EVT in patients presenting with acute DMVO. Routine EVT for DMVO is not supported by current evidence; however, performing EVT in patients with disabling acute dominant M2 occlusion remains reasonable.
At present, there is still debate about the treatment strategies for acute ischemic stroke patients with low National Institute of Health Stroke Scale (NIHSS) scores (<6 points) and large vessel occlusion (LVO). Our objective is to assess whether endovascular treatment (EVT) could be beneficial in acute ischemic stroke patients with low NHISS scores and LVO. We searched the PubMed, Embase, Cochrane Library, and Web of Science databases to obtain articles related to EVT for patients with low NHISS score with LVO until 1 January 2024. The primary outcome was a good functional outcome (modified Rankin Scale [mRS] 0-2). Effect sizes were computed as risk ratio (RR) with random-effects or fixed-effects models. The quality of articles was evaluated through the Cochrane risk assessment tool and the Newcastle-Ottawa Scale. A total of 2,275 articles were obtained through the search, and articles that did not meet the inclusion criteria were excluded after review of the title, abstract, and full text. Finally, 2 randomized controlled trials (RCTs) and 22 cohort studies met the inclusion criteria. In the EVT group, 77.8% of patients achieved a good functional outcome, while 77.1% of patients achieved functional independence in the best medical treatment (BMT) group. EVT was not associated with excellent functional outcome (mRS 0-1; risk ratio 1.04 [95% CI, 0.97-1.11]) or with a good functional outcome (mRS 0-2; risk ratio 1.00 [95% CI, 0.95-1.04]). Symptomatic intracranial hemorrhage was more common in patients receiving EVT (risk ratio 2.82 [95% CI, 2.18-3.65]). There was no correlation between EVT and 3-month mortality (risk ratio 1.15 [95% CI, 0.93-1.43]). This meta-analysis shows that, in patients with low NIHSS score combined with LVO, EVT did not demonstrate clear improvement in neurologic outcomes but was associated with an increased incidence of symptomatic intracranial hemorrhage (sICH) compared to BMT.
To evaluate the alterations and associations of thiol-disulfide homeostasis (TDH), ischemia-modified albumin (IMA), and superoxide dismutase (SOD) levels in patients with retinal vein occlusion (RVO). This prospective case-control study included 23 treatment-naïve RVO patients and 34 healthy control subjects comparable in terms of age and sex. Serum total thiol, native thiol, IMA levels and serum and urine SOD activity were measured using a spectrophotometric assay. Patients with RVO demonstrated markedly reduced levels of native thiol (252.84 ± 66.08 vs. 308.77 ± 33.21 μmol/L, p = 0.003), total thiol (294.02 ± 73.09 vs. 355.83 ± 36.92 μmol/L, p = 0.002), and disulfide concentrations (20.59 ± 3.65 vs. 23.53 ± 2.34 μmol/L, p = 0.001) in comparison to healthy controls. The computed ratio of disulfide to native thiol was comparable between the two groups (p > 0.05). No differences were seen in serum IMA levels and SOD levels in both serum and urine samples between RVO and healthy controls (p > 0.05). Our findings suggest a potential association between altered TDH and RVO. The observed biomarker profile indicates a complex redox pattern, highlighting the need for further studies to better understand the underlying mechanisms.
Deflectable delivery systems have been introduced to enhance coaxial alignment and procedural efficacy during left atrial appendage occlusion (LAAO), yet randomized comparisons with conventional fixed-curve systems are lacking. The GUIDE-LAAO trial evaluated whether the TruSteer deflectable delivery system is non-inferior to the FXD Double Curve (FXD DC) delivery system for procedural success in patients undergoing LAAO with the Watchman FLX Pro device. In this prospective, randomized, all-comers trial, 50 patients with non-valvular atrial fibrillation undergoing LAAO were assigned 1:1 to TruSteer (n = 25) or FXD DC (n = 25). The primary endpoint was procedural success, defined as successful device implantation without major procedural or periprocedural complications. Secondary endpoints included technical success, device success, procedural efficiency, and safety outcomes. Procedural success occurred in 100% of TruSteer-treated patients and 84% of FXD DC-treated patients (risk difference 16%; 95% confidence interval -6.9% to 34.7%), meeting criteria for non-inferiority; superiority was not demonstrated (p = 0.11). Technical and device success were 100% with TruSteer and 92% with FXD DC. Procedural time (34.6 ± 7.1 vs. 36.5 ± 13.0 min), fluoroscopy time (22.3 ± 4.4 vs. 22.1 ± 7.2 min), and contrast volume (34.5 ± 12.1 vs. 36.8 ± 13.5 mL) were similar. Periprocedural complications occurred in 4% and 16%, respectively, with no deaths or strokes. In this first randomized comparison of LAAO delivery systems, TruSteer was non-inferior to a standard fixed-curve system, with comparable efficiency and safety in an unselected population. These findings provide randomized evidence supporting deflectable delivery technology in contemporary LAAO practice and inform future studies in anatomically complex subsets.
Lipoprotein(a) [Lp(a)] has been established as a significant prognostic marker in patients with chronic total occlusion (CTO) of the coronary artery. Left ventricular systolic dysfunction (LVSD) is a common and serious complication associated with CTO. This study aimed to explore the relationship between Lp(a) and LVSD in patients with CTO. A total of 309 patients with CTO who underwent elective percutaneous coronary intervention were consecutively enrolled in the study. The patients were stratified by left ventricular ejection fraction (LVEF) into the LVSD group (LVEF < 50%, n = 80) and preserved systolic function group (LVEF ≥ 50%, n = 229). The mean age of the cohort was 61.5 ± 11.3 years, 83.8% were males, and the prevalence of LVSD was 25.9%. Compared with patients with preserved systolic function, those with LVSD tended to be older, had a higher prevalence of arrhythmia, a history of myocardial infarction, and multivessel CTO disease, and exhibited more severe calcified lesions, while having a lower prevalence of hypertension. They also exhibited higher levels of Lp(a), NT-proBNP, and neutrophils, but had a lower body mass index, lower albumin levels, and a reduced LVEF (all P < 0.05). Multivariate regression analysis revealed that Lp(a) was significantly associated with LVSD, with an odds ratio (OR) per 100 mg/L of 1.149 (95% CI: 1.042-1.267; P = 0.005) after adjusting for potential confounding factors. Furthermore, incorporating Lp(a) into a model based on traditional risk factors significantly improved its discriminatory ability for LVSD (AUC = 0.839, 95% CI: 0.786-0.891, P < 0.001). Subgroup analysis indicated that the association between Lp(a) and LVSD was more pronounced in patients with multivessel CTO disease (P for interaction = 0.034). Elevated Lp(a) levels were significantly associated with LVSD in patients with CTO of the coronary artery.
In cavernous sinus dural arteriovenous fistulas (CS-dAVFs), posterior venous drainage may become occluded first, followed by anterior drainage, occasionally leading to spontaneous resolution. Immediately before this stage, however, a phenomenon known as paradoxical worsening may occur, in which symptoms rapidly deteriorate despite apparent angiographic improvement because of progressive venous outflow obstruction. In such cases, the shunt pouch (SP) becomes nearly isolated, and the lesion must be reached by penetrating the occluded cavernous sinus (CS) along a conventional access route, which is not always technically straightforward. We report a case in which a chronic total occlusion (CTO) wire enabled access to the lesion and definitive cure. An 83-year-old woman presented to a local ophthalmologist with left conjunctival injection. Ophthalmological examination revealed full and smooth ocular movements without any obvious abnormality. Intraocular pressure was within the normal range, and no abnormal findings were noted in the visual fields or visual acuity. Brain magnetic resonance imaging demonstrated a left CS-dAVF. The lesion was fed by the middle meningeal artery and the meningohypophyseal trunk of the internal carotid artery and drained from the left CS into the left superior ophthalmic vein. Transvenous embolization (TVE) was selected, and access was obtained through the right internal jugular vein. We entered the normal right CS via the right inferior petrosal sinus and then attempted to advance into the contralateral isolated sinus; however, passage was difficult with a conventional wire. By using a CTO wire (Vassallo 40), we were able to reach the isolated SP, and the microcatheter was subsequently advanced to the shunt point, allowing curative TVE. We experienced a favorable case of an isolated CS shunt in which access from the normal CS was difficult, but the lesion was reached with a CTO wire and successfully treated by TVE. In cases with difficult venous access, a CTO wire may represent a useful adjunct.
Perinatal arterial ischemic stroke (PAIS) constitutes one of the leading causes of neurological deficits in children. Internal carotid artery occlusion (ICAO) represents a rare etiology of PAIS and has been documented in only a limited number of case reports. Herein, we present two cases of PAIS related to ICAO. Both neonates were discharged following resolution of acute clinical symptoms; however, follow-up assessments revealed persistent contralateral limb hypokinesia. ICAO is a rare entity in neonates, characterized by insidious and atypical manifestations in the neonatal period, and is associated with relatively poor neurological outcomes. For neonates diagnosed with PAIS, comprehensive cervical vascular imaging should be performed to enable early and definitive diagnosis of neonatal ICAO.
Final infarct volume (FIV) on 24-hour magnetic resonance imaging is a well-established imaging biomarker linked to functional recovery after ischemic stroke, yet its prognostic value in intracranial atherosclerosis-related large vessel occlusion remains poorly explored. The impact of adjunct intracranial stenting on both infarct size and progression also remains unclear in this population. This study aimed to examine the association between FIV and clinical outcome, evaluate the effect of adjunct stenting on FIV and infarct progression, and assess the relationship between infarct progression and functional independence. We conducted a post hoc secondary analysis of the RESCUE-ICAS registry (Registry of Emergent Large Vessel Occlusion due to Intracranial Stenosis); only patients with anterior circulation large vessel occlusion with magnetic resonance imaging after thrombectomy were included. FIV was measured on diffusion-weighted magnetic resonance imaging performed 24 to 36 hours postthrombectomy. Infarct progression was defined as the difference between baseline computed tomography perfusion infarct volume (cerebral blood flow <30%) on presentation and 24- to 36-hour FIV. The primary outcome was 90-day functional independence (modified Rankin Scale score 0-2). Additional analyses evaluated the association between adjunct intracranial stenting and FIV, and the association between infarct progression and 90-day functional outcome. Associations were analyzed using multivariable logistic regression and inverse probability of treatment weighting. Of the 417 patients included in RESCUE-ICAS, 203 had anterior circulation intracranial atherosclerosis-related large vessel occlusion and underwent magnetic resonance imaging 24 to 36 hours postthrombectomy. Among these, 80 patients (39%) received adjunct stenting. FIV was independently associated with 90-day functional independence (adjusted odds ratio per 10 mL increase, 0.8 [95% CI, 0.68-0.94]; P=0.007). Adjunct stenting was associated with a significant relative reduction in FIV, with inverse probability of treatment weighting-adjusted analyses demonstrating a 37.8% lower FIV compared with no stenting (β=-0.47 [95% CI, -0.93 to -0.02]; P=0.043). Among 108 patients with baseline computed tomography perfusion data, infarct progression was strongly associated with outcome, with each additional 10 mL associated with ≈25% lower odds of achieving modified Rankin Scale score 0 to 2 at 90 days (adjusted odds ratio, 0.74 [95% CI, 0.60-0.90]; P=0.004), although infarct progression did not differ significantly between stented and nonstented groups (Δ -9.53 mL [95% CI -37.9 to 18.8]; P=0.506). In inverse probability of treatment weighting-weighted models adjusted for successful recanalization, stenting was not independently associated with reduced FIV (β=-0.41; P=0.066), but remained independently associated with higher odds of 90-day functional independence (odds ratio, 2.29 [95% CI, 1.24-4.27]; P=0.008). Among intracranial atherosclerosis-related large vessel occlusion patients, 24- to 36-hour FIV is a strong predictor of functional outcome. Adjunct stenting is associated with smaller FIV. Lower infarct progression was also associated with favorable outcome. These findings highlight FIV as a reliable imaging biomarker and potential surrogate end point in future trials.
In a standard pancreaticoduodenectomy (Whipple procedure), the gastroduodenal artery (GDA) is ligated. In a patient with celiac axis occlusion with prominent GDA collaterals, the decision of whether to preserve the GDA comes into play. We report the case of an otherwise healthy 60-year-old woman who presented with a pancreatic mass with concurrent celiac axis occlusion. Pre-operative imaging illustrated a celiac axis occlusion with prominent collaterals from the gastroduodenal artery supplying the distal pancreas, spleen, and stomach. Arteriography further demonstrated a replaced right hepatic artery originating from the superior mesenteric artery and a diminutive left hepatic artery. Based on these findings, the decision was made to re-implant the gastroduodenal artery to preserve the aforementioned structures. Thus far, there have been no instances of GDA re-implantation in the literature. A review of the literature was performed using PubMed, Embase, and Google Scholar with search terms including 'gastroduodenal artery reimplantation,' 'GDA reconstruction,' 'Whipple,' 'pancreaticoduodenectomy,' and 'celiac axis occlusion.' To our knowledge, no prior reports of gastroduodenal artery re-implantation during pancreaticoduodenectomy have been identified.
Brain tumors are a leading cause of cancer-related mortality, and manual MRI screening remains time-consuming and observer-dependent. Deep learning (DL) offers automated detection, but clinical translation requires rigorous validation and interpretability. This study introduces a DL framework for brain tumor detection that addresses two major challenges in medical AI: limited dataset availability and lack of interpretability. Preliminary experiments identified InceptionV3 optimized with Nadam as the optimal architecture. To ensure robust validation, this model was retrained using patient-wise stratified fivefold cross-validation on 90% of the data incorporating augmentation and minority oversampling to prevent data leakage. This achieved an overall accuracy of 98.3 ± 0.9%. The final model was then trained on the entire development set using the optimal configuration, thereby leveraging all available labeled data to maximize learning capacity and enhance generalization. Performance evaluation was conducted on three levels: (i) a held out internal test set (10% of the data) for internal assessment, (ii) an external dataset of 3000 unseen images for independent validation, and (iii) quantitative explainable AI (XAI) analyses performed on both internal and external test datasets. The proposed model achieved perfect classification metrics on the internal test set, with 100% accuracy and minimal loss (0.01), and demonstrated strong generalizability on the external dataset with 96% accuracy and minimal loss (0.11). Quantitative XAI analysis demonstrated high faithfulness (Grad-CAM vs. occlusion sensitivity correlation exceeded 0.8), causal importance (top-10% occlusion drop 44% vs. 9% for random occlusion), and specificity to learned weights (Spearman correlation ≈ - 0.01). The proposed pipeline establishes a rigorous, transparent framework for data-limited medical imaging, demonstrating high diagnostic performance with clinically aligned explanations and providing a reliable foundation for trustworthy AI in brain tumor detection.
Linguoverted mandibular canine (LMC) teeth are a common form of malocclusion in dogs. If left untreated, contact between the mandibular canine tooth crown tips and the palatal mucosa can result in ulceration, inflammation, infection, and potentially the formation of an oronasal fistula. Various treatment modalities have been described, including both active and passive orthodontic techniques. This report describes the combined use of an active appliance (elastic power chain) and a passive appliance (inclined plane) for the correction of unilateral and bilateral LMC teeth in 2 Shiba Inu dogs. Treatment duration was approximately 60 days in both cases, and follow-up examinations confirmed stable, functional, and atraumatic occlusion. This combined approach may represent an effective and safe treatment option for achieving self-retaining occlusion in similar cases.