Factors Associated with Early and Late Seizure Related to Aneurysmal Subarachnoid Hemorrhage.

Post-stroke epilepsy may occur after aneurysmal subarachnoid hemorrhage (aSAH). Both early and late seizures could cause severe neurocognitive deficits if administration of appropriate antiseizure medication is delayed. Therefore, it is important to elucidate the risk factors for early and late seizures, which could be shared with medical teams to promptly manage seizures. There are aspects of both hemorrhage and ischemia in aSAH, and thus, numerous risk factors are considered for early and late seizures. We examined factors associated with aSAH-related early and late seizures. Among 297 patients who had aSAH and underwent direct or endovascular surgery, 25 had early seizures and 20 had late seizures. Patients who did not experience any seizures in at least 2-years of follow-up (n = 81) were used as the control group. Early seizures were associated with older age and acute severe nonneurological infection, whereas late seizures were associated with intraparenchymal lesion volume >10 mL and shunt placement. In patients with late seizures, consistency was frequently observed between electroencephalogram and the presence of intraparenchymal lesions. The frontopolar electrode on electroencephalogram was highly sensitive to abnormality in early seizures. Early seizures were induced by the patient's systemic factors, which may lower the threshold for cortical excitability. Patients with intraparenchymal lesions who undergo shunt placement should be carefully followed up for late seizures.

Giant cell arteritis with severe intracranial involvement diagnosed and treated early.

Background: Ischemic cerebrovascular accidents (CVA) occur in 3.3-7.2% of patients with giant cell arteritis (GCA), and intracranial vessels are rarely affected. We, herein, report a case of intracranial GCA with rapidly progressive multiple intracranial vascular lesions. Case Description: A 76-year-old woman visited a local doctor due to a headache; then, it improved spontaneously. Three months later, she suddenly had cerebral infarctions of bilateral pons and cerebellum. Magnetic resonance angiography (MRA) revealed the left internal carotid artery (ICA) occlusion, the right vertebral artery (VA) occlusion, and the left VA stenosis. She was diagnosed with atherothrombotic stroke and dual antiplatelet therapy was administered. However, 2 weeks later, the left VA stenosis was aggravated. Therefore, we reviewed the data of MRA performed 3 months ago and noted no lesions in the ICA and VA. T1 black-blood post-gadolinium imaging sequence magnetic resonance imaging (MRI) revealed vessel wall enhancement in the bilateral VA, left ICA, and bilateral superficial temporal artery. We performed a temporal artery biopsy and diagnosed her with GCA. The progression of the intracranial vascular lesions was decelerated by oral glucocorticoid administration. Conclusion: Intracranial vascular lesions in GCA can be formed later than initial symptoms, such as headache, and aggravated despite improvement in headache. In patients with GCA, evaluating intracranial vessels as a control is useful for distinguishing them from arteriosclerotic lesions at the onset of CVA. Intracranial GCA is characterized by rapidly progressive vascular lesions in the bilateral ICA and VA. In addition, T1 black-blood post-gadolinium imaging sequence MRI may lead to early diagnosis and treatment.

Cerebral Aneurysm Coil Embolization with a Coil-Assisted Technique Using a Small-Diameter Helical Coil.

Objective: We introduce a coil-assisted technique using a small diameter helical coil to preserve a branch artery in the aneurysm neck or dome during coil embolization of a cerebral aneurysm. Case Presentations: We report three cases that were treated with the coil-assisted technique. Using this method, the branch artery was preserved with a small diameter helical coil that was placed to support another frame coil. The first case was a ruptured internal carotid artery-posterior communicating artery (IC-Pcom) aneurysm, the second case was a ruptured anterior communicating artery aneurysm, and the third case was an unruptured IC-Pcom aneurysm, with branching of the Pcom, A2, and Pcom, respectively, from the neck or dome of the aneurysm. We were able to preserve the branch artery in all cases. Conclusion: This technique is feasible and safe for coil embolization of intracranial branch-incorporated aneurysms. The technique is especially useful for preserving branch arteries that are difficult to preserve by conventional techniques.

Clinical Evaluations of the Ischemic Core in Acute Ischemic Stroke Using Modified Diffusion-Weighted Imaging-Alberta Stroke Program Early Computed Tomography Scores by Ischemic Reversibility Using the Signal Intensity.

Objective: Early recanalization of acute stroke caused by large vessel occlusion (LVO) may improve high signal intensity (HSI) on diffusion-weighted imaging (DWI). In this study, we investigated whether subtraction of reversible ischemic lesions (RIL) from the HSI lesions on DWI improves the diagnostic accuracy for the ischemic core. Methods: A total of 35 patients from April 2013 and December 2019 were included in this study. These patients presented acute ischemic stroke due to anterior circulation LVO and underwent thrombectomy. All patients underwent DWI within 48 hours after thrombectomy. HSI ratios were calculated, and compared between ischemic lesions and contralateral normal tissue. Ischemic lesions with improvement in the HSI ratio from initial to postoperative DWI were defined as RIL. Based on a receiver operating characteristic (ROC) curve analysis that compared the HSI ratio of all ischemic lesions, the cutoff value of HSI ratio of RILs was calculated. Results: In all, 127 ischemic lesions were identified in 35 patients. HSI ratios of RILs were significantly lower than those of irreversible ischemic lesions (IILs) (p <0.0001). Based on a ROC curve analysis that compared the HSI ratio of all 127 lesions, the cutoff value of the HSI ratio of RILs was 1.4. After applying this cutoff value to the 127 ischemic lesions of the 35 patients, 20 patients (57%) were identified as having RILs with a HSI ratio of <1.4. In this 20 patients, the postoperative National Institutes of Health Stroke Scale (NIHSS) score at 24 hours was significantly lower (p = 0.007) and improvement in the NIHSS score was significantly higher (p = 0.018) than in the other patients. Conclusion: A HSI ratio of <1.4 on preoperative DWI may reflect ischemic reversibility. In this study, the HSI ratio correlated with clinical findings associated with cerebral ischemia, and our method may be useful in assessing ischemic cores.

Renal Artery Injury Caused by a 0.035-Inch Guidewire in Navigating a Guiding Sheath during Coil Embolization: A Case Report of Rescue Embolization with n-Butyl-2-Cianoacrylate.

Objective: We report renal artery injury by a guidewire during coil embolization of a cerebral artery aneurysm, which was successfully treated by transarterial embolization using n-butyl-2-cianoacrylate (NBCA). Case Presentation: A 65-year-old woman underwent coil embolization for an unruptured cerebral aneurysm, resulting in its complete occlusion. However, her blood pressure decreased during embolization and postoperative abdominal computed tomography (CT) revealed a retroperitoneal hematoma. Intraoperative video revealed that the 0.035-inch guidewire had passed deeply into the right renal artery when the guiding sheath was navigated into the abdominal aorta, suggesting renal artery perforation. Transarterial embolization using NBCA was performed immediately, which resulted in hemostasis. Conclusion: Although renal artery perforation with a guidewire is a rare complication, it can have severe consequences. Early diagnosis with prompt and definitive hemostasis is important.

Simple and Reproducible Microcatheter Shaping Method for Coil Embolization of Medially-directed Paraclinoid Internal Carotid Artery Aneurysms.

Objective: It is important to guarantee intra-aneurysmal stability of microcatheters during coil embolization. We developed a simple and reproducible microcatheter shaping method for medially-directed paraclinoid internal carotid artery aneurysms. Methods: An injection needle cap was used to make a smooth curve on the mandrel, which was first wound around the back end of the cap to create a primary curve. Next, a secondary curve was created using near the tip of the cap. Thus, a two-dimensional (2D), pigtail-shaped mandrel with a two-stage curve was created. The pigtail-shaped mandrel was inserted from the tip of a straight microcatheter and heat-shaped using a heat gun. Lastly, a microcatheter having a curve whose tip was approximately 6 mm longer than that of the preshaped J was created. We evaluated the ease of navigating the microcatheter into the aneurysm and its stability during coil embolization. Results: In all, 34 consecutive medially-directed paraclinoid internal carotid artery aneurysms were treated using the shaped catheters. It took 50-300 seconds (intermediate value: 90 seconds) from inserting the microcatheter with a microguide wire to navigate and place it into an aneurysm. There were no cases that required reshaping of the microcatheters during navigation into the aneurysm. There were no cases that resulted in kickback of the microcatheters from the aneurysm during coil placement, and microcatheter stability was good until the end of the procedure. In all, 12 cases required the balloon-assisted technique and three cases required stent-assisted coiling. The angiographic outcomes immediately after embolization were as follows: 25 cases (73.5%) with complete occlusion; 3 cases (8.8%) with dome filling; and 6 cases (17.6%) with a neck remnant. There were no perioperative complications. Conclusion: The shaping method with a pigtail-shaped mandrel using an injection needle cap is simple and reproducible, and is useful for medially-directed paraclinoid internal carotid artery aneurysms.

[Tentorial Dural Arteriovenous Fistula Presenting with Ocular Symptoms:A Case Report].

Tentorial dural arteriovenous fistula(dAVF)is classified as Cognard 4 with a high risk of aggressive feature, such as intracranial hemorrhage, venous infarction, and intracranial hypertension. We report a rare case presenting with ocular symptoms caused by tentorial dAVF. A 59-year-old man presented with progressive chemosis and exophthalmos of his left eye. Angiography showed a tentorial dAVF that was primarily fed by the middle meningeal artery and the meningohypophyseal artery. The AVF drained into the superior ophthalmic vein and the cerebellar cortical vein via an enlarged petrosal vein. Because transarterial Onyx embolization resulted in incomplete obliteration of the fistula, he underwent microsurgery via a suboccipital approach to obliterate the shunt. Postoperative angiography showed complete obliteration of the shunt. His ocular symptoms rapidly cured. We present this rare case and discuss the pathomechanism associated with the development of ocular symptoms secondary to a tentorial dAVF from the viewpoint of microvascular anatomy.