Background: Early‐stage unilateral moyamoya disease (MMD) is difficult to discriminate from isolated intracranial atherosclerotic stenosis, and identification of contralateral progression may aid in the diagnosis of MMD. The RNF213 (ring finger protein 213) R4810K variant is a strong genetic susceptibility factor for MMD; however, the role of contralateral progression in unilateral MMD is unknown. Methods and Results: Patients who had undergone RNF213 R4810K genotyping with suspected unilateral MMD between January 2017 and August 2021 from 2 tertiary university hospitals were retrospectively reviewed. We compared the clinical features and radiographic outcomes of patients with and without this variant. The risk factors of contralateral progression in patients with suspected unilateral MMD were evaluated. The RNF213 R4810K variant was observed in 72 of 123 patients with suspected unilateral MMD, all of which were heterozygous. The allele frequency of the R4810K variant was significantly higher in the suspected unilateral MMD group compared with the historical control group (29.3% versus 1.2%; P <0.0001). Family history of MMD was significantly more common in patients with the variant than in those without (17% versus 4%; P =0.003). Eleven of 72 patients with the variant developed contralateral progression, whereas only 1 of 51 patients without the variant developed contralateral progression during a median follow‐up period of 28 months (log‐rank test; P =0.03). The presence of the RNF213 R4810K variant significantly correlated with contralateral progression (adjusted odds ratio, 6.39 [95% CI, 1.11–36.63]; P =0.04). Conclusions: Contralateral progression is more likely to occur in patients with suspected unilateral MMD with the RNF213 R4810K variant than in those without the variant. However, because our study used a small sample size, this finding should be carefully interpreted and requires further studies with more patients and longer follow‐up periods.

BACKGROUND: Smoking is a well-established risk factor for subarachnoid hemorrhage (SAH), and current smokers have an increased risk of SAH. However, there are insufficient data on whether smoking cessation in current smokers reduces the risk of SAH. METHODS: A nested case-control study was conducted based on the National Health Insurance Service-National Health Screening Cohort, which comprises nationwide health claims data and a national health screening program in Korea (2002–2019). We constructed a cohort of current male smokers without a history of stroke at the baseline health screening (2002–2003). From this cohort, cases were defined as individuals who experienced a nontraumatic SAH during the follow-up period up to 2019. Five controls were matched to each case using incidence density sampling. Smoking status (continuation or cessation) before the occurrence of SAH was evaluated using the repeated national health screening program. We conducted a multivariable conditional logistic regression analysis, adjusting for alcohol consumption, physical activity, body mass index, systolic blood pressure, and fasting blood glucose levels, to evaluate the association between SAH risk and smoking cessation. RESULTS: At baseline, there were 112 142 current male smokers. After excluding individuals with prior stroke or insufficient data, the cohort consisted of 105 223 eligible participants (mean age, 50.3±8.5 years). Among them, we identified 318 cases of SAH and 1590 matched controls. Those who quit smoking had a significantly lower risk of SAH compared with current smokers (adjusted odds ratio, 0.55 [95% CI, 0.41–0.73]). The risk of SAH decreased with a longer period of smoking cessation. The risk reduction with smoking cessation was consistent even among prior heavy smokers. CONCLUSIONS: Smoking cessation in current male smokers reduced the risk of SAH, and the risk reduction was greater as the cessation period increased. These findings warrant intensive efforts to encourage smokers, even heavy smokers, to quit.

Ok T, et al. J Korean Med Sci. 2022 Dec;37(50):e358. https://doi.org/10.3346/jkms.2022.37.e358

A rupture of a femoral pseudoaneurysm is an extremely rare complication of endovascular procedures, but its outcome can be life-threatening. In this report, we present a case of a femoral pseudoaneursym rupture in a patient in their early 90s following intra-arterial mechanical thrombectomy for acute ischemic stroke. Despite receiving medical and surgical interventions, the patient subsequently developed multiple organ failure, ultimately resulting in death. This case emphasizes the critical role of appropriate selection of vascular closure technique and careful post-procedural monitoring, particularly in high-risk patients.

Mechanical thrombectomy using a stent retriever is a widely-used technique for recanalizing occluded cerebral arteries in acute ischemic stroke. Although rare, inadvertent stent detachment has primarily been reported with earlier stent retriever designs. We present 2 cases of inadvertent stent detachment with the pRESET stent. In the first case, an elderly patient presented with right middle cerebral artery occlusion and experienced stent detachment during the second retrieval. Despite this, successful recanalization was achieved through balloon angioplasty. In the second case, an elderly patient experienced stent detachment after the third retrieval, and recanalization of the M1 segment was unsuccessful due to the inability to pass the microcatheter. The first patient had a modified Rankin scale (mRS) score of 3, while the second had a poor prognosis with an mRS score of 5. These cases highlight that inadvertent stent detachment can impact outcomes, and balloon angioplasty may serve as a useful salvage therapy.

Background: Current stroke guidelines lack subtype‐specific recommendations for optimal low‐density lipoprotein cholesterol targets. Indeed, most lipid‐lowering trials have not differentiated between stroke subtypes or focused primarily on large artery atherosclerosis, leaving a gap in evidence for other stroke subtypes, such as small vessel occlusion stroke. This study is designed to evaluate whether intensive lipid‐lowering therapy is superior to standard therapy in reducing major adverse cardiovascular events among patients with small vessel occlusion stroke. Methods: SVO70 (Optimal Target Low‐Density Lipoprotein Cholesterol Level for Small Vessel Occlusion Stroke) is a multicenter, prospective, randomized, open, blinded‐end point clinical trial in which adult patients with neuroimaging‐confirmed small vessel occlusion stroke within 180 days of randomization will be enrolled. Key exclusion criteria include predefined low‐density lipoprotein cholesterol targets for other comorbidities, contraindications to statin, and pregnancy or lactation. Eligible participants will be randomized 1:1 to achieve low‐density lipoprotein cholesterol <70 mg/dL (intensive group) or 90 to 110 mg/dL (standard group). The trial aims to enroll 4016 participants over a 2‐year recruitment period, with a minimum follow‐up of 4 years. The primary end point is the occurrence of major adverse cardiovascular events, defined as cardiovascular death, stroke, and acute coronary syndrome, during the follow‐up period. Secondary end points include (1) any stroke, (2) ischemic stroke or transient ischemic attack, (3) hemorrhagic stroke, (4) cardiovascular death, (5) myocardial infarction, (6) all‐cause death, and (7) acute coronary syndrome. Conclusions: This study will provide valuable information for determining optimal low‐density lipoprotein cholesterol targets for patients with small vessel occlusion stroke. Registration: URL: https://ClinicalTrials.gov ; Unique Identifier: NCT06649240, Clinical Research Information Service (KCT0009043).