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The trans-cell approach using a low-profile visualized intraluminal support (LVIS) device is sometimes used for aneurysm coil embolization. However, factors related to microcatheter passage remain uninvestigated. We aimed to examine in-vitro factors related to microcatheter passage using the trans-cell approach with an LVIS.Silicone vessel models (inner diameter, 4 mm) were created with different bend segments and a 4-mm hole assuming an aneurysm neck on the side of the greater curvature. The LVIS Blue (4.5 × 32 mm) was deployed at the bend segment, and passability on the trans-cell surface was evaluated by passing the microcatheter along the micro guidewire. A total of 800 passage experiments were performed using two types of microcatheter, ten types of silicone vessel, four cell widths, five cells with the same LVIS device, and two micro guidewire directions in the aneurysm.The Headway Duo microcatheter (35.5%, 142/400) tended to have better passability compared with the Headway 17 microcatheter (29.3%, 117/400) (p = 0.070). As the cell width and angle between the trans-cell surface and microcatheter direction increased, passability significantly increased (p = 0.027 and p 0.001, respectively). There was no significant difference in passability when the micro guidewire was directed to the proximal side versus the distal side (p = 0.45).A large cell width and an obtuse angle between the trans-cell surface and microcatheter direction facilitated good passability. Although statistically marginal, microcatheters with small ledges and small tips had relatively good passability.

Objectives Thrombi in cerebral large vessel occlusion associated with active cancer are often fibrin and platelet-rich white thrombi. However, evaluating the thrombus composition in a short time before thrombectomy is often ineffective. We sought to determine factors related to white thrombi in acute ischemic stroke due to large vessel occlusion in cancer patients. Methods Consecutive cancer patients undergoing thrombectomy for acute ischemic stroke due to large vessel occlusion between January 2018 and May 2022 were retrospectively reviewed. The patients were classified into white thrombus and red thrombus groups on the basis of the pathological findings of retrieved thrombi. Patient characteristics and laboratory findings were compared between the two groups. Results There were 12 patients in the white thrombus group and 11 patients in the red thrombus group. Active cancer was significantly more in the white thrombus group than in the red thrombus group (91.7% vs. 36.3%, p = 0.0094). Internal carotid artery occlusion was significantly less in the white thrombus group than in the red thrombus group (0% vs. 36.4%, p = 0.037). Among laboratory findings, D-dimer levels were an independent factor associated with white thrombi (odds ratio 8.97 [95% confidence interval 1.71–368.99], p < 0.0001). The cutoff value of D-dimer levels for predicting white thrombi was 3.5 μg/mL (83.3% sensitivity and 100% specificity). Conclusions In acute ischemic stroke in cancer patients, active cancer, no internal carotid artery occlusion, and higher D-dimer levels (≥3.5 μg/mL) may be associated with occlusion with fibrin and platelet-rich white thrombi.

Surgical clipping of anterior communicating artery (ACoA) aneurysms remains challenging due to their complex anatomy. Anatomical risk factors for ACoA aneurysm surgery require further elucidation. The aim of this study is to investigate whether proximity of the midline perforating artery, subcallosal artery (SubCA), and associated anomaly of the ACoA complex affect functional outcomes of ACoA aneurysm surgery. A total of 92 patients with both unruptured and ruptured ACoA aneurysms, who underwent surgical clipping, were retrospectively analyzed from a multicenter, observational cohort database. Association of ACoA anatomy with SubCA origin at the aneurysmal neck under microsurgical observation was analyzed in the interhemispheric approach subgroup (n = 56). Then, we evaluated whether anatomical factors associated with SubCA neck origin affected surgical outcomes in the entire cohort (both interhemispheric and pterional approaches, n = 92). In the interhemispheric approach cohort, combination of A1 asymmetry and aneurysmal size ≥ 5.0 mm was stratified to have the highest probability of the SubCA neck origin by a decision tree analysis. Then, among the entire cohort using either interhemispheric or pterional approach, combination of A1 asymmetry and aneurysmal size ≥ 5.0 mm was significantly associated with poor functional outcomes by multivariable logistic regression analysis (OR 6.76; 95% CI 1.19–38.5; p = 0.03) as compared with A1 symmetry group in the acute subarachnoid hemorrhage settings. Combination of A1 asymmetry and larger aneurysmal size was significantly associated with SubCA aneurysmal neck origin and poor functional outcomes in ACoA aneurysm surgery. Interhemispheric approach may be proposed to provide a wider and unobstructed view of SubCA for ACoA aneurysms with this high-risk anatomical variant.

Background There is no consensus as to whether balloon angioplasty alone or stent placement is effective for sinus occlusion associated with dural arteriovenous fistula (DAVF). Herein, we first report a case of transverse sinus occlusion associated with DAVF in which gradual sinus dilatation was observed after balloon angioplasty with embolization of the affected sinus with shunt flow. Case presentation A 69-year-old man presented with executive dysfunction. Magnetic resonance imaging revealed left transverse sinus–sigmoid sinus DAVF with occlusion of the left jugular vein and right transverse sinus. Before endovascular treatment, the patient had symptomatic epilepsy and subarachnoid hemorrhage. Retrograde leptomeningeal venous drainage disappeared with packing of the left transverse sinus–sigmoid sinus. Subsequently, balloon angioplasty of the right occluded transverse sinus was performed to maintain the normal venous drainage and remaining shunt outflow. Dilatation of the right transverse sinus was poor immediately after surgery. However, angiography after 10 days and 6 months revealed gradual dilatation of the right transverse sinus. Conclusion Sinus occlusion, which is thought to be caused by sinus hypertension associated with DAVF rather than chronic organized thrombosis or thrombophilia, may dilate over time after balloon angioplasty and shunt flow reduction if occluded sinus is necessary for facilitating normal venous drainage.

Low-profile visualized intraluminal support deployment in an Enterprise has been reported; however, that in an Atlas has yet to be in detail. Enterprise has a closed-cell design, while Atlas has an open-cell design. We detail here a case of a large wide-necked aneurysm treated by coil embolization with low-profile visualized intraluminal support Blue deployment within a Neuroform Atlas and a bench-top experiment using a silicon tube to test low-profile visualized intraluminal support, Atlas, Enterprise, and their combinations. A better low-profile visualized intraluminal support expansion was achieved by simultaneously pushing the wire and the system within the Atlas placed at the aneurysm neck, which resulted in an increased metal coverage of the aneurysm neck and a shorter transition zone with low metal coverage at both ends of the aneurysm neck. This technique may enable a high metal coverage by low-profile visualized intraluminal support expansion without restriction by the Atlas and contribute to aneurysm occlusion by increasing the flow-diverting effect.

The endoscopic removal of subdural hematomas is well reported, but its use in high-energy trauma cases has not been completely elucidated. Moreover, questions persist regarding the need for an emergency puncture, craniotomy range, and the adaptation of endoscopic technique to clinical settings; this includes cases where brain swelling is expected. Here, we describe a novel technique of endoscopic hematoma removal in an elderly patient with an acute subdural hematoma associated with high-energy trauma.

In symptomatic low-grade stenosis, most of the reports did not clarify the long-term outcome. This study aims to clarify the clinical features and long-term outcomes of symptomatic low-grade stenosis cases.We included 123 symptomatic patients with low-grade (50%) carotid stenosis. The relative plaque signal intensity (rSI) and expansive remodeling rate (ERR) were measured using carotid magnetic resonance imaging (MRI). Antiplatelet therapy and treatment for atherosclerosis risk factors were administered in all cases. Carotid endarterectomy (CEA) was performed when ischemic symptoms appeared, or the percent stenosis progressed despite medical treatment.The mean percent stenosis, rSI, and ERR on admission were 22.3, 1.70, and 2.01, respectively. The mean volume of the hyperintense plaque on carotid MRI was 641.4± 540 mm3. Sixty percent of cases involved intraplaque hemorrhage and expansive remodeling. During a mean follow-up of 52 months, recurrence of ischemic events was confirmed in 45 cases (36.6%). Of the 67 cases performed follow-up MRI, 34 cases (50%) had an increased volume of T1-hyperintense plaque. CEA or carotid artery stenting was performed in 49 cases. During a mean follow-up of 57.8 months after CEA, two cases of death (fatal intracerebral hemorrhage and asphyxia) and one case of brain stem lacunar infarction were observed, but ipsilateral ischemic events were not.Most of the symptomatic patients with low-grade stenosis had both intraplaque hemorrhage and expansive remodeling and presented a high risk of recurrence and stenosis progression. CEA may have preventive effects against ischemic events in low-grade stenosis.

Trigeminal meningocele is a rare disease that results in rhinorrhea. Treatments with endoscopic approaches and open craniotomies have high recurrence rates, and controversy regarding the most effective surgical strategy for trigeminal meningocele is ongoing. The authors report a case of a 13-year-old female patient with a diagnosis of trigeminal meningocele determined after she presented with a history of intermittent headaches, suspected rhinorrhea, and recurrent meningitis. In addition to the conventional method of covering the efflux point of CSF and filling the inside of the meningocele with fascial tissues, the authors selectively closed the influx point of CSF from the prepontine cistern to the meningocele using an anterior transpetrosal approach. On the basis of the preoperative images, the authors hypothesized that the influx point of CSF could not be observed under the microscopic direct view and instead used a flexible endoscope. A check valve–like structure with one-way communication of CSF from the prepontine cistern into the cystic cavity was identified and was closed. At the time of this report, 36 months postoperatively, the patient had no indications of recurrence. Although cases of trigeminal meningoceles are infrequently encountered and require a tailored approach, the results in this case thus far indicate that the use of an endoscope and open craniotomy is an effective strategy for surgical treatment.

Objective Pseudoaneurysms are a serious complication of neuroendovascular therapy with femoral artery puncture, for which ultrasound-guided compression repair (UGCR) is often the first choice of radical therapy. We sought to retrospectively investigate the factors for failure of UGCR for pseudoaneurysm at the femoral artery puncture site. Methods Among patients undergoing neuroendovascular therapy with femoral artery puncture at our hospital between January 2018 and April 2021, those who received a diagnosis of pseudoaneurysm and underwent UGCR were enrolled. They were classified into two groups according to whether UGCR was successful (UGCR group) or was converted to surgical repair (SR group). Patient and procedural characteristics were compared between the two groups. Results During the study period, 577 patients underwent neuroendovascular therapy with femoral artery puncture, 10 of whom (1.7%) received a diagnosis of pseudoaneurysm and underwent UGCR. There were seven patients in the UGCR group and three patients in the SR group. The sheath diameter tended to be larger in the SR group than in the UGCR group ( p = 0.16). The modified Rankin scale score when a diagnosis of pseudoaneurysm was made was significantly lower in the SR group than in the UGCR group (1 [0–2] vs. 3 [2–5], p = 0.037). Conclusions Physical activity may be associated with failure of UGCR. In patients with high physical activity, the use of sedatives and analgesics to keep them at rest during puncture site compression after UGCR may lead to successful UGCR.

Introduction: Sinus pericranii is a vascular anomaly with extra- and intracranial venous connections. Sinus pericranii is categorized into 2 groups according to its contribution to the normal venous circulation. The accessory type sinus pericranii, which does not contribute to the normal major venous circulation, can be managed. Despite several proposed operative maneuvers, a standardized technique is yet to be established to control intraoperative bleeding. Case Presentation: A 2-week-old neonate underwent examination of a subcutaneous mass in the parieto-occipital region. The subcutaneous mass had a major venous connection to the superior sagittal sinus on ultrasonography. The subcutaneous mass was partially thrombolized on magnetic resonance imaging and was minimally enhanced on computed tomography venography. The subcutaneous mass seemed not to contribute to the normal venous circulation. Surgical removal of the subcutaneous mass was performed due to its increased size at the age of 1 year and 3 months. While subcutaneous mass was detached from the scalp, the major venous connection was manually compressed, and minor venous connections were easily detected. The intraoperative bleeding was controllable. The pathological diagnosis was sinus pericranii. The patient is now followed up in the outpatient clinic. No recurrence was seen 18 months after the surgery. Discussion/Conclusion: Intraoperative hemostasis is essential while sinus pericranii is detached from the cranium. Hemostatic agents such as bone wax or absorbable gelatin and heat coagulation seem to be useful. However, complicative hemorrhage concerning to the preceded technique has been also reported. As seen in our case, to detect minor shunting points between the sinus pericranii and the intracranial veins, the major venous connection was manually compressed. Intraoperative manual compression of a major venous connection of sinus pericranii can be an option to manage intraoperative bleeding.

OBJECTIVEAccumulated findings in the pathophysiology of atherosclerosis have demonstrated that not only luminal narrowing but also plaque characteristics influence the risk of future ischemic events. The morphology of the carotid artery (CA) changes in response to atherosclerotic development by expansive remodeling (ER), the clinical significance of which remains unclear. This study aimed to define associations between ER and local risk factors, including CA geometry and traditional systemic risk factors for ischemic events, to determine whether ER could serve as a clinical marker of carotid vulnerable plaque.METHODSThe authors retrospectively analyzed 66 patients with CA stenosis who were scheduled to undergo carotid endarterectomy or CA stenting. They calculated ER ratios in the internal CA (ICA) from long-axis MR images and as the maximal distance between the lumen and the outer borders of the plaque perpendicular to the axis of the ICA/the maximal luminal diameter of the distal ICA at a region unaffected by atherosclerosis. Relative overall signal intensity (roSI) was calculated to assess intraplaque hemorrhage and defined as the signal intensity of plaque on an axial T1-weighted image with maximal stenosis relative to that of the adjacent sternocleidomastoid muscle. The authors evaluated CA geometry by calculating the angles between the common CA (CCA) and ICA, and between the CCA and external CA (ECA) using digital subtraction angiography. The ER ratios, age, sex, percentage of stenosis, roSI, hypertension, hyperlipidemia, low-density lipoprotein, statin medication, diabetes, smoking habit, and ischemic heart disease were compared between 33 symptomatic and 33 asymptomatic patients. The authors also compared symptomatic status, age, sex, percentage of stenosis, ICA angle, ECA angle, roSI, and other traditional atherosclerotic risk factors between groups with extensive and slight ER.RESULTSThe ER ratio was significantly greater in symptomatic than in asymptomatic patients (1.91 ± 0.46 vs 1.68 ± 0.40, p < 0.05). The ICA angle was significantly larger in the group with extensive ER than in those with slight ER (33.9° ± 20.2° vs 21.7° ± 13.8°, p < 0.01). The roSI, ECA angle, percentage stenosis, or any other traditional vascular risk factors were not associated with ER.CONCLUSIONSCarotid ER might be an independent indicator of carotid vulnerable plaque, which should be validated in a longitudinal study of patients with carotid atherosclerosis, including those with nonstenotic to moderate stenosis.

When a microcatheter is in the aneurysm, it may move due to low-profile visualized intraluminal support (LVIS) deployment. This study was designed to determine this mechanism.Six silicon aneurysm models were created by combining the aneurysm location (side wall or bifurcation) and the parent vessel configuration (straight, ipsilateral bending, or contralateral bending). After adjusting the microcatheter tip position in the aneurysm by pushing or pulling, an LVIS stent was deployed to cover the aneurysm neck, and the changes in the microcatheter tip position was measured. Pushing and pulling were performed 15 times each for each model, for a total of 180 experiments.In all experiments, the microcatheter tip moved with LVIS deployment. The total movement distance was 3.00±1.59 mm, which was significantly different between the push and pull groups (p = 0.049), between the three side-wall aneurysm models (p0.0001), and between the three bifurcation aneurysm models (p0.0001). Backward movement in the aneurysm occurred in 21% (37/180). The frequency of backward movement was significantly different between the side-wall and bifurcation aneurysm models (p = 0.0265) and between the push and pull groups (p0.0001). The forward movement distance was significantly different between the side-wall (n = 78) and bifurcation (n = 65) aneurysm models (p0.0001).The aneurysm location, the parent vessel configuration, and adjustment of the microcatheter tip position by pushing or pulling may affect the total movement distance and forward/backward movement of the microcatheter tip due to LVIS deployment.

Background: We report a case of proximal internal carotid artery (ICA) collapse due to severe distal stenosis that dilated after angioplasty for distal stenosis. Case Description: A 69-year-old woman underwent thrombectomy for the left ICA occlusion due to stenosis of C3 portion and was discharged home with a modified Rankin Scale score of 0. One year later, she developed cerebral infarction due to progressive stenosis of the C3 portion of the left ICA with proximal ICA collapse and underwent emergency percutaneous transluminal angioplasty (PTA) for distal stenosis. Device guidance to the stenosis was difficult due to proximal ICA collapse. After PTA, blood flow in the left ICA increased, and proximal ICA collapse dilated over time. Due to severe residual stenosis, she underwent more aggressive PTA followed by Wingspan stenting. Device guidance to the residual stenosis was facilitated because proximal ICA collapse had already dilated. Six months later, proximal ICA collapse further dilated. Conclusion: PTA for severe distal stenosis with proximal ICA collapse may result in dilation of proximal ICA collapse over time.

Background: In rare cases, septic embolism is diagnosed on the basis of pathological findings of retrieved thrombi. Infected aneurysms can rapidly form and rupture after septic embolism, leading to a poor prognosis. We report a case of subcortical hemorrhage due to an infected aneurysm forming shortly after septic embolism in the left anterior cerebral artery. Case Description: In this case, the diagnosis of septic embolism was made on the basis of pathological findings of a thrombus retrieved from the simultaneously occluded left middle cerebral artery, and endovascular embolization of the infected aneurysm was performed. Conclusion: The pathological findings of a retrieved thrombus were useful for making a diagnosis of septic embolism. The possibility of short-term formation and rupture of an infected aneurysm after septic embolism should be noted. Endovascular embolization of occluded vessels due to septic embolism may prevent aneurysm formation and subsequent bleeding.

Plaque characteristics play pivotal roles in ischemic events, but stenosis severity does not accurately reflect carotid plaque volume due to expansive remodeling in some patients with low-grade stenosis (LGS). This study aimed to assess the safety, efficacy, and durability of carotid endarterectomy (CEA) for symptomatic LGS.Study participants comprised 61 consecutive patients who underwent CEA for symptomatic carotid stenosis. Patients were divided into an LGS group (50%, n = 17) and a non-LGS group (≥50%, n = 44). Patient characteristics and short-term (within 30 days of CEA) and long-term outcomes were compared between groups for selective usage of internal shunt and known complications of CEA.Magnetic resonance imaging-detected intraplaque hemorrhage was more significant in LGS than in non-LGS (P = 0.04). For short-term outcomes, no symptomatic infarcts, hyperperfusion syndrome, or acute myocardial infarction was confirmed in either group. Internal shunts were used in 4 LGS (23.5%) and 6 non-LGS (13.6%). Asymptomatic diffusion-weighted imaging-positive lesions were confirmed in 2 LGS patients (11.8%) and 5 non-LGS patients (11.4%), neck hematoma in 1 LGS patient, and transient cranial nerve palsy in 1 LGS patient and 2 non-LGS patients, with no significant differences apparent between groups. For long-term outcomes, 5 non-LGS patients showed restenosis (P = 0.17). Hemorrhagic stroke was not observed in either group. No significant differences were seen for infarct in the ipsilateral carotid territory, any ischemic stroke, AMI, or mortality.CEA represents a safe and feasible therapeutic option for a subset of patients with symptomatic LGS.

Background Pituitary apoplexy (PA) is a life-threatening syndrome. The usage of a dopamine agonist, such as bromocriptine or cabergoline, is considered a predisposing factor for PA, which commonly occurs 1.5 years within commencement. Case Description A 64-year-old female with a >15-year history of cabergoline therapy for pituitary prolactinoma was referred to our department of neurosurgery after complaining of headache, blurred vision, diplopia, and ptosis for 3 days during hospital admission for chemotherapy of chronic myelocytic leukemia. Computed tomography and magnetic resonance imaging revealed findings indicative of PA. As the patient was experiencing thrombocytopenia related to chemotherapy, blood transfusion was preceded, and after a platelet count of 15.0 × 104/μL was confirmed, transnasal neuroendoscopic surgery was performed 5 days from the onset of symptoms. The majority of the prolactinoma was removed, and the prolactinoma in the cavernous sinus was intentionally left. The postoperative course was generally good. The ptosis and diplopia improved, and the blurred vision resolved. Conclusions PA related to dopamine agonist therapy can occur in cases of elevated bleeding tendency, even in long-term users, suggesting that attention should be paid in the administration of a dopamine agonist in the patient experiencing thrombocytopenia. Surgical intervention should be performed after the preoperative platelet number and adequate response to transfusion are confirmed, and the aggressive removal of prolactinoma in the cavernous sinus should be avoided to reduce the risk of hemorrhagic complications.

Introduction: The evaluation of ischemic core is important in acute cerebral infarction with large vessel occlusion. The ischemic core is thought to approximate the region that is difficult to receive collateral circulation. We classified the ischemic core distribution pattern into four types on the basis of the tendency of cerebral blood volume (CBV) decrease in the ischemic core, and examined the prognostic ability. Methods: We included M1 or ICA occlusion which completely recanalized (TICI3) by thrombectomy in our institute from January 2015 to May 2019. The ischemic core was defined as a region where CBV were reduced less than 1.9 ml/100cc. Ischemic core distribution pattern was classified into the following 4 types. Type A: absent of ischemic core. Type B: ischemic core is confined to the basal ganglia and white matter. Type C1: ischemic core is present in the cortex but less than half of MCA region. Type C2: ischemic core is present in the cortex, and more than half of MCA region. The patient characteristics, temporal parameters, ASPECTS and ischemic core distribution pattern were analyzed with mRS0-2 at discharge as a good outcome group. Results: A total of 47 cases (14 ICA, 33 M1) were included. Ischemic core distribution pattern correlated well with mRS at discharge (p Conclusions: The distribution pattern of ischemic core defined by reduced CBV have good correlation with outcome. There is a possibility that it can be used as a simple tool to predict prognosis using CT perfusion in anterior circulation acute large vessel occlusion.

OBJECTIVEDelayed cerebral ischemia (DCI) is an important complication after aneurysmal subarachnoid hemorrhage (aSAH). Although intrathecal milrinone injection via lumbar catheter to prevent DCI has been previously reported to be safe and feasible, its effectiveness remains unknown. The goal of this study was to evaluate whether intrathecal milrinone injection treatment after aSAH significantly reduced the incidence of DCI.METHODSThe prospectively maintained aSAH database was used to identify patients treated between January 2010 and December 2015. The cohort included 274 patients, with group assignment based on treatment with intrathecal milrinone injection or not. A propensity score model was generated for each patient group, incorporating relevant patient variables.RESULTSAfter propensity score matching, 99 patients treated with intrathecal milrinone injection and 99 without treatment were matched on the basis of similarities in their demographic and clinical characteristics. There were significantly fewer DCI events (4% vs 14%, p = 0.024) in patients treated with intrathecal milrinone injection compared with those treated without it. However, there were no significant differences between the 2 groups with respect to their 90-day functional outcomes (46% vs 36%, p = 0.31). The likelihood of chronic secondary hydrocephalus, meningitis, and congestive heart failure as complications of intrathecal milrinone injection therapy was also similar between the groups.CONCLUSIONSIn propensity score–matched groups, the intrathecal administration of milrinone via lumbar catheter showed significant reduction of DCI following aSAH, without an associated increase in complications.

Background Perforator infarction is a procedure-related complication of surgical clipping of ruptured anterior communicating artery (ACoA) aneurysms. Patients with perforator infarction may present with specific clinical features. The aim of this study was to elucidate incidence, risk factors, clinical course, and outcomes of perforator infarction following surgical clipping of ruptured ACoA aneurysms. Methods Retrospective analysis was performed of 104 patients from a single-center, observational cohort database who underwent surgical clipping for ruptured ACoA aneurysm. Risk factors of perforator infarction were identified. Correlation of perforator infarction with clinical course during hospitalization was investigated, focusing on dysfunction of hypothalamus and cerebral limbic system. We also evaluated any associations between perforator infarction and poor outcomes. Results Perforator infarction was observed in 24 (23.1%) patients. Use of temporary clip ( P = 0.019, χ 2 test) and intraoperative rupture ( P 2 test) were significantly associated with perforator infarction. Patients with perforator infarction had increased likelihood of hyponatremia (odds ratio 6.41 [95% confidence interval 2.27–18.1], P P = 0.004) in the subacute stage of subarachnoid hemorrhage by multivariate analyses. Perforator infarction was an independent risk factor of poor functional outcomes at 3 months (modified Rankin Scale score 3–6; odds ratio 5.29 [95% confidence interval 1.62–17.2], P = 0.006). Conclusions Perforator infarction following surgical clipping of ruptured ACoA aneurysms caused region-specific complications, including hyponatremia and insufficient oral intake, and was associated with poor functional outcomes.

OBJECTIVEPlasma D-dimer levels elevate during acute stages of aneurysmal subarachnoid hemorrhage (SAH) and are associated with poor functional outcomes. However, the mechanism in which D-dimer elevation on admission affects functional outcomes remains unknown. The aim of this study is to clarify whether D-dimer levels on admission are correlated with systemic complications after aneurysmal SAH, and to investigate their additive predictive value on conventional risk factors for poor functional outcomes.METHODSA total of 187 patients with aneurysmal SAH were retrospectively analyzed from a single-center, observational cohort database. Correlations of plasma D-dimer levels on admission with patient characteristics, initial presentation, neurological complications, and systemic complications were identified. The authors also evaluated the additive value of D-dimer elevation on admission for poor functional outcomes by comparing predictive models with and without D-dimer.RESULTSD-dimer elevation on admission was associated with increasing age, female sex, and severity of SAH. Patients with higher D-dimer levels had increased likelihood of nosocomial infections (OR 1.22 [95% CI 1.07–1.39], p = 0.004), serum sodium disorders (OR 1.11 [95% CI 1.01–1.23], p = 0.033), and cardiopulmonary complications (OR 1.20 [95% CI 1.04–1.37], p = 0.01) on multivariable analysis. D-dimer elevation was an independent risk factor of poor functional outcome (modified Rankin Scale Score 3–6, OR 1.50 [95% CI 1.15–1.95], p = 0.003). A novel prediction model with D-dimer had significantly better discrimination ability for poor outcomes than conventional models without D-dimer.CONCLUSIONSElevated D-dimer levels on admission were independently correlated with systemic complication, and had an additive value for outcome prediction on conventional risk factors after aneurysmal SAH.

Objective Although carotid artery stenting (CAS) has been gaining popularity as an alternative to carotid endarterectomy (CEA), perioperative stroke rate following contemporary CAS remains significantly higher than stroke rate after CEA. The purpose of this study was to assess perioperative (within 30 days) therapeutic results in patients with carotid stenosis (CS) after introduction of preoperative carotid magnetic resonance imaging plaque evaluation in a single center performing both CEA and CAS. Methods Based on prospectively collected data for patients with CS who were scheduled for carotid revascularization, retrospective analysis was conducted of 295 consecutive patients with CS. An intervention was selected after consideration of periprocedural risks for both CEA and CAS. Concerning risk factors for CAS, results of magnetic resonance imaging plaque evaluation were emphasized with a view toward reducing embolic complications. Results CAS was performed in 114 patients, and CEA was performed in 181 patients. Comparing baseline characteristics of the 295 patients, age, T1 signal intensity of plaque, symptomatic CS, urgent intervention, and diabetes mellitus differed significantly between CAS and CEA groups. Among patients who underwent CAS, new hyperintense lesions on diffusion-weighted imaging were confirmed in 47 patients. New hyperintense lesions on diffusion-weighted imaging were recognized in 21.4% of patients who underwent CEA ( n = 39), significantly less frequent than in patients who underwent CAS. Conclusions The overall short-term outcome of CEA and CAS is acceptable. Preoperative carotid magnetic resonance imaging evaluation of plaque might contribute to low rates of ischemic complications in CAS.

The surgical removal of giant solid hemangioblastoma involves a high risk of perioperative bleeding and requires attentive hemostasis. Here, we present a case of a giant solid hemangioblastoma accompanied with hemophilia which was previously undiagnosed. A 35-year-old man without any past medical history was admitted with diplopia and ocular motility disorder. computed tomography (CT) and magnetic resonance imaging (MRI) revealed obstructive hydrocephalus and a solid giant tumor of more than 4.0 cm in diameter in the right cerebellopontine angle (CPA). Hemangioblastoma was suspected on cerebral angiography. After ventriculoperitoneal shunt for obstructive hydrocephalus, oozing from the skin incision continued for several days. Hemophilia type A was diagnosed based on the result of laboratory blood coagulability examination. Supplemental administration of factor VIII and coil embolization of the feeding arteries of the lesion on the CPA were performed, and the tumor was subtotally resected without hemorrhagic complications. The histopathological diagnosis was hemangioblastoma. We report this case to emphasize the importance not to overlook previously undiagnosed coagulopathy before surgical excision of hemangioblastoma. And, with appropriate perioperative management for coagulopathy, surgical treatment involving a high risk of perioperative bleeding can be safely undertaken.

Objectives The goal of this study was to compare the risk of stroke between patients with carotid artery disease with and without the presence of intraplaque hemorrhage (IPH) on magnetic r...

Background The detection of a feeder aneurysm and an arteriovenous malformation (AVM) is relatively rare for the intracranial AVM. The distal posterior inferior cerebellar artery aneurysm (DPICAAn) is reported to coexist or relate with the cerebellar AVM. In previous reports about the treatment of a DPICAAn and a cerebellar AVM, endovascular embolization with the sacrifice of the posterior inferior cerebellar artery (PICA) has often been selected. However, there have been few reports of simultaneous open surgery for coexistent cases of DPICAAn and cerebellar AVM. Case description A 67-year-old male presented with a headache. We detected a right DPICAAn in the telovelotonsillar segment and a cerebellar AVM primarily fed by the left superior cerebellar artery (SCA). In addition, the nidus was located medially in the left upper cerebellar hemisphere. Magnetic resonance imaging raised suspicions of asymptomatic past hemorrhage in the cerebellar AVM. The left PICA was agenesis, and the right PICA perfused the bilateral inferior cerebellar hemispheres; thus, the right PICA could not be sacrificed. We selected open surgery to prevent any hemorrhagic event from the DPICAAn and the cerebellar AVM. The cerebellar AVM was completely removed, and the DPICAAn was successfully clipped in a single-session open surgery. Conclusions Open surgery can be considered for DPICAAn and cerebellar AVM. The anatomical location of the DPICAAn and AVM contributed to the success of a single-session open surgery.

Purpose: Cerebral hyperperfusion syndrome (CHS) is a rare devastating complication associated with hyperperfusion after carotid endarterectomy. Single photon emission computed tomography (SPECT) is usually used with acetazolamide challenge to measure the cerebrovascular reserve (CVR), and a decreased CVR is indicative of a high risk of post CEA hyperperfusion. However, acetazolamide administration can rarely cause serious adverse effects, and thus, alternative methods may be required. Perfusion computed tomography (PCT) is a rapid, more accessible modality, which can be acquired with CT angiography. PCT seems to be useful as a screening tool in identifying groups at high-risk of hyperperfusion, but its usefulness has not sufficiently investigated. Our purpose was to clarify the relationship between hyperperfusion and the preoperative PCT parameters of cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT). Method: We included patients who underwent carotid endarterectomy in our hospital from 2014 December to 2018 April. PCT was obtained preoperatively and on postoperative day 1. Hyperperfusion is defined as a postoperative CBF of the middle cerebral artery area which has increased twice that of the preoperative value. CHS was defined as any symptom and imaging findings related with hyperperfusion, which include headache, seizure, neurological dysfunction, and any intracranial hemorrhage in the related area. Preoperative CBF, CBV, MTT and other patient characteristics are statistically analyzed between a hyperperfusion group and non-hyperperfusion group. Result: There are 73 patients who underwent CEA during the study period, and hyperperfusion was observed in 5 cases, from which 2 were considered as CHS. In the hyperperfusion group, the preoperative CBF was significantly lower (p=0.0008), and the CBV and MTT significantly higher (p=0.0196, p=0.0002). ROC analysis showed that the PCT parameters with the maximal area under the receiver-operating characteristic curve for hyperperfusion was preoperative MTT with an optimal threshold at 8.0 seconds (sensitivity 100%, specificity 100%). Conclusion: Patient with prolonged preoperative MTT tend to develop hyperperfusion, which is related to CHS.

Introduction: From the results of NASCET and ECST, surgical treatment for carotid artery near occlusion (NO) has not been as effective as of that for severe stenosis. A meta-analysis published in 2015 supported surgical treatment for NO, but this is still controversial because recent large prospective studies such as CREST or ICSS exclude NO. Method: We conducted a retrospective single center case-controlled study in Japan. Among all NO cases from May 2006 to May 2017, we selected those who had internal carotid artery (ICA) without collapse, with collapse but with detection of vascular lumen from neck to intracranium by angiography and MRI, and without mechanical changes of vessel wall. We excluded patients who had ICA with full collapse and without the possibility for expansion. The carotid artery endarterectomy (CEA) or carotid artery stenting (CAS) was performed according to plaque character, position, and expectancy of expansion. The primary outcome was ipsilateral stroke within 90 days after surgery. Secondary outcomes included restenosis of more than 50%, and perioperative complications (postoperative procedural DWI positive, myocardial infarction, death). Result: In the eligible 60 patients, 56 were male, and the median age was 73±6.3. The number of symptomatic lesions and string signs were 27 and 5, and the CEA and CAS groups consisted of 33 and 27 patients, respectively. There was no significant difference between each group in the patient backgrounds other than the age and follow-up period (71 and 76 [p = 0.0093], 63 and 39 months, respectively [p = 0.0185]). Ipsilateral stroke within 90 days after surgery occurred in 0 and 4 patients (p = 0.0328), and restenosis in 7 (3 needed additional CAS) and 3 patients (p = 0.490). The postoperative DWI positive was 7 and 11 (p = 0.095), and all of them were asymptomatic or transient. There were no cases of perioperative myocardial infarction, and perioperative death occurred in 1 patient. Conclusion: CEA group had the advantage of procedural safety but also the risk of restenosis. In CAS group, we can expect good expansions of ICA, but perioperative complications are relatively high. Our results suggest that there exist specific factors including surgical indication which lead to good outcome by surgical treatment.

OBJECT Plaque characteristics and morphology are important indicators of plaque vulnerability. MRI-detected intraplaque hemorrhage has a great effect on plaque vulnerability. Expansive remodeling, which has been considered compensatory enlargement of the arterial wall in the progression of atherosclerosis, is one of the criteria of vulnerable plaque in the coronary circulation. The purpose of this study was risk stratification of carotid artery plaque through the evaluation of quantitative expansive remodeling and MRI plaque signal intensity. METHODS Both preoperative carotid artery T1-weighted axial and long-axis MR images of 70 patients who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) were studied. The expansive remodeling ratio (ERR) was calculated from the ratio of the linear diameter of the artery at the thickest segment of the plaque to the diameter of the artery on the long-axis image. Relative plaque signal intensity (rSI) was also calculated from the axial image, and the patients were grouped as follows: Group A = rSI ≥ 1.40 and ERR ≥ 1.66; Group B = rSI< 1.40 and ERR ≥ 1.66; Group C = rSI ≥ 1.40 and ERR < 1.66; and Group D = rSI < 1.40 and ERR < 1.66. Ischemic events within 6 months were retrospectively evaluated in each group. RESULTS Of the 70 patients, 17 (74%) in Group A, 6 (43%) in Group B, 7 (44%) in Group C, and 6 (35%) in Group D had ischemic events. Ischemic events were significantly more common in Group A than in Group D (p = 0.01). CONCLUSIONS In the present series of patients with carotid artery stenosis scheduled for CEA or CAS, patients with plaque with a high degree of expansion of the vessel and T1 high signal intensity were at higher risk of ischemic events. The combined assessment of plaque characterization with MRI and morphological evaluation using ERR might be useful in risk stratification for carotid lesions, which should be validated by a prospective, randomized study of asymptomatic patients.

The goal of this study was to compare the risk of stroke between patients with carotid artery disease with and without the presence of intraplaque hemorrhage (IPH) on magnetic resonance imaging.IPH in carotid stenosis increases the risk of cerebrovascular events. Uncertainty remains whether risk of stroke alone is increased and whether stroke is predicted independently of known risk factors.Data were pooled from 7 cohort studies including 560 patients with symptomatic carotid stenosis and 136 patients with asymptomatic carotid stenosis. Hazards of ipsilateral ischemic stroke (primary outcome) were compared between patients with and without IPH, adjusted for clinical risk factors.IPH was present in 51.6% of patients with symptomatic carotid stenosis and 29.4% of patients with asymptomatic carotid stenosis. During 1,121 observed person-years, 66 ipsilateral strokes occurred. Presence of IPH at baseline increased the risk of ipsilateral stroke both in symptomatic (hazard ratio [HR]: 10.2; 95% confidence interval [CI]: 4.6 to 22.5) and asymptomatic (HR: 7.9; 95% CI: 1.3 to 47.6) patients. Among patients with symptomatic carotid stenosis, annualized event rates of ipsilateral stroke in those with IPH versus those without IPH were 9.0% versus 0.7% (50% stenosis), 18.1% versus 2.1% (50% to 69% stenosis), and 29.3% versus 1.5% (70% to 99% stenosis). Annualized event rates among patients with asymptomatic carotid stenosis were 5.4% in those with IPH versus 0.8% in those without IPH. Multivariate analysis identified IPH (HR: 11.0; 95% CI: 4.8 to 25.1) and severe degree of stenosis (HR: 3.3; 95% CI: 1.4 to 7.8) as independent predictors of ipsilateral stroke.IPH is common in patients with symptomatic and asymptomatic carotid stenosis and is a stronger predictor of stroke than any known clinical risk factors. Magnetic resonance imaging might help identify patients with carotid disease who would benefit from revascularization.

Carotid endarterectomy (CEA) requires complete control of the blood backflow. An anomalous ascending pharyngeal artery (AphA) has been reported to result in incomplete control of the blood flow during CEA. Here, we present a case of symptomatic right internal carotid stenosis for which CEA was performed. An anomalous AphA was confirmed based on its origin from the distal internal carotid artery (ICA) on 3-dimensional rotational angiography (3DRA). The anomalous AphA arose near the distal end of the plaque, and the origin of the AphA was located in the dorsal wall of the ICA, hidden from the surgical view. The origin of the AphA was detected with rotation of the ICA within the carotid sheath (CS). Intraoperatively, the blood flow from the AphA was completely controlled with clamping of the origin of the AphA. We emphasize the importance of the 3DRA to detect an anomalous AphA and propose the use of the CS as an anchor to rotate the ICA for optimizing the surgical view behind the ICA. This simple surgical technique facilitates to detect and clamp an anomalous AphA arising from the ICA.

Background: Ischemic events caused by carotid artery stenosis are affected not only by stenosis but also by the instability of plaque. In symptomatic low-grade stenosis cases medical treatment is generally performed, but there are cases with repeated recurrence. The purpose of this study is to clarify the clinical features and long-term outcomes in cases of symptomatic low-grade stenosis. Methods: We included seventy-one symptomatic patients with carotid low-grade stenosis ( Results: The mean stenosis rate, rSI and ERR on admission were 20.4, 1.75 and 1.96, respectively. Seventy percent of cases involved intraplaque hemorrhage and positive remodeling. During a mean of 52-months follow-up, a recurrence of ischemic events was confirmed in 33 cases (46%), from which the duration until recurrence was within 7 days (33%), 3 months (18%), 1 year (18%), 2 years (21%), and over 2 years (15%). Nine cases had impending stroke, 3 of which were associated with major artery occlusion. CEA was performed in 28 cases (39%) for impending stroke (25%), recurrence of ischemic events (46%), asymptomatic infarction (7%), and stenosis rate progression (11%). During a mean of 47-months follow-up after CEA, 2 cases of death (fetal intracerebral hemorrhage, asphyxia) and one case of brain stem lacunar infarction were observed, but an ipsilateral ischemic event was not observed. Conclusion: Most of the symptomatic patients with low-grade stenosis had both intraplaque hemorrhage and positive remodeling. The risk of recurrence and stenosis progression was high. CEA might have had a preventive effect against ischemic events in low-grade stenosis.

OBJECT The purpose of the present study was to investigate the association between carotid artery (CA) expansive remodeling (ER) and symptoms of cerebral ischemia. METHODS One hundred twenty-two consecutive CAs scheduled for CA endarterectomy (CEA) or CA stent placement (CAS) were retrospectively studied. After excluding 22 CAs (2 were contraindicated for MRI, 8 had near-occlusion, 6 had poor image quality, and 6 had restenosis after CEA or CAS), there were 100 CAs (100 patients) included in the final analysis. The study included 50 symptomatic patients (mean age 73.6 ± 8.9 years, 6 women, mean stenosis 68.5% ± 21.3%) and 50 asymptomatic patients (mean age 72.0 ± 5.9 years, 5 women, mean stenosis 79.4% ± 8.85%). Expansive remodeling was defined as enlargement of the internal carotid artery (ICA) with outward plaque growth. The ER ratio was calculated by dividing the maximum distance between the lumen and the outer borders of the plaque perpendicular to the axis of the ICA by the maximal luminal diameter of the distal ICA at a region unaffected by atherosclerosis using long-axis, high-resolution MRI. RESULTS The ER ratio of the atherosclerotic CA was significantly greater than that of normal physiological expansion (carotid bulb; p < 0.01). The ER ratio of symptomatic CA stenosis (median 1.94, interquartile range [IQR] 1.58–2.23) was significantly greater than that of asymptomatic CA stenosis (median 1.52, IQR 1.34–1.81; p = 0.0001). When the cutoff value of the ER ratio was set to 1.88, the sensitivity and specificity to detect symptoms were 0.6 and 0.78, respectively. The ER ratio of symptomatic patients was consistently high regardless of the degree of stenosis. CONCLUSIONS There was a significant correlation between ER ratio and ischemic symptoms. The ER ratio might be a potential indicator of vulnerable plaque, which requires further validation by prospective observational study of asymptomatic patients.

Introduction: Plasma D-dimer levels elevate during acute stage of aneurysmal subarachnoid hemorrhage (SAH) and are associated with poor functional outcomes. However, the mechanism in which D-dimer elevation on admission affects functional outcomes remains unknown. Hypothesis: We hypothesize that D-dimer levels on admission are correlated with systemic complications rather than neurological complications, and therefore have an additive predictive value on conventional risk factors for poor functional outcomes. Methods: A total of 187 patients with aneurymal SAH were retrospectively analyzed from a single center, observational cohort database. Correlations of plasma D-dimer levels on admission with patients’ characteristics, initial presentation, neurological complications, and systemic complications were identified. We also evaluated additive value of D-dimer elevation on admission for poor functional outcomes by comparing predictive models with and without D-dimer. Result and Conclusions: D-dimer elevation on admission was associated with increasing age, women, and severity of SAH. Patients with higher D-dimer levels had increased likelihood of nosocomial infections (OR 1.22 [95% CI 1.07-1.39], p = 0.004), serum sodium disorders (OR 1.11 [95% CI 1.01-1.23], p = 0.033), and cardiopulmonary complications (OR 1.20 [95% CI 1.04-1.37], p = 0.01) by multivariable analysis. D-dimer elevation was an independent risk factor of poor functional outcomes (modified Rankin scale 3-6, OR 1.50 [95% CI 1.15-1.95], p = 0.003). A novel prediction model with D-dimer had significantly better discrimination ability for poor outcomes than conventional models without D-dimer, evaluated by C statistics, net reclassification improvement, and integrated discrimination improvement methods. These results suggest that elevated D-dimer levels on admission were independently correlated with systemic complications, and had an additive value for outcome prediction on conventional risk factors after aneurysmal SAH.

Objective To evaluate the efficacy of flow control of the internal carotid artery (ICA) by the clamping of the common carotid artery, external carotid artery, and superior thyroid artery during surgical ICA dissection to reduce ischemic complications after carotid endarterectomy (CEA). Methods Sixty-seven patients (59 men; age, 70.5 ± 6.2 years) who underwent CEA by the same surgeon were retrospectively studied. Both conventional CEA (n = 29) and flow-control CEA (n = 38) were performed with the patient under general anesthesia and with the use of somatosensory-evoked potential and near-infrared spectroscopy monitoring as a guide for selective shunting. The number of new postoperative infarcts was assessed with preoperative and postoperative diffusion-weighted images (DWIs) obtained within 3 days of surgery. In addition to surgical technique, the effects of the following factors on new infarcts also were examined: age, side of ICA stenosis, high-grade stenosis, symptoms, and application of shunting. Results New postoperative DWI lesions were observed in 7 of 67 patients (10.4%), and none of them was symptomatic. With respect to operative technique, the incidence rate of DWI spots was significantly lower in the flow-control group (2.6%) than in the conventional group (20.7%), odds ratio: 0.069; 95% confidence interval: 0.006–0.779; P = 0.031). On multiple logistic regression analysis, age, side of ICA stenosis, high-grade stenosis, symptoms, and the use of internal shunting did not have significant effects on new postoperative DWI lesions, whereas technique did have an effect. Conclusion The proximal flow-control technique for CEA helps avoid embolic complications during surgical ICA dissection.

Backgrounds and Purpose— Predictive value of reflux of anterior spinal artery for recurrent posterior circulation ischemia in bilateral vertebral arteries steno-occlusive disease was evaluated. Methods— We retrospectively reviewed 55 patients with symptomatic posterior circulation stroke caused by bilateral stenotic (>70%) lesions of the vertebral artery. We investigated any correlation of clinical and angiographic characteristics including collateral flow patterns, with recurrent stroke. Risk factors for poor 3-month functional outcome were also evaluated. Results— Recurrent posterior circulation stroke was observed in 15 (27.3%) patients. Multivariable analysis using Cox proportional hazards model showed anterior spinal artery reflux as a significant risk factor for stroke recurrence (adjusted hazard ratio, 19.3 [95% confidence interval, 5.35–69.9]; P P =0.028). Conclusions— In patients with symptomatic bilateral vertebral artery occlusive disease, anterior spinal artery reflux predicted recurrent posterior circulation stroke and poor functional outcome.