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Background: Only few studies have investigated the relationship between the histopathology of retrieved thrombi and clinical outcomes. This study aimed to evaluate thrombus composition and its association with clinical, laboratory, and neurointerventional findings in patients treated by mechanical thrombectomy due to acute large vessel occlusion. Methods: At our institution, 79 patients were treated by mechanical thrombectomy using a stent retriever and/or aspiration catheter between August 2015 and August 2016. The retrieved thrombi were quantitatively analyzed to quantify red blood cells, white blood cells, and fibrin by area. We divided the patients into two groups – a fibrin-rich group and an erythrocyte-rich group – based on the predominant composition in the thrombus. The groups were compared for imaging, clinical, and neurointerventional data. Results: The retrieved thrombi from 43 patients with acute stroke from internal carotid artery, middle cerebral artery, or basilar artery occlusion were histologically analyzed. Erythrocyte-rich thrombi were present in 18 cases, while fibrin-rich thrombi were present in 25 cases. A cardioembolic etiology was significantly more prevalent among the patients with fibrin-rich thrombi than among those with erythrocyte-rich thrombi. Attenuation of thrombus density as shown on computed tomography images was greater in patients with erythrocyte-rich thrombi than in those with fibrin-rich thrombi. All other clinical and laboratory characteristics remained the same. Patients with erythrocyte-rich thrombi had a smaller number of recanalization maneuvers, shorter procedure times, a shorter time interval between arrival and recanalization, and a higher percentage of stent retrievers in the final recanalization procedure. The occluded vessels did not differ significantly. Conclusions: In this study, erythrocyte-rich thrombus was associated with noncardioembolic etiology, higher thrombus density, and reduced procedure time.

Delayed cerebral ischemia (DCI) is a significant cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). Recently, we reported the possibility that computational fluid dynamics (CFD) could predict DCI in terms of the cross-sectional area and flow velocity of the ipsilateral extracranial internal carotid and distal parent arteries in a single-center retrospective study.This is a multicenter, prospective, cohort study. Patients with aneurysmal SAH will undergo CFD analyses using preoperative three-dimensional computed tomography angiography, and we will investigate hemodynamic features of cerebral arteries in an acute stage of SAH. Primary outcome measures will be CFD features in patients with subsequent occurrence of DCI. Secondary outcome measures will be CFD features in patients with subsequent occurrence of cerebral vasospasm and cerebral infarction and the relationships with eventual modified Rankin scale score at 3 months.The present protocol for a multicenter prospective study is expected to provide a novel diagnostic method to predict DCI before aneurysmal obliteration in an acute stage of SAH.

Background: Delayed cerebral ischemia (DCI) is a significant cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). Recently, we reported the possibility that computational fluid dynamics (CFD) could predict DCI in terms of the cross-sectional area and flow velocity of the ipsilateral extracranial internal carotid and distal parent arteries in a single-center retrospective study.

The epidemiology of patients with traumatic brain injury (TBI) has changed dramatically over recent decades as a result of rapid advances in aging societies. We assessed the influence of age on outcomes of patients with TBI and sought to identify prognostic factors for in-hospital mortality of TBI among elderly patients.Using a nationwide database, we analyzed data from 5651 patients with TBI. Univariate analysis was conducted to compare patient demographics, neurologic status on admission, radiologic findings, systemic complication rates, length of hospital stay, in-hospital mortality, and home discharge rates between elderly and nonelderly groups. Multivariable analysis was conducted to determine prognostic factors for in-hospital mortality among elderly patients.Overall in-hospital mortality was significantly higher in elderly patients (12.8% vs. 19.3%; P0.001). In-hospital mortality of elderly patients with mild TBI increased significantly at7 days after admission, whereas that of elderly patients with moderate or severe TBI was significantly higher immediately after admission. Age (odds ratio [OR], 1.62; P = 0.024), male sex (OR, 1.30; P = 0.004), Japan Coma Scale score on admission (OR, 5.95, P0.001), and incidence of acute subdural hematoma (OR, 1.89; P0.001) were associated with in-hospital mortality in elderly patients with TBI.Elderly patients with TBI showed significantly higher in-hospital mortality. Delayed increases in in-hospital mortality were observed among elderly patients with mild TBI. Level of consciousness on admission was the strongest predictor of in-hospital mortality among elderly patients.

Background and Purpose: Intravenous thrombolysis tissue plasminogen activator (IV rt-PA) is known as effective to improve functional outcome for acute ischemic stroke. Also, it is known that rapid endovascular treatment improve functional outcome of patients after IV rt-PA. However, the rate of early reperfusion in patients with occluded artery just after IV rt-PA remains unclear. Purpose of this study was to evaluate prevalence of the early reperfusion after IV rt-PA, before mechanical thrombectomy. Methods: Between January 2015 and April 2018, 1753 consecutive ischemic stroke patients who were hospitalized were identified using prospective stroke registry. Four dimensional computed tomography (4DCT) were performed to identify an occulted artery before IV rt-PA. After IV rt-PA, vessel recanalization was diagnosed using Digital subtraction angiography or MR Angiography. Results: Among 1753 consecutive patients, 246 (14%) patients were received IV rt-PA. 117 patients were enrolled, with a mean age of 77 years (SD, 11 years), 66 (56.4%) were male (91 patients without occlusive artery, 24 without 4DCTA before IV rt-PAand 14 with insufficient 4DCT were excluded). The locations of occlusive artery were ACA (n=2), MCA (n=75), ICA (n=23), PCA (n=7) and BA (n=10).IV rt-PAto DSA was 26 ± 22 minutes. Successful and partial reperfusions of the occluded territory were achieved in 11 (9.4%) and 18 (15.4%), respectively. Initial NIHSS of successful/partial reperfusionwas lower than no recanalization group (13.4 ± 9 vs 19.3 ± 9; P Conclusions: Successful reperfusion and partial recanalization rate were 9.4% and 15.4% just after IV rt-PA therapy, respectively. IV rt-PA may promote isolated ICA occlusion worsening.

Introduction: Previous studies showed that recombinant tissue plasminogen activator (rt-PA) administration preceding mechanical thrombectomy reduced puncture to recanalization times. Fibrin rich thrombus was associated with extended puncture to recanalization times. Hypothesis: rt-PA administration preceding mechanical thrombectomy is associated with reduced procedure time and low proportion of fibrin in retrieved thrombus Methods: All retrieved thrombus was stained with hematoxylin-eosin. Embolic debris underwent quantitative analysis to quantify three main components: red blood cells, white blood cells and fibrin, by color based segmentation. Patients were assingned to receive either mechanical thrombectomy with rt-PA (IVTMT group) or mechanical thrombectomy alone (MT group). Considering influence by stroke etiology, patients with non-cardioembolism were excluded. Results: From August 2015 to March 2018, 173 consecutive patients were treated in our hospital by MT for acute large vessel occlusion. Histopathologic analysis of retrieved thrombus from 90 patients with acute stroke. 70 patients with cardioembolism were included. Patients were assigned to IVTMT group (n=29) or MT group (n=41). Onset to recanalization time was significantly shorter in IVTMT group than in MT group (median 167 vs 455 minutes; p < 0.01). The other clinical backgrounds were not significantly different. IVTMT group had shorter puncture to recanalization time (median 45 vs 63 minutes; p=0.02), shorter door to recanalization time (median 91 vs 120 minutes; p=0.02). IVTMT group had lower proportion of fibrin in retrieved thrombus (59.6% vs 77.5%, p=0.03). Conclusion: Intravenous thrombolysis preceding mechanical thrombectomy is significantly associated with reduced procedure time and lower proportion of fibrin in retrieved thrombus.

A 69-year-old man was admitted to the hospital with right hemiparesis and global aphasia. Perfusion computed tomography imaging revealed ischemic penumbra in the middle cerebral artery territory. Angiography showed left middle cerebral artery occlusion. Mechanical thrombectomy with one pass was performed, and successful recanalization was obtained. Embolic material was retrieved; it contained tumor fragments with atypical keratinizing squamous cell carcinoma. Contrast computed tomography imaging indicated tumor invasion into the superior vena cava, and contrast transcranial Doppler indicated the presence of a right-to-left shunt after the Valsalva maneuver. We diagnosed the patient with acute ischemic stroke of large vessel occlusion due to venous invasion of esophageal carcinoma via a right-to-left shunt. To the best of our knowledge, this is the first case of embolic occlusion resulting from an extracardiac tumor via a right-to-left shunt. Contrast transcranial Doppler potentially detects right-to-left shunts in patients who cannot undergo transesophageal echocardiography.

Object: We investigated possible associations among the presence of cholesterol crystals in embolic debris, the proportions of debris components, and postoperative cerebral embolism in patients undergoing carotid artery stenting (CAS). Methods: Sixty-seven consecutive procedures were performed for internal carotid artery stenosis with CAS at our hospital between November 2015 and February 2018. Procedures for emergency CAS for stroke in evolution or crescendo transient ischemic attack were excluded (n = 12). The embolic debris from remaining procedures (n = 55) was stained with hematoxylin-eosin and the red blood cells, white blood cells, and fibrin were quantified by color-based segmentation. Cholesterol crystals and calcification were examined histopathologically. Diffusion-weighted imaging (DWI) was performed 1–3 days after CAS, and the images were used to classify procedures according to the presence of new lesions. Results: Of the 55 CAS procedures, new DWI lesions were identified after 32. One patient had symptomatic cerebral embolism. Higher proportions of patients with cholesterol crystals in embolic debris (17 vs. 78%, p < 0.001) and higher proportion of white blood cells (mean 2.3 [0–9.9] vs. 4.2% [0–29.9%], p < 0.01) were observed in the embolic debris of procedures with and without new DWI lesions. Conclusions: Cholesterol crystals were common in the embolic debris from patients with postoperative ischemic lesions after CAS. These results suggest that inflammatory destabilization of the intraplaque lipid component is related to postprocedural DWI lesions.

A 51-year-old man was diagnosed with eosinophilic granulomatosis with polyangiitis 6 years ago due to asthma, sinusitis, hypereosinophilia, and peripheral neuropathy based on the diagnostic criteria of American College of Rheumatology, and corticosteroid therapy achieved a remission. One year ago, he was hospitalized due to deep venous thrombosis (DVT) and pulmonary embolism, and rivaroxaban was administrated. He was admitted to our hospital for acute onset of diplopia and right hemiparesis. Peripheral blood examinations disclosed leukocytosis with hypereosinophilia. Perinuclear anti-neutrophil cytoplasmic antibodies were positive. Diffusion-weighted imaging showed multiple fresh ischemic lesions. Chronic ischemic lesions were seen in subcortical cerebral region. No stenosis or occlusion was shown in extracranial and intracranial arteries on magnetic resonance angiography. Ultrasonography of leg vein showed DVT. Right-to-left shunt through patent foramen ovale after Valsalva maneuver was seen on transesophageal echocardiography. Treatment with corticosteroid and cyclophosphamide alleviated clinical deterioration. Rivaroxaban was changed to warfarin. Diplopia and muscle strength of right limbs were improved. This is a first case of multiple cerebral infarction caused by paradoxical embolism due to patent foramen ovale with DVT based on hypercoagulable state of hypereosinophilia. Overall this case illustrates that eosinophilic granulomatosis with polyangiitis can be a risk factor for multiple cerebral infarction in the systemic phase and that transesophageal echocardiography and ultrasonography of leg vein should be conducted in stroke patient with eosinophilic granulomatosis with polyangiitis.

Post-traumatic pituitary apoplexy is uncommon, most of which present with a sudden onset of severe headache and visual impairments associated with a dumbbell-shaped pituitary tumor. We experienced an unusual case of post-traumatic pituitary apoplexy with atypical clinical features. A 66-year-old man presented with mild cerebral contusion and an incidentally diagnosed intrasellar tumor after a fall accident with no loss of consciousness. The patients denied any symptoms before the accident. After 4 days, the left oculomotor nerve palsy developed and deteriorated associated with no severe headache. Repeated neuroimages suggested that pituitary apoplexy had occurred at admission and showed that the tumor compressed the left cavernous sinus. The patient underwent endonasal transsphenoidal surgery at 6 days after head injury, and the mass reduction improved the oculomotor nerve palsy completely within the following 14 days. The pathologic diagnosis was nonfunctioning pituitary adenoma with hemorrhage and necrosis.

Background Blood blister-like aneurysms (BBAs) are a subgroup of aneurysms located on nonbranching sites of the internal carotid artery (ICA) and characterized by small size, a fragile wall, and a poorly defined broad-based neck. Both direct surgery and endovascular treatment for BBAs are often challenging. Some of the BBAs have been reported to look like true saccular aneurysms, and the misdiagnosis of BBA might result in catastrophic outcomes. The purpose of this study is to clarify the clinical and intraoperative findings of saccular BBAs. Methods We analyzed clinical and intraoperative findings in consecutive 11 patients with subarachnoid hemorrhage caused by ruptured BBA. BBAs were divided into typical BBAs, which were defined as typical tiny, broad-based, blister-like aneurysms, and saccular BBAs, which seemingly looked like true saccular aneurysms but were demonstrated to be BBAs by the intraoperative findings of the laceration of the ICA. The characteristics of saccular BBAs were analyzed. Results There were 4 patients with saccular BBAs in which the admission day was diverse from the onset day to several days after the onset. The origin of saccular BBAs was the medial (n = 2) or anterior (n = 2) walls of the ICA. Three of the 4 saccular BBAs pointed toward the optic nerve, whereas none of the typical BBAs pointed toward the optic nerve. Conclusions Saccular BBAs may not merely develop secondarily from typical BBAs, but also form by the surrounding structures-dependent mechanisms when an aneurysm points toward the optic nerve. The findings in this study suggest that saccular-shaped aneurysms at nonbranching sites of the ICA toward the optic nerve should be considered as saccular BBAs.

The efficacy of carotid artery stenting (CAS) for patients in the acute poststroke phase has not been established. We investigated the outcome of CAS for patients with symptomatic internal carotid artery (ICA) stenosis in the acute poststroke phase.We performed a retrospective analysis of all patients who underwent CAS for symptomatic ICA stenosis in our institution. Patients in whom the time interval between neurological deterioration and the CAS procedure was less than 3 days were included in the early group, and the other patients were included in the delayed group. Perioperative complications including major adverse events (MAEs) were compared between the early and the delayed groups.One hundred five patients were included in the study. Forty patients were assigned to the early group and 65 patients were assigned to the delayed group. The overall MAE rate was 4.8%. There was no significant increase in the perioperative MAE in the early group compared with the delayed group (early group 2.5% versus delayed group 6.5%, P = .65). In the early group, 25 of 40 patients (62.5%) were functionally independent (modified Rankin scale [mRS] score of 0-2) at discharge. Significant differences between the independent patients and the disabled patients (mRS score of 3-6) included age (independent 72 versus disabled 79, P .01) and prevalence of transient ischemic attack (36.0% versus .0%, P = .02).CAS performed within 3 days from the last ischemic event did not increase the risk of perioperative complication. Early CAS may be a useful option for the treatment of symptomatic carotid artery stenosis.

Objective: The aim of this study was to evaluate thrombus composition and its association with clinical, laboratory, and neurointerventional findings in patients treated by mechanical thrombectomy due to acute large vessel occlusion. Methods: From August 2015 to June 2016, 72 patients were treated in our hospital by mechanical thrombectomy using stent retriever and/or aspiration catheter. Retrieved thrombi underwent semiquantitative analysis to quantify red blood cells, white blood cells, and fibrin by area. We divided patients into two groups as fibrin rich group or erythrocyte rich group according to predominant composition in thrombus. Two groups were compared with respect to imaging, clinical, and neurointerventional data. Results: Histopathologic analysis of retrieved thrombus from 37 patients with acute stroke due to internal carotid artery, middle cerebral artery, or basilar artery occlusion was performed. Erythrocyte rich thrombi were present in 13 (35%) of cases, and fibrin rich thrombi in 24 (65%). Cardioembolic etiology was significantly more in patients with fibrin rich thrombi than those with erythrocyte rich thrombi (79% vs. 38%; p=0.01). All other clinical and laboratory characteristics did not differ. Patients with fibrin rich thrombi had greater number of recanalization maneuvers (2.8 ± 1.2 vs. 1.8 ± 1.6, p=0.04) and longer interval time between puncture and recanalization (62 ± 33.6 minutes vs. 42 ± 21.3 minutes; p=0.04). There is no significant difference in occluded vessels and mechanical thrombectomy devices between two groups. Patients with fibrin rich thrombi were lower rate of functional independence (mRS score, 0-2) at 90 days (33% vs. 75%; p=0.04). Conclusion: This study showed that fibirin rich thrombus was associated with extended procedure time, unfavorable clinical outcome and cardioembolic etiology.

Background Positional compression of the vertebral artery (VA) owing to cervical spondylosis is an uncommon cause of stroke. We report two cases of cervical spondylosis causing wake-up stroke, which is extremely rare. Case Description The first patient was a 78-year-old woman with vertigo and vomiting lasting from waking up. Magnetic resonance imaging (MRI) and angiography documented right cerebellar infarction, and stenosis of the right cervical VA. Dynamic angiography revealed that the right VA was occluded when her neck was extended or rotated to the right. Computed tomography (CT) angiography revealed the right VA compression by the right C5 superior articular process osteophytes. The second patient was a 77-year-old man with dysarthria from waking up. MRI and angiography revealed right cerebellar infarction associated with the right VA stenosis and the left VA occlusion at C5-C6, whose cause was diagnosed as compression caused by bilateral uncovertebral osteophytes on CT angiography. Dynamic angiography showed that neck rotation to the right aggravated the right VA stenosis while recanalizing the left VA. Both patients were treated with a free radical scavenger (edaravone) and heparin, and underwent surgical decompression of VAs 14 or 18 days after onset. No recurrent ischemic events occurred thereafter. Conclusions Magnetic resonance angiography of extracranial cervical VAs may be useful as an initial screening test for VA compression secondary to cervical spondylosis as a rare cause of wake-up stroke, especially in cases of cerebral infarction in the posterior circulation with no evidences of causative arrhythmia and intracranial lesions.

An 87-year-old female presented altered mental status and left hemiparesis. A cerebral angiogram showed abrupt cutoff of the right internal carotid artery. Mechanical thrombectomy was performed. Postoperative transthoracic echocardiography revealed a free-floating ball thrombus (FFBT) in left atrium. Surgical removal of the thrombus was recommended, but, due to the patient's poor general health status, she was treated with anticoagulation therapy. Her clinical course was uneventful. This article is protected by copyright. All rights reserved.

In adult rat cerebellum, HPC-1/syntaxin 1 is detected at high density on the plasma membrane of the non-synaptic region of parallel fibers in addition to the synaptic terminal membranes and the synaptic vesicles (Koh, S., Yamamoto, A., Inoue, A., Inoue, Y., Akagawa, Y., Kawamura, Y., Kawamoto, Y., and Tashiro, Y. (1993). J. Neurocytology 22: 995-1005). To assess the possibility that HPC-1/syntaxin 1 participates in the morphogenesis of the nervous system, we examined changes in the localization of HPC-1/syntaxin 1 during postnatal development of the molecular layer of the rat cerebellum. HPC-1/syntaxin 1 appeared in the granule cells in the outer granule cell layer in 3-days-old rat cerebellum when the formation of synapses and the appearance of a synaptic vesicle protein, synaptophysin, had not yet been observed in the molecular layer. At this stage, the granule cells began to form parallel fibers. Confocal laser microscopy and immune-electron microscopy showed that HPC-1/syntaxin 1 was localized on the extruding plasma membrane of the granule cells to form parallel fibers. In 8-days-old rats, synapses formed between the parallel fibers and the developing dendrites of Purkinje cells, and the HPC-1 immunoreactivity appeared on the axons of parallel fibers and on the synapses. In 21-days-old rats, the HPC-1/syntaxin 1 immunostaining pattern was similar to that of adult rats. These results suggest that HPC-1/syntaxin 1 is involved in the formation of the molecular layer, especially in the axonal growth of the parallel fibers.

Summary: We report a novel technique that fuses 3D digital subtraction angiograms and MR images. Image fusion was successfully performed within 20 minutes each in 11 consecutive cases. Our initial experience showed that this image fusion enabled clear and simultaneous visualization of perforating arteries and surrounding tissues. The relation between perforating arteries and normal brain or lesions was easily understood in a clinical setting by using this image fusion.