Orbital Arteriovenous Fistula Causing Only Visual Impairment due to Compression of the Optic Nerve by the Dilated Superior Ophthalmic Vein.

Orbital arteriovenous fistula (AVF) is a rare disease, and its standard therapeutic strategy has not been established. A 70-year-old male consulted an ophthalmologist due to a visual field defect in his left eye. Neurological findings showed visual impairment but no symptoms such as exophthalmos, conjunctival congestion, or diplopia. Magnetic resonance imaging showed marked dilation of the left superior ophthalmic vein (SOV). Cerebral angiography revealed an AVF that was limited to the left orbit. The feeder was a branch of the ophthalmic artery that originated from the first portion, and the drainer was the SOV, which was meandering and significantly dilated. Since the only symptom was visual impairment, the etiology was considered to be compression of the optic nerve due to a dilated SOV rather than increased venous pressure. Transvenous embolization via the facial vein was performed, and a visual field examination 1 week after the operation revealed marked improvement. Orbital AVF that develops only with visual impairment is extremely rare. As demonstrated with this case, coil embolization for proper position and reduction of the venous pressure, which relieves compression on the optic nerve, may be useful in improving the visual impairment.

Extradural Middle Fossa and Transcavernous Approach for Resection of Trigeminal Neurinoma at Lateral Cavernous Sinus.

We present a 52-year-old male case of right trigeminal neurinoma at lateral cavernous sinus. The tumor was 40 mm in maximum diameter, obviously compressed temporal lobe and encased internal carotid artery. Extradural middle fossa and transcavernous approach was applied and the tumor was resected via Parkinson's triangle. This approach enabled safe and effective tumor resection, sufficient visualization, and operative field ( Figs. 1 and 2 ). We performed dissection of the tumor from trigeminal nerve, tentorium, and middle fossa and resect the tumor around internal carotid artery sufficiently. Postoperative course was good without any new neurological deficit. This surgical method is considered safe and effective for the resection of the tumor at lateral cavernous sinus. The link to the video can be found at: https://youtu.be/2ekuILIgEuo.

STA-A3 Bypass Using Radial Artery Graft for Progressive Cerebral Infarction of Bilateral ACA Region after STA-MCA Bypass Surgery for Moyamoya Disease.

Direct revascularization surgery, such as superficial temporal artery (STA)-middle cerebral artery (MCA) bypass, is effective in preventing ischemia and hemorrhage for moyamoya disease. On the other hand, when ischemia of the anterior cerebral artery (ACA) region progresses after ipsilateral STA-MCA bypass, it is difficult to perform revascularization from the viewpoint of the donor artery. A 55-year-old woman with right hemiparesis was diagnosed with cerebral infarction due to moyamoya disease. Left STA-MCA bypass was performed with no postoperative complications, but memory impairment and decreased motivation were observed 2 months after the operation. Magnetic resonance imaging and angiography revealed new infarction in the bilateral ACA area and deterioration in the signal intensity of bilateral ACAs. Revascularization of the bilateral ACA regions was considered necessary, but the left STA was already used in the previous surgery. Therefore, STA-radial artery (RA)-A3 bypass using RA graft combined with right STA-MCA bypass was performed. STA-A3 bypass using an RA graft may be the optimal treatment for ischemia of the ACA region that progresses after STA-MCA bypass.

Impact of Extracranial-Intracranial Bypass on Cognitive Function in a Patient with Chronic Cerebral Ischemia.

Extracranial-intracranial (EC-IC) arterial bypass surgery was developed to prevent subsequent stroke by improving hemodynamics distal to the occluded intracranial artery, but its utilization has been decreasing due to the development in medical treatment. However, EC-IC bypass surgery may be effective for arresting or reversing cognitive decline in patients with cerebral ischemia. A 69-year-old man with the left internal carotid artery occlusion that manifested as scattered cerebral infarction of the left hemisphere presented with dysarthria and transient right hemiparesis. Hemodynamic condition was impaired in the left side, and therefore, EC-IC bypass surgery was performed to prevent recurrence of cerebral infarction. Neuropsychological examination at 6 months after the surgery showed marked improvement as compared to the preoperative examination and there was no recurrence of stroke in the patient. EC-IC bypass may contribute to the improvement of cognitive function as well as the prevention of recurrence of cerebral infarction in patients with hemodynamic insufficiency, but there might be a threshold of hemodynamic impairment with respect to the reversibility of cognitive performance. Investigation of the target and timing can identify cases in which the cognitive function is improved by surgery.

T11/T12 ossification of the yellow ligament contributing to thoracic myelopathy in patient with posterior fossa arachnoid cyst and acquired incidental Chiari I malformation/syrinx.

BACKGROUND: Thoracic ossification of the yellow ligament (OYL) may contribute to myelopathy. In the case presented, the patient additionally had a chronic posterior fossa arachnoid cyst with an acquired Chiari I malformation and cervicothoracic syrinx. CASE DESCRIPTION: A 40-year-old female with a posterior fossa arachnoid cyst found 17 years ago, and newly acquired Chiari I malformation (tonsils down 5 mm) with a C7-T5 syrnix, presented with the new onset of lower extremity myelopathy. The MR documented marked dorsolateral cord compression due to T11/T12 OYL. Six months following a laminectomy for resection of OYL, the patient was asymptomatic. CONCLUSION: In patients presenting with the new onset of lower extremity myelopathy, evaluation of the complete neuraxis may be warranted. Here, the patient has an unchanged posterior fossa arachnoid cyst with an acquired Chiari I malformation/C7-T5 syrinx. However, the patient's symptoms were fully attributed to the MR-documented T11/T12 OYL that was successfully resected.

Emergent surgical embolectomy for middle cerebral artery occlusion related to cerebral angiography followed by neck clipping for an unruptured aneurysm in the anterior communicating artery.

BACKGROUND: Intracranial embolism related to cerebral angiography is rare but one of the complications of the procedure. However, the standard management of acute intracranial embolism for this etiology has not been established, and there have been very few reports in the past. CASE DESCRIPTION: A 68-year-old male was incidentally found to have an unruptured aneurysm of anterior communicating artery (ACoA). Immediately after the cerebral angiography for the purpose of detailed examination of the aneurysm, the right partial hemiparalysis and mild aphasia developed. Magnetic resonance imaging/angiography (MRI/A) revealed an occlusion in the peripheral part of the left middle cerebral artery (MCA). Due to the existence of magnetic resonance angiography-diffusion mismatch, emergent craniotomy was immediately performed to remove intra-arterial thrombus. We also performed clipping for an unruptured ACoA aneurysm with this approach. Postoperative MRI/A showed that the occluded artery was recanalized and a slight infarction was observed in the left cerebral hemisphere. The patient was discharged on foot and followed at outpatient clinic over 4 years without no neurological deficit. CONCLUSION: Emergent surgical embolectomy for distal MCA occlusion related to cerebral angiography followed by neck clipping for an unruptured aneurysm of the ACoA was successful in treating acute occlusion of the peripheral part of the MCA in a patient with an unruptured aneurysm. As there are few similar cases, there is controversy about the best management, but this surgical method can be a safe and effective treatment.

Superficial temporal artery-superior cerebellar artery bypass and proximal occlusion through anterior petrosal approach for subarachnoid hemorrhage due to basilar artery dissection.

BACKGROUND: Subarachnoid hemorrhage (SAH) due to rupture of basilar artery dissection (BAD) is extremely rare and often has a poor prognosis. Since ruptured BAD has high rate of rebleeding and mortality, treatment to prevent rerupture is mandatory in the acute phase. However, to date, no optimal treatment has been established which satisfies secure prevention of rerupture and ischemia simultaneously. Herein, we report a case of SAH due to BAD treated with proximal occlusion of basilar artery with superficial temporal artery (STA)-superior cerebellar artery (SCA) bypass, preventing rebleeding securely and ensuring adequate blood flow in the upper basilar region. CASE DESCRIPTION: A 48-year-old male presenting with headache and altered mental status was found to have SAH and BAD. To prevent rerupture, proximal occlusion of basilar artery with STA-SCA bypass using anterior transpetrosal approach was performed. The postoperative course was relatively good and there is no evidence of recurrent arterial dissection. CONCLUSION: Proximal occlusion of the basilar artery combined with STA-SCA bypass was successful in preventing rerupture of BAD and ensuring blood flow in the upper basilar region. Although there is controversy regarding acute treatment for ruptured BAD, direct proximal occlusion with sufficient revascularization using bypass skull base technique may be one of the optimal treatments even in this era of endovascular treatment.

Trapping, dome puncture, and direct suction decompression in conjunction with assistant superficial temporal artery- middle cerebral artery bypass to clip giant internal carotid artery bifurcation aneurysm.

BACKGROUND: Very large and giant aneurysms (≥20 mm) of the internal carotid artery (ICA) bifurcation (ICAbif) are definitely rare, and optimal treatment is not established. Endovascular treatments are reported as suboptimal due to difficulties of complete occlusion and tendencies to recanalization. Therefore, direct surgery remains an effective strategy if the clipping can be performed safely and reliably, although very difficult. CASE DESCRIPTION: Two cases of ICAbif aneurysms (>20 mm) were treated. Prior assistant superficial temporal artery (STA)-middle cerebral artery (MCA) bypass was performed to avoid ischemic complications during prolonged temporary occlusion of the arteries in both cases. In Case 1 (22-mm aneurysm), the dome was inadvertently torn in applying the clip because trapping had resulted in insufficient decompression. Therefore, in Case 2 (28-mm aneurysm), almost complete trapping of the aneurysm and subsequent dome puncture was performed, and the aneurysm was totally deflated by suction from the incision. This complete aneurysm decompression allowed safe dissection and successful clipping. CONCLUSION: Trapping, deliberate aneurysm dome puncture, and suction decompression from the incision in conjunction with assistant STA-MCA bypass can achieve complete aneurysm deflation, and these techniques enable safe dissection of the aneurysm and direct clipping of the aneurysm neck. Direct clipping with this technique for very large and giant ICAbif aneurysms may be the optimal treatment choice with the acceptable outcome if endovascular treatment remains suboptimal.

Recurrent Embolic Stroke Caused by Large Cavernous Carotid Aneurysm: Stroke Recurrence Prevention with High-Flow Bypass Followed by Proximal Occlusion.

Intracranial aneurysms may cause embolic stroke. Medical or surgical management is selected on an individual basis, as the optimal treatment strategy has not been established. A 79-year-old woman with a large cavernous carotid aneurysm suffered repeated embolic stroke after enlargement and partial thrombosis of the aneurysm, in spite of antiplatelet therapy. Coil embolization of the primitive trigeminal artery and ligation of the internal carotid artery (ICA) at the cervical portion followed by high-flow bypass from the cervical external carotid artery to the middle cerebral artery were performed. The aneurysm was thrombosed, and prevention of further stroke was achieved. Acute enlargement and thrombosis of large or giant cavernous carotid aneurysm may cause repeated embolic stroke, and requires emergent exclusion of the aneurysm from circulation by proximal ICA occlusion together with distal revascularization before devastating embolic stroke occurs.

Combined Interhemispheric and Transsylvian Approach for Resection of Craniopharyngioma.

We present a 37-year-old male case of cystic suprasellar huge craniopharyngioma, who presented with significant memory disturbance due to obstructive hydrocephalus. Combined interhemispheric and pterional approach was chosen to resect huge suprasellar tumor. Interhemispheric trans-lamina terminalis approach was quite effective to resect third ventricular tumor, while pterional approach was useful to dissect tumor out of basilar perforators and stalk. The link to the video can be found at: https://youtu.be/BoYIPa96kdo .

High-flow bypass with radial artery graft followed by internal carotid artery ligation for large or giant aneurysms of cavernous or cervical portion: clinical results and cognitive performance.

High-flow bypass followed by ligation of the internal carotid artery (ICA) is an effective treatment, but the impact of abrupt occlusion of the ICA is unpredictable, especially on postoperative cognitive function. The present study evaluated the clinical results as well as cognitive performances after high-flow bypass using radial artery graft (RAG) with supportive superficial temporal artery (STA)-middle cerebral artery (MCA) bypass, followed by ICA ligation. Ten consecutive patients underwent high-flow bypass surgery for large or giant ICA aneurysms of cavernous or cervical portion. Demographics, clinical information, magnetic resonance (MR) imaging, computed tomography, digital subtraction angiography (DSA), intraoperative somatosensory evoked potentials, neuropsychological examinations including the Wechsler Adult Intelligence Scale-Third Edition and the Wechsler Memory Scale-Revised (WMS-R), and follow-up data were analyzed. The aneurysm was located on the cavernous segment in eight cases and cervical segment in two cases, and mean aneurysm size was 27.9 mm. Postoperative DSA demonstrated robust bypass flow from the external carotid artery to MCA via the RAG, and no anterograde flow into the aneurysm. No patient showed new symptoms after the operation. Follow-up clinical study and MR imaging were performed in nine patients and showed no additional ischemic lesion compared with preoperative imaging. Seven patients completed neuropsychological examinations before and after surgery. All postoperative scores except WMS-R composite memory score slightly improved. High-flow bypass followed by ICA ligation can achieve good clinical outcomes. Successful high-flow bypass using RAG with supportive STA-MCA bypass and ICA ligation does not adversely affect postoperative cognitive function.

Giant cavernous carotid aneurysm causing pituitary dysfunction: Pituitary function recovery with high-flow bypass.

BACKGROUND: Giant internal carotid artery (ICA) aneurysms extending into the sellar region, mimicking pituitary tumors, and causing pituitary dysfunction are relatively rare. Open surgery or endovascular treatment can treat these aneurysms, but achieving recovery of endocrine function is difficult. CASE DESCRIPTION: A 56-year-old man presented with giant aneurysm of the ICA causing pituitary impairment, leading to disturbance of consciousness due to hyponatremia. High-flow bypass from the cervical external carotid artery to the middle cerebral artery and ligation of the ICA at the cervical portion were performed. One year after the operation, his pituitary function recovered well; he was followed up as an outpatient without hormonal replacement therapy for 8 years after the operation. CONCLUSION: Giant ICA aneurysm causing pituitary dysfunction is relatively rare, but it is important to consider in the differential diagnosis for hypopituitarism. Treatment with high-flow bypass using radial artery graft can achieve both prevention of aneurysm rupture and recovery of pituitary function.

Technique for rerouting a bridging vein that hinders the anterior interhemispheric approach: a technical note.

BACKGROUND: The frontal bridging vein, which is the venous drainage route of the frontal cortex into the superior sagittal sinus (SSS), sometimes poses an obstacle in the anterior interhemispheric approach during surgery for anterior cerebral artery aneurysms. Although severe complications including venous infarction or edema due to damage to the bridging vein are well known, only a few reports have discussed how to avoid venous injury when we must sacrifice the bridging vein to obtain an appropriate surgical field. This report describes a microvascular technique performed in two patients who underwent rerouting of the bridging vein to obtain an appropriate anterior interhemispheric surgical corridor to treat a ruptured anterior cerebral artery aneurysm. The hindering bridging vein was resected from the entrance to the SSS and anastomosed toward the adjacent cortical vein. METHODS: A 65-year-old male and a 43-year-old male were admitted to our hospital for sudden headache. Computed tomography, magnetic resonance angiogram, or digital subtraction angiography demonstrated a subarachnoid hemorrhage and an anterior cerebral artery aneurysm in both patients. In both cases, a relatively robust bridging vein, which appeared problematic to sacrifice, was draining into the SSS, resulting in a limited surgical corridor. Thus, we performed cortical vein reconstruction, and the aneurysms were successfully clipped under a wider surgical view. RESULTS: We confirmed completed clipping without postoperative venous complications. One patient demonstrated patency of reconstructed venous flow by digital subtraction angiography. No apparent cognitive impairment was seen in either patient. CONCLUSIONS: This technique may be useful for obtaining an appropriate surgical corridor when the frontal bridging vein may be damaged.

Middle cerebral artery dissection causing subarachnoid hemorrhage and cerebral infarction: Trapping with high-flow bypass preserving the lenticulostriate artery.

BACKGROUND: Spontaneous intracranial arterial dissection (IAD) is an increasingly important cause of stroke, such as subarachnoid hemorrhage (SAH) and hemodynamic or thromboembolic cerebral ischemia. IAD usually occurs in the posterior circulation, and is relatively rare in the anterior circulation including the middle cerebral artery (MCA). Various surgical and endovascular methods to reduce blood flow in the dissected lesion have been proposed, but no optimum treatment has been established. CASE DESCRIPTION: An 80-year-old woman with dissection in the M1 portion of the MCA manifesting as SAH presented with repeated hemorrhage and cerebral infarction in the area of the inferior trunk of the MCA. High-flow bypass to the MCA was performed and the dissecting lesion was trapped. Prevention of repeated hemorrhage was achieved, and blood flow was preserved to the lenticulostriate artery as well as the MCA area distal to the lesion. CONCLUSIONS: Treatment strategy for IAD of the MCA should be planned for each patient and condition, and surgery should be performed promptly to prevent critical rebleeding given the high recurrence rate. In addition, preventing re-rupture of the IAD, and preserving important perforators around the lesion and blood flow distal to the dissection should be targeted by the treatment strategy.

Surgical strategy to minimize ischemia during trapping/resection of giant extracranial carotid artery aneurysm stratified by collateral evaluation.

BACKGROUND: Extracranial carotid artery aneurysm (ECAA) is a rare clinical entity, and no standard treatment strategy has been established for this condition. METHODS: Data from three patients who underwent surgical treatment of enlarging giant ECAAs were retrospectively reviewed. Based on the collateral status, as evaluated by preoperative digital subtraction angiography (DSA), surgical strategy was stratified into (1) high flow bypass followed by cervical ICA (internal carotid artery) ligation, when the collateral status was judged as poor/fair or (2) direct cervical repair with patch application after aneurysmal wall resection when the collateral status was judged as robust. Postoperative results were evaluated by magnetic resonance imaging (MRI). RESULTS: Postoperative follow-up (day 0 to 1, as well as midterm at approximately 6 months) confirmed completely trapped aneurysm with successful robust bypass and robust anterograde flow of the reconstructed cervical carotid artery on magnetic resonance angiography with no additional ischemic lesions on diffusion weighted imaging and T2-weighted imaging when compared with preoperative imaging in all three patients. Postoperatively, there was no stroke event during the midterm follow-up at 6 months. CONCLUSIONS: Clinical results of ECAAs treated by a surgical strategy stratified based on collateral status, as evaluated by preoperative DSA, were favorable, without postoperative ischemic event, and with satisfactory mid-term MRI results.

Tailored flow sequestration treatment using high-flow and low-flow bypass for partially thrombosed giant internal carotid artery aneurysm-a technical case report.

Direct clipping of giant partially thrombosed intracranial internal carotid artery (ICA) aneurysms is challenging, especially when important perforating arteries are involved. Proximal occlusion with bypass represents a possible alternative approach. An 80-year-old female presented with worsening visual acuity and severe headache caused by partially thrombosed giant (38 mm in diameter) aneurysms of the right ICA, suggestive of impending rupture. Direct clipping in conjunction with temporary occlusion of the lesion involving the anterior choroidal artery (AChA) was considered too risky. Thus, we sequestrated the ipsilateral ICA flow into a low-flow and a high-flow system using two external carotid artery (ECA)-ICA bypasses and one in situ bypass with cervical ICA ligation. As a result, the low-flow system by the superficial temporal artery-middle cerebral artery (MCA) bypass perfused mainly the proximal MCA lesions and aneurysm, whereas the high-flow system by ECA-radial artery-M2 bypass exclusively supplied the residual distal MCA area. This tailored flow sequestration successfully interrupted intra-aneurysmal flow and accelerated near-complete thrombosis of the aneurysm while preserving the AChA and avoiding any significant neurological deterioration. We conclude that this method is effective for the management of giant partially thrombosed aneurysms of the ICA, especially when direct clipping is difficult.

Extracranial-intracranial bypass for internal carotid/middle cerebral atherosclerotic steno-occlusive diseases in conjunction with carotid endarterectomy for contralateral cervical carotid stenosis: clinical results and cognitive performance.

Clinical results as well as cognitive performances after extracranial to intracranial (EC-IC) bypass in conjunction with contralateral carotid endarterectomy (CEA) are poorly understood. Data from 14 patients who underwent unilateral EC-IC bypass for atherosclerotic internal carotid artery (ICA)/middle cerebral artery (MCA) steno-occlusive disease in conjunction with CEA for contralateral cervical carotid stenosis were retrospectively reviewed. Postoperative results were evaluated by MRI imagings. Nine patients also underwent neuropsychological examinations (NPEs), including assessment by the Wechsler Adult Intelligence Scale-Third Edition and the Wechsler Memory Scale-Revised (WMS-R) before and about 6 months after bilateral surgeries. Postoperative MRI follow-up (median, 8 months; interquartile range, 7-8 months) confirmed successful bypass in all patients, with no additional ischemic lesions on T2WI when compared with preoperative imaging. Further, MRA showed patent bypass and contralateral smooth patency at CEA portion in all patients. In the group rate analysis, all five postoperative NPE scores (Verbal IQ, Performance IQ, WMS-memory, WMS-attention, and Average scores of all those four scores) were improved relative to preoperative NPE scores. Performance IQ and Average score improvements were statistically significant. Clinical results after EC-IC bypass in conjunction with contralateral CEA were feasible. Based on the group rate analysis, we conclude that successful unilateral EC-IC bypass and contralateral carotid endarterectomy does not adversely affect postoperative cognitive function.

Postoperative transient neurological symptoms and chronic subdural hematoma after extracranial-intracranial bypass for internal carotid/middle cerebral atherosclerotic steno-occlusive diseases: negative effect on cognitive performance.

BACKGROUND: The mechanisms underlying post-extracranial to intracranial (EC-IC) bypass neurocognitive changes are poorly understood. METHODS: Data from 55 patients who underwent a unilateral EC-IC bypass for atherosclerotic internal carotid artery (ICA)/middle cerebral artery (MCA) steno-occlusive disease were retrospectively evaluated. These patients underwent neuropsychological examinations (NPEs), including assessment by the Wechsler Adult Intelligence Scale-Third Edition and Wechsler Memory Scale-Revised (WMS-R) before and 6 months after EC-IC bypass. Results of NPEs were converted into Z-scores from which preoperative cognitive composite scores (CSpre) and postoperative cognitive composite scores (CSpost) were obtained. The association between the change of composite score between pre- and postoperative NPEs (CSpost-pre = CS post - CS pre) and various variables were assessed. These latter variables included occluded artery (ICA or MCA), preexisting ischemic lesion as verified in preoperative T2WI, robust bypass patency as verified by MRA performed approximately 6 months postoperatively, and postoperative transient neurological symptoms and/or postoperative chronic subdural hematoma (CSDH), both of which were dichotomized as postoperative events. RESULTS: Postoperative MRI follow-up (median, 6 months; interquartile range, 5-8 months) confirmed successful bypasses in all patients, with no additional ischemic lesions on T2WI when compared with preoperative imaging. Further, MRA showed patent bypasses in all patients. A nearly statistically significant CS post-pre decrease was observed in patients with postoperative events when compared with those without postoperative events (-0.158 vs. 0.039; p = 0.069). A multiple regression model predicting CSpost-pre was performed. After controlling for occluded arteries, postoperative events were identified as an independent predictor of a decline in CSpost-pre (p = 0.044). In the group rate analysis, three of four postoperative NPE scores (Performance IQ, WMS-memory, WMS-attention) were significantly improved relative to preoperative NPE scores. CONCLUSIONS: Postoperative transient neurological symptoms and/or CSDH might play a significant role in the subtle decline in cognition following an EC-IC bypass. However, this detrimental effect was small, and based on the group rate analysis, we concluded that a successful unilateral EC-IC bypass does not adversely affect postoperative cognitive function.

Volumetric analyses of cerebral white matter hyperintensity lesions on magnetic resonance imaging in a Japanese population undergoing medical check-up.

AIM: To clarify growth patterns, spatial distribution and risk factors of cerebral white matter hyperintensity (WMH) lesions on magnetic resonance imaging. METHODS: We analyzed volumes of cerebral WMH lesions in those who underwent brain magnetic resonance imaging as a hospital-based health check-up in 2012 and 2013 by using a computational quantitative image analysis software (Software for NeuroImage Processing in Experimental Research). After excluding subjects not suitable for volumetric analyses because of pathological brain conditions, a total of 1047 healthy participants (mean age 56.6 years) were included for the analyses. First, the relationship of computational volumetry and conventional qualitative visual evaluation by Shinohara grading was evaluated. Volumes of WMH lesions were analyzed according to age and the different cerebral lobes. Finally, clinical risk factors associated with WMH lesions were assessed. RESULTS: Volumes of WMH lesions were significantly correlated with Shinohara grading (P < 0.001). WMH lesions significantly enlarged with aging (P < 0.001) except for the occipital lobe, especially in participants aged 50 years or older. Age and systolic blood pressure were significantly related to volumes of WMH lesions in all the lobes, whereas diastolic blood pressure was not related only in the occipital lobe. CONCLUSION: Based on computational quantitative volumetric analyses, cerebral WMH lesions increased with age, and were associated with blood pressure. However, the occipital lobe was the only exception to these findings.

Emergent cervical surgical embolectomy for extracranial internal carotid artery occlusion.

BACKGROUND: Acute extracranial internal carotid artery (ICA) occlusion by a huge cardiogenic embolus is rare, but can be catastrophic. METHODS: Seven patients with acute ischemic stroke due to embolic occlusion of extracranial ICA who underwent emergent cervical surgical embolectomy were retrospectively reviewed. Diagnosis was made in six patients with magnetic resonance imaging (MRI) with optional digital subtraction angiography (DSA), while computed tomography (CT) and DSA were used in one patient with an implanted pacemaker. Clinical outcomes, including recanalization rate, recanalization time, complications, modified Rankin scale (mRS) at 3 months, and National Institute of Health Stroke Scale (NIHSS) score improvement at 1 month were evaluated. RESULTS: Complete recanalization was obtained in seven patients (100 %). Median recanalization time from symptom onset and from start of surgery was 402 and 40 min, respectively. All seven patients showed severe left ventricular hypertrophy (LVH) according to an increased cardiothoracic ratio (CTR) ≥50 %. Complications included recurrence of cardioembolic stroke with the right middle cerebral artery occlusion, minimal expansion of infarction, and aggravation of heart failure, each in one patient, respectively. Four (57.1 %) patients had a history or postoperative recurrence of cardioembolic stroke. Median NIHSS at 1 month was 2 (range, 0-30). Median mRS at 3 months was 2 (range, 0-5). Five patients (71.4 %) had a favorable outcome (mRS2). CONCLUSIONS: Cervical surgical embolectomy for acute extracranial ICA occlusion resulted in a high complete recanalization rate with an acceptable safety profile. A possible association between severe cardiac illness and huge embolus occluding proximal large artery was suggested.