Mechanical thrombectomy (MT) is an effective treatment in patients with acute ischemic stroke (AIS) due to emergent large-vessel occlusion in the anterior circulation. Occlusion of the anterior cerebral artery (ACA) affects up to 15% of these patients. Here we report a case of an elderly patient with an successful MT of an embolic A2-segment occlussion with the anatomic variation of a triplication. Triplication of ACA is a rare anatomical variation, and the occlusion could have been easily overlooked in case of not performing the CT-perfusion (CTP) sequences. As anatomical variations of the circle of Willis are present in most subjects, CTA alone might be limited in the acute setting, particularly for young residents performing the first view on call. This case highlights the importance of including CTP in the initial CT-diagnostic algorithm in AIS patients who are basically eligible for recanalization therapies, irrespective of inconspicuous initial findings in CTA.

Mechanical thrombectomy (MT) is an effective treatment in patients with acute ischemic stroke (AIS) due to emergent large-vessel occlusion in the anterior circulation. Occlusion of the anterior cerebral artery (ACA) affects up to 15% of these patients. Here we report a case of an elderly patient with an successful MT of an embolic A2-segment occlussion with the anatomic variation of a triplication. Triplication of ACA is a rare anatomical variation, and the occlusion could have been easily overlooked in case of not performing the CT-perfusion (CTP) sequences. As anatomical variations of the circle of Willis are present in most subjects, CTA alone might be limited in the acute setting, particularly for young residents performing the first view on call. This case highlights the importance of including CTP in the initial CT-diagnostic algorithm in AIS patients who are basically eligible for recanalization therapies, irrespective of inconspicuous initial findings in CTA.

and Purpose Many patients with stroke cannot receive intravenous thrombolysis because the time of symptom onset is unknown. We tested whether a simple method of computed tomography (CT)-based quantification of water uptake in the ischemic tissue can identify patients with stroke onset within 4.5 hours. Methods This retrospective analysis of the MissPerfeCT study (August 2009 to November 2017) includes consecutive patients with known onset of symptoms from seven tertiary stroke centers. We developed a simplified algorithm based on region of interest (ROI) measurements to quantify water uptake of the ischemic lesion and thereby quantify time of symptom onset within and beyond 4.5 hours. Perfusion CT was used to identify ischemic brain tissue, and its density was measured in non-contrast CT and related to the density of the corresponding area of the contralateral hemisphere to quantify lesion water uptake. Results Of 263 patients, 204 (77.6%) had CT within 4.5 hours. Water uptake was significantly lower in patients with stroke onset within (6.7%; 95% confidence interval [CI], 6.0% to 7.4%) compared to beyond 4.5 hours (12.7%; 95% CI, 10.7% to 14.7%). The area under the curve for distinguishing these patient groups according to percentage water uptake was 0.744 with an optimal cut-off value of 9.5%. According to this cut-off the positive predictive value was 88.8%, sensitivity was 73.5%, specificity 67.8%, negative predictive value was 42.6%. Conclusions Ischemic stroke patients with unknown time of symptom onset can be identified as being within a timeframe of 4.5 hours using a ROI-based method to assess water uptake on admission non-contrast head CT.

BACKGROUND AND PURPOSE: Current guidelines do not provide firm directions on atrial fibrillation (AF) screening after ischemic stroke (IS). We sought to investigate the association of implantable cardiac monitoring (ICM) duration with the yield of AF detection in IS patients. METHODS: We included studies reporting AF detection rates by ICM in IS patients with negative initial AF screening. We excluded studies reporting prolonged cardiac monitoring with devices other than ICM, not providing AF detection rates or monitoring duration, and reporting overlapping data for the same population. The random-effects model was used for all pooled estimates and meta-regression analyses. RESULTS: We included 28 studies (4,531 patients, mean age 65 years). In meta-regression analyses, the proportion of AF detection by ICM was independently associated with monitoring duration (coefficient=0.015; 95% confidence interval [CI], 0.005 to 0.024) and mean patient age (coefficient=0.009; 95% CI, 0.003 to 0.015). No associations were detected with other patient characteristics, including IS subtype (cryptogenic vs. embolic stroke of undetermined source) or time from IS onset to CM implantation. In subgroup analyses, significant differences (P<0.001) in the AF detection rates were found for ICM duration (<6 months: 5% [95% CI, 3% to 6%]; ≥6 and ≤12 months: 21% [95% CI, 16% to 25%]; >12 and ≤24 months: 26% [95% CI, 22% to 31%]; >24 months: 34% [95% CI, 29% to 39%]). CONCLUSIONS: Extended duration of ICM monitoring and increased patient age are factors that substantially increase AF detection in IS patients with initial negative AF screening.
Atrial Fibrillation ; Humans ; Mass Screening ; Stroke