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Background and Purpose: High blood pressure increases bleeding risk during treatment with antithrombotic medication. The association between blood pressure levels and the risk of recurrent stroke during long-term secondary stroke prevention with thienopyridines (particularly prasugrel) has not been well studied. Methods: This was a post hoc analysis of the randomized, double-blind, multicenter PRASTRO-I trial (Comparison of Prasugrel and Clopidogrel in Japanese Patients With Ischemic Stroke-I). Patients with noncardioembolic stroke were randomly assigned (1:1) to receive prasugrel 3.75 mg/day or clopidogrel 75 mg/day for 96 to 104 weeks. Risks of any ischemic or hemorrhagic stroke, combined ischemic events, and combined bleeding events were determined based on the mean level and visit-to-visit variability, including successive variation, of systolic blood pressure (SBP) throughout the observational period. These risks were also compared between quartiles of mean SBP level and successive variation of SBP. Results: A total of 3747 patients (age 62.1±8.5 years, 797 women), with a median average SBP level during the observational period of 132.5 mm Hg, were studied. All the risks of any stroke (146 events; hazard ratio, 1.318 [95% CI, 1.094–1.583] per 10-mm Hg increase), ischemic stroke (133 events, 1.219 [1.010–1.466]), hemorrhagic stroke (13 events, 3.247 [1.660–6.296]), ischemic events (142 events, 1.219 [1.020–1.466]), and bleeding events (47 events, 1.629 [1.172–2.261]) correlated with increasing mean SBP overall. Similarly, an increased risk of these events correlated with increasing successive variation of SBP (hazard ratio, 3.078 [95% CI, 2.220–4.225] per 10-mm Hg increase; 3.051 [2.179–4.262]; 3.276 [1.172–9.092]; 2.865 [2.042–4.011]; 2.764 [1.524–5.016], respectively). Event rates did not differ between the clopidogrel and prasugrel groups within each quartile of SBP or successive variation of SBP. Conclusions: Both high mean SBP level and high visit-to-visit variability in SBP were significantly associated with the risk of recurrent stroke during long-term medication with either prasugrel or clopidogrel after stroke. Control of hypertension would be important regardless of the type of antiplatelet drugs. Registration: URL: https://www.clinicaltrials.jp ; Unique identifier: JapicCTI-111582.

Cerebrovascular disorders complicated by persistent primitive arteries are commonly reported, but, we herein present a 78-year-old man with cerebral infarction due to stenosis of a persistent primitive artery by itself. Cerebral angiography revealed bilateral vertebral artery aplasia to be complicated by a persistent primitive proatlantal artery which had become an important collateral circulation pathway. While the patient was hospitalized because of mild sensory impairment, he also developed visual field constriction and cerebellar symptoms due to recurrent stroke despite anticoagulation treatment. Based on the results of various examinations, cerebral embolism, probably caused by stenosis at the origin of the persistent proatlantal artery, was diagnosed. Carotid artery stenting for the stenosis was planned. A filter protection device was found to be very useful for stenting with maintenance of blood flow in the persistent primitive proatlantal artery. There have been no reports of stenting in persistent primitive proatlantal arteries, such as that our present case is considers. It provides valuable information on the management of this rare disorder.

We report two cases of patients who underwent stent-assisted percutaneous transluminal angioplasty for intracranial vertebral artery (VA) and basilar artery (BA) stenosis. They presented with sudden onset of vertigo and right hemiparesis. Vertebral angiographies revealed severe proximal BA stenosis (case 1) and intracranial VA stenosis (case 2). They underwent angioplasty and stenting, with excellent angiographic results. The availability of new flexible intravascular stents, allowing access to tortuous proximal intracranial vessels, provides a new therapeutic approach for patients with vertebral and basilar artery stenosis.

Acute cavernous sinus syndrome developed in a 44-year-old man after he had experienced symptoms resembling cluster headache for 3 weeks. The cause was determined to be the sudden appearance of a large saccular aneurysm of the intracavernous portion of the left carotid artery secondary to an acute inflammation of the left cavernous sinus. The absence of this aneurysm before the onset of the ophthalmoplegia was confirmed by a computed tomographic scan and angiogram performed only 1 week earlier. The patient was treated with antibiotics in combination with a short regimen of steroids, which resulted in a slowly developing thrombosis of the aneurysm, although the cavernous sinus syndrome remained. This case suggests several important aspects regarding the pathogenesis of mycotic intracavernous carotid aneurysms, the mechanism of an acute manifestation of the cavernous sinus syndrome by an intracavernous carotid aneurysm, and the relation of the intracavernous portion of the carotid artery to cluster headache. (Neurosurgery 29:594-599, 1991)

Since October 1979, real-time gray-scale ultrasonography has been intraoperatively performed on 18 patients who had previous preoperative CT examinations. Electronic linear scanning ultrasonography was applied in the first three cases using a probe pressed against the dura mater or the brain surface with an intervening saline-filled rubber bag. This, however, proved unsatisfactory because of poor contact between the probe and the brain and also because of a relatively narrow scanning field deep in the brain. Fifteen cases were examined using electronic sector scanning ultrasonography combined with probes of either 2.4 MHz. or 3.0 MHz. ultrasonic frequencies. After sterilization, the probe was gently pressed against the brain surface which was moistened with saline solution. The visible field deep in the brain with the sector type ultrasonography was wide due not only to the fan-shaped (78°) scanning field but also to the relatively easy manual angulation of the scanning probe. Ventricles, falx and the inner surface of the skull were always visualized, and these findings were helpful in orienting the operative field. In five cases with early operations against ruptured intracranial aneurysms, the lateral ventricles were well visualized. In one of these cases, a ventricular tap and subsequent insertion of a drainage tube were performed with confidence and ease although the anterior horns were fairly narrow. In one case of spontaneous intracerebral hemorrhage, use of ultrasound was most helpful in selecting the corticotomy site. The extent of the hematoma cavity was disclosed by placement of a G18 ventricular needle as a marker. The introduction of the probe intracerebrally through the corticotomy gap showed no residual clot. Among five supratentorial tumors, three subcortical tumors were visualized, but one small pituitary adenoma and one small skull base tumor were not. One subcortical solid tumor (glioblastoma multiforme) was remarkably echogenic and this was successfully needle-biopsied under ultrasonic monitoring. This should be the first step in the future development of ultrasonically-guided stereotactic biopsy. Two subcortical cystic tumors were easily punctured and aspirated under ultrasonic monitoring. However, the full extent of the needle was not well visualized even though the surface of the needle had been roughened to enhance the echogenicity. Good alignment of the needle with the fan-shaped ultrasound field using, for instance, a mechanical needle holder might give better visualization. In one case of chronic subdural hematoma and three cases of infratentorial tumors, the pathologies were visualized although they were not particularly contributary to the operation. Therefore, electronic sector scanning ultrasonography was useful, when combined with preoperative CT examinations, in operations on the supratentorial subcortical mass and in intraoperative punctures of the ventricles and/or cysts.