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BACKGROUND Thrombosed intracranial aneurysms can lead to large vessel occlusion as a result of spontaneous thrombosis. Although mechanical thrombectomy is likely effective, recurrent thromboembolism can occur if the thrombotic source remains untreated. The authors describe a case of recurrent vertebrobasilar artery occlusion due to thrombus migration from a large thrombosed vertebral artery (VA) aneurysm that was successfully treated with mechanical thrombectomy followed by stenting. OBSERVATIONS A 61-year-old male previously diagnosed with a large, thrombosed VA aneurysm presented with right hypoesthesia. Imaging on admission showed left VA occlusion and an acute ischemic lesion in the left medial medulla. His symptoms worsened, with complete right hemiparesis and tongue deviation occurring 3 hours after admission, and mechanical thrombectomy was performed to recanalize the left-dominant VA. Despite several attempts, reocclusion of the vertebrobasilar system occurred after each mechanical thrombectomy because of repeated thrombus formation in the thrombosed aneurysm. Therefore, a low-metal–density stent was deployed to prevent thrombus migration into the parent artery, which resulted in complete recanalization and rapid improvement of the symptoms. LESSONS Stenting with a low-metal–density stent for recurrent embolism secondary to thrombus migration from a large thrombosed aneurysm was feasible in the acute stroke setting.

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.

The relatively high rate of post-operative recurrence in the treatment of chronic subdural hematoma (CSDH) is a significant problem. Goreisan is an herbal medicine that exhibits a hydragogue effect by inhibiting the expression of aquaporins, and its efficacy in preventing post-operative CSDH recurrence has been suggested by several case trials. This multi-center prospective randomized controlled trial was performed to investigate the preventative effect of goreisan on post-operative CSDH recurrence. Patients with symptomatic CSDH over 60 years old undergoing burr hole surgery were enrolled in this study. The patients were randomly allocated to the control group or the goreisan group, in which oral administration of goreisan (7.5 g daily) was continued for 12 weeks. The primary end-point was the post-operative recurrence rate at 12 weeks and the secondary end-point was hematoma volume reduction rates on computed tomography scan at 12 weeks. The analyses were performed not only on patients of all ages older than 60 years, but also on patients divided into those over or under 75 years old. One hundred and eighty patients were followed and analyzed (the control group, n = 88; the goreisan group, n = 92). The recurrence rates considering patients of all ages and patients under 75 years old were relatively low in the goreisan group but without a significant difference. The hematoma volume reduction rates showed no significant difference. Based on the results of the present study, a larger-scale study including more cases is necessary in future to confirm the efficacy of goreisan.

Object Although angioplasty and stent placement for vertebral artery (VA)–origin stenosis have been performed using endovascular techniques, a high likelihood of restenosis has been observed in the long term. Therefore, the authors assessed the long-term clinical and angiographic outcomes in patients after VA–subclavian artery (SA) transposition. Methods Thirty-six patients (31 men, 5 women; mean age 64.3 years, range 46–76 years) underwent clinical evaluation (modified Rankin Scale [mRS]) and cervical angiographic evaluation preoperatively and within 1 month of and 6 months after VA-SA transposition undertaken to treat symptomatic stenosis of VA origin. Results Postoperative neurological deficits due to intraoperative brain ischemia did not occur, and MR imaging demonstrated no new postoperative ischemic lesions in any of the patients. One patient died of acute myocardial infarction 2 months after surgery and another developed a left thalamic hemorrhage (mRS score of 5) at 42 months postsurgery. None of the remaining 34 patients experienced further ischemic events, and the mRS score in all of these patients remained unchanged during a mean follow-up period of 54 months. The degree of VA-origin stenosis (preoperative mean 84%) was reduced to ≤ 30% after surgery (mean 2%). Long-term follow-up angiography in 29 patients (81%) revealed the absence of restenosis, defined as > 50% luminal narrowing, in all of them. Conclusions The clinical and angiographic long-term outcomes demonstrated here suggest that VA-SA transposition will be useful in patients with symptomatic stenosis of VA origin.

We review cerebral hyperperfusion following carotid endarterectomy (CEA). Persistence of cerebral hyperperfusion greater than several days after CEA is associated with development of hyperperfusion syndrome. Postoperative cerebral hyperperfusion, even when asymptomatic, is associated with impairment of cognitive function in patients undergoing CEA. Further, development of hyperperfusion syndrome is associated with persistent postoperative cognitive impairment. Pretreatment with a novel free radical scavenger—edaravone—prevents occurrence of cerebral hyperperfusion itself after CEA. Intraoperative monitoring of transcranial regional cerebral oxygen saturation using near-infrared spectroscopy or monitoring of intraoperative middle cerebral artery blood flow velocity using transcranial Doppler ultrasonography identifies patients at risk for hyperperfusion after CEA. Reduced preoperative cerebrovascular reactivity to acetazolamide is a significant independent predictor of post-CEA hyperperfusion.

Magnetic resonance (MR) imaging is an important diagnostic tool for neurosurgical diseases but susceptibility artifacts caused by biomaterial instrumentation frequently causes difficulty in visualizing postoperative changes. The susceptibility artifacts caused by neurosurgical biomaterials were compared quantitatively by 0.5, 1.5, and 3.0 Tesla MR imaging. MR imaging of uniform size and shape of pieces ceramic (zirconia), pure titanium, titanium alloy, and cobalt-based alloy was performed at 0.5, 1.5, and 3.0 Tesla. A linear region of interest was defined across the center of the biomaterial in the transverse direction, and the susceptibility artifact diameter was calculated. Susceptibility artifacts developed around all biomaterials at all magnetic field strengths. The artifact diameters caused by pure titanium, titanium alloy, and cobalt-based alloy increased in the order of 0.5, 1.5, to 3.0 Tesla magnetic fields. The artifact diameter of ceramic was not influenced by magnetic field strength, and was the smallest of all biomaterials at all magnetic field strengths. The artifacts caused by biomaterials except ceramic increase with the magnetic field strength. Ceramic instrumentation will minimize artifacts in all magnetic fields.

✓ Although various biomaterials such as ceramics or titanium alloy are widely used in neurosurgery, the susceptibility artifacts that appear around these materials cause problems when a magnetic resonance (MR) imager is used to assess lesions after surgery. The purpose of the present study was to quantify the susceptibility artifacts produced by various biomaterials used for neurosurgical implants. Using a 3-tesla MR imaging unit, we obtained MR images of various biomaterials, including six types of ceramics, a cobalt-based alloy (Elgiloy), pure titanium, a titanium alloy, and stainless steel. All implants shared a uniform size and shape. In each image, a linear region of interest was defined across the center of the biomaterial in the transverse direction, and the diameter of the susceptibility artifact was calculated. The ceramics produced a considerably smaller artifact diameter than those produced by other biomaterials. Among the types of ceramics, zirconia was found to produce the smallest artifact diameter. Among the remaining biomaterials, the diameters of the artifacts decreased in order from that associated with stainless steel to those associated with cobalt-based alloys, pure titanium, and titanium alloy. Little difference was observed between the artifact diameters associated with pure titanium and titanium alloy. Ceramics are the most suitable biomaterials for minimizing artifacts in high-field MR imaging.

It has been reported that Tc-99m ethyl cysteinate dimer (ECD) SPECT imaging may not show reperfusion hyperemia in patients with subacute stroke. The authors describe a patient with embolic middle cerebral artery occlusion who was examined using xenon-133 and dynamic and standard Tc-99m ECD SPECT immediately after early recanalization. Standard Tc-99m ECD SPECT images revealed hypoactivity in the ipsilateral middle cerebral artery territory. In contrast, the dynamic Tc-99m ECD SPECT images from the first scan (very early images acquired 36 seconds after injection) showed hyperactivity in the same region and provided imaging contrast comparable to what would be obtained with xenon-133 tomography. Hemorrhagic transformation later developed in this region. These results indicate that images from very early dynamic Tc-99m ECD SPECT of areas with irreversible changes produced by acute stroke can reveal reflow hyperemia that standard Tc-99m ECD SPECT images fail to show.

The aim of this study was to investigate the efficacy of pre-and posttreatment 99mTc-ethyl cysteinate dimer (99mTc-ECD) single photon emission computed tomography (SPECT) for predicting the ischemic outcome of embolic middle cerebral artery occlusion after treatment with local intraarterial thrombolysis. The authors examined 28 patients with a moderately ischemic area (ratio of affected regional activity to cerebellar activity (A/C ratio) of 0.4 to 0.7) determined using pretreatment SPECT, and with complete recanalization within 6 hours. Posttreatment dynamic and static SPECT studies were performed immediately after thrombolysis. The extent of the affected area outlined on pretreatment SPECT was used for the posttreatment SPECT images, and A/C ratios were calculated. The relative retention ratio of 99mTc-ECD in the affected area was also analyzed using posttreatment dynamic SPECT. Fourteen patients either without infarction or with small subcortical and basal ganglial infarction, 11 patients with medium or large cortical infarction, and 3 patients with hemorrhage were identified by follow-up computed tomography. Ischemic outcome correlated with the relative retention ratio of 99mTc-ECD more closely than either the pre-or posttreatment A/C ratios. In particular, a threshold value for the development of hemorrhage was distinct only in the relative retention ratio of 99mTc-ECD. Pretreatment 99mTc-ECD SPECT did not always predict the occurrence of hemorrhagic transformation, whereas dynamic 99mTc-ECD SPECT performed immediately after thrombolysis allowed clear identification of patients at risk for hemorrhagic transformation.

Although angioplasty and stent placement for vertebral artery (VA)-origin stenosis have been performed using endovascular techniques, a high likelihood of restenosis has been observed in the long term. Therefore, the authors assessed the long-term clinical and angiographic outcomes in patients after VA-subclavian artery (SA) transposition.Thirty-six patients (31 men, 5 women; mean age 64.3 years, range 46-76 years) underwent clinical evaluation (modified Rankin Scale [mRS]) and cervical angiographic evaluation preoperatively and within 1 month of and 6 months after VA-SA transposition undertaken to treat symptomatic stenosis of VA origin.Postoperative neurological deficits due to intraoperative brain ischemia did not occur, and MR imaging demonstrated no new postoperative ischemic lesions in any of the patients. One patient died of acute myocardial infarction 2 months after surgery and another developed a left thalamic hemorrhage (mRS score of 5) at 42 months postsurgery. None of the remaining 34 patients experienced further ischemic events, and the mRS score in all of these patients remained unchanged during a mean follow-up period of 54 months. The degree of VA-origin stenosis (preoperative mean 84%) was reduced toor = 30% after surgery (mean 2%). Long-term follow-up angiography in 29 patients (81%) revealed the absence of restenosis, defined as50% luminal narrowing, in all of them.The clinical and angiographic long-term outcomes demonstrated here suggest that VA-SA transposition will be useful in patients with symptomatic stenosis of VA origin.

A cor triatriatum is a congenital malformation of the heart which, in almost all cases, is diagnosed in childhood, whereas adult cases are very rare. The hemodynamics of the cor triatriatum is similar to that of mitral stenosis, which sometimes, but rarely, causes embolism. We present a case of multiple cerebral infarctions accompanied with a cor triatriatum. A 57-year-old female suddenly displayed impaired consciousness and hemiparesis immediately after cranioplasty for another disease, and was diagnosed by a diffusion weighted MRI as having multiple infarctions. A transesophageal echocardiography detected a membrane-like, echo-dense structure across the left atrium, suggesting a cor triatriatum. We suspect that her multiple infarctions were caused by embolism due to a cor triatriatum. Here, we discuss the relationship between her embolic stroke and the cor triatriatum, with references to literature on the subject.

Background Symptomatic, medically refractory vertebrobasilar stenosis carries a poor prognosis and is an indication for vascular reconstruction. Case Presentation A 67-year-old man suffered medically refractory recurrent vertigo due to artery-to-artery embolism caused by long, eccentric, and severe stenosis at the extradural-intradural junction of the right vertebral artery. Transluminal angioplasty was deferred because of the occurrence of critical brain ischemia during temporary balloon occlusion. After an occipital artery to posterior inferior cerebellar artery bypass, the vascular lesion in the right vertebral artery was resected and was reconstructed with interposition of a saphenous vein graft. The postoperative course was uneventful, and the patient did not experience further symptoms. Postoperative angiography revealed a widely patent right vertebral artery. Conclusion This surgical procedure is useful for the vascular reconstruction of symptomatic stenosis at the extradural-intradural junction of the vertebral artery when transluminal angioplasty is contraindicated and when bypass surgery is not sufficient.

Diffusion tensor (DT) imaging provides quantitative information about the magnitude and the directionality (anisotropy) of water diffusion in vivo and can detect pathologic changes in brain ischemia. This study tried to detect ischemic brain damage using DT imaging in patients with symptomatic chronic major cerebral artery occlusive disease. DT imaging was performed using a 3.0 Tesla magnetic resonance (MR) scanner in 50 patients with unilateral internal carotid artery or middle cerebral artery stenosis or occlusion, who had no obvious infarct lesions on conventional MR imaging. Thirty-three patients underwent DT imaging before and after vascular reconstruction surgery. Fractional anisotropy (FA) was calculated in the middle cerebral artery territory. Preoperative FA values in the ipsilateral side were significantly lower than those in the contralateral side. After surgery, the FA value was significantly increased. DT imaging may indicate ischemic brain damage, not visualized by conventional MR imaging, in patients with major cerebral artery occlusive disease.

OBJECTIVE Hyperperfusion syndrome is a rare but potentially devastating complication that can occur after carotid endarterectomy (CEA). The purpose of this study was to determine whether intraoperative transcranial regional cerebral oxygen saturation (rSO(2)) monitoring via near-infrared spectroscopy could be reliably used to identify patients at risk for post-CEA hyperperfusion. METHODS rSO(2) was intraoperatively monitored for 50 patients undergoing CEA for treatment of ipsilateral internal carotid artery stenosis (>/=70%). Cerebral blood flow (CBF) was also assessed, with single-photon emission computed tomography, before and immediately after CEA. RESULTS Post-CEA hyperperfusion (CBF increase of >/=100%, compared with preoperative values) was observed for six patients. A significant linear correlation was observed between the rSO(2) increases immediately after declamping of the internal carotid artery and the CBF increases immediately after CEA (r(2) = 0.247, P = 0.0002). The sensitivity and specificity of the rSO(2) increases for detection of post-CEA hyperperfusion were 100 and 86.4%, respectively, with a cutoff point of 5%. A strong linear correlation was observed between the rSO(2) increases at the end of the procedure and the CBF increases immediately after CEA (r(2) = 0.822, P < 0.0001). Both the sensitivity and the specificity of the rSO(2) increases for detection of post-CEA hyperperfusion were 100% with a cutoff point of 10%. Hyperperfusion syndrome developed for one patient with post-CEA hyperperfusion, but intracerebral hemorrhage did not occur. CONCLUSION Intraoperative rSO(2) monitoring can reliably identify patients at risk for hyperperfusion after CEA.

The aim of this study was to investigate the prognostic utility of post-treatment technetium-99m ethyl cysteinate dimer (99mTc-ECD) single-photon emission tomography (SPET) for predicting ischemic tissue outcome in cases involving embolic middle cerebral artery occlusion treated with local intra-arterial thrombolysis. We examined twenty-five patients with a moderately ischemic area determined using pretreatment technetium-99m hexamethylpropylene amine oxime (99mTc-HMPAO) SPET, and with complete recanalization within 6 h. Post-treatment 99mTc-ECD SPET studies, consisting of scanning for 0.5–6.5 min (early scan) and 15–21 min (delayed scan) after tracer injection, were performed immediately after thrombolysis. The extent of the affected area outlined on pretreatment 99mTc-HMPAO SPET was used for the post-treatment early and delayed 99mTc-ECD SPET images, and the AR/CE ratio (ratio of affected regional activity to cerebellar activity) was calculated. The washout index of 99mTc-ECD in the affected area was also calculated by dividing the difference between the AR/CE ratio in the early and delayed images by the AR/CE ratio in the early image. Twelve patients without infarction or with small subcortical/basal ganglial infarction, ten with medium or large cortical infarction, and three with hemorrhage were identified by follow-up computed tomography. Although the AR/CE ratio in post-treatment early 99mTc-ECD SPET images was significantly higher in the hemorrhagic group than in the cortical infarction group, this value did not differentiate the reversible ischemia group from either the cortical infarction or the hemorrhagic group. The AR/CE ratio in post-treatment delayed 99mTc-ECD SPET images statistically differentiated the reversible ischemia group from both the cortical infarction and the hemorrhagic group. However, the difference between the cortical infarction and hemorrhagic groups was not statistically significant. The washout index of 99mTc-ECD statistically differentiated all three groups. This study demonstrated that a combination of early and delayed 99mTc-ECD SPET imaging performed immediately after thrombolysis predicts ischemic tissue outcome.