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Objective: Acute mechanical thrombectomy (AMT) in patients with acute ischemic stroke from large vessel occlusion (LVO) is performed without directly identifying the occluded vessels. In this study, we evaluated whether 1.5 T magnetic resonance imaging (MRI) with 3D-fast imaging employing steady-state acquisition (FIESTA) could visualize the occluded intracranial middle cerebral artery (MCA) and internal carotid artery (ICA) before AMT.Methods: This retrospective study included 21 consecutive patients who underwent time-of-flight magnetic resonance angiography (TOF MRA) and 3D-FIESTA MRI immediately before AMT. The patients also underwent TOF MRA after AMT and achieved TICI 2b or 3 by AMT at our hospital between February 2018 and April 2019. When LVO in the anterior circulation was detected by TOF MRA, 3D-FIESTA MRI was additionally performed. Then, the occluded intracranial MCA and ICA, including their branches, were constructed on the workstation with volume rendering. The obtained images were fused with the TOF MRA images to create combined 3D images.Results: The length and top-to-bottom distance of the affected M1 segment (calculated by the ipsilateral-to-contralateral ratio) were 1.29 and 1.17, respectively, on 3D-FIESTA MRI before AMT and 1.34 and 1.24, respectively, on TOF MRA after AMT. We assessed the number of M2 segments branching from the affected M1/M2 junction and visualized the affected anterior temporal artery. The 3D-FIESTA MRI before AMT and TOF MRA after AMT were consistent in all patients, except for two who moved vigorously during imaging.Conclusions: Images acquired by 1.5T 3D-FIESTA MRI can visualize to predict the existing path of the occluded MCA and ICA before AMT in patients with LVO of the anterior circulation.

Background and Purpose— Endovascular therapy (EVT) is strongly recommended for acute cerebral large vessel occlusion with the Alberta Stroke Program Early CT Score (ASPECTS) ≥6 due to occlusion of the internal carotid artery or M1 segment of the middle cerebral artery. However, the effect of EVT for patients who have ischemic core with ASPECTS ≤5 (0–5) was not established. The purpose of this study was to elucidate the outcomes of EVT for patients with large ischemic core. Methods— Based on the data of The Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2, patients with internal carotid artery or M1 segment of the middle cerebral artery occlusion and pretreatment ASPECTS 0 to 5 on noncontrast CT or diffusion-weighted image were extracted, and the outcomes by EVT were analyzed. Primary end point was defined as a good functional outcome (modified Rankin Scale score of ≤2) after 90 days. Result— Among 2420 registered patients, 504 patients were with internal carotid artery or M1 segment of the middle cerebral artery occlusion and ASPECTS 0 to 5. Among these 504 patients, 172 (34.1 %) were treated with EVT (EVT group) and 332 (65.9 %) without (no-EVT group). In the no-EVT group, elderly patients, females, poor prestroke modified Rankin Scale, high National Institutes of Health Stroke Scale, low ASPECTS, and late admission were significantly more observed. Good functional outcomes were significantly more observed in the EVT group than in the no-EVT group (19.8 % versus 4.2 %; P <0.0001; adjusted odds ratio, 2.33; 95% CI, 1.10–4.94). The incidences of symptomatic intracranial hemorrhage within 72 hours did not significantly different between the EVT group and the no-EVT group (3.7 % versus 4.9%; P =0.55; adjusted odds ratio, 0.50; 95% CI, 0.14–1.73). Conclusions— Although outcomes in this group of patients were usually poor, the data suggested EVT may increase the likelihood of a good functional outcome.

Objective: Traumatic arteriovenous fistula (AVF) concomitant with pesudoaneurysm involving the middle meningeal artery is uncommon. Traumatic AVF is also known to occasionally show spontaneous closure. We report a rare case of traumatic pseudoaneurysm of the middle meningeal artery identified after spontaneous closure of a traumatic AVF. Case presentation: A 36-year-old right-handed man suffered a head injury after falling from a step at home, and was brought to our institute. The patient showed no neurological deficits. Computed tomography (CT) showed no intracranial hemorrhage and he was discharged to home. Six days later, he consulted our outpatient clinic because of dizziness and pulsatile tinnitus on the right side. Fracture in the right temporal bone was found on review of the initial CT. Magnetic resonance (MR) imaging showed cerebral contusion in the left temporal lobe and MR angiography demonstrated AVF involving the middle meningeal artery. Angiography revealed direct AVF supplied by the dilated right middle meningeal artery and draining into the cavernous sinus with no cortical venous reflux. Transarterial embolization was attempted 56 days after head injury. Right external carotid artery angiography revealed spontaneous obstruction of the AVF. Selective middle meningeal artery angiography disclosed a small aneurysm, which was embolized completely by coils and glue material. Conclusion: It may be sometimes difficult to detect a traumatic pseudoaneurysm associated with a traumatic arteriovenous fistula of the middle meningeal artery. Close radiographical follow-up is necessary in this lesion.• Key words • traumatic arteriovenous fistula, pseudoaneurysm, spontaneous closure, middle meningeal artery 652-0803 9-2-6

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