Retrospective Observational Study of Patients With Subdural Hematoma Treated With Idarucizumab.

Use of anticoagulants is increasing with the aging of societies. The safe first-line drug is likely to be a direct oral anticoagulant (DOAC), but outcomes of treatment of traumatic brain injury (TBI) with anticoagulants are uncertain. Therefore, we examined the clinical effect of idarucizumab as reversal therapy in elderly patients with TBI who were treated with dabigatran. A retrospective multi-center observational study was performed in patients ≥65 years of age who developed acute traumatic subdural hematoma during treatment with dabigatran and underwent reversal therapy with idarucizumab. The items examined included patient background, neurological and imaging findings at arrival, course after admission, complications, and outcomes. A total of 23 patients were enrolled in the study. The patients had a mean age of 78.9 years. Cause of TBI was fall in 60.9% of the subjects. Mean Glasgow Coma Scale score at arrival was 8.7; anisocoria was present in 31.8% of cases. Exacerbation of consciousness was found in 30.4%, but only in 13.3% of subjects treated with idarucizumab before consciousness and imaging findings worsened. Dabigatran was discontinued in 81.8% of cases after hematoma development, with a mean withdrawal period of 12.1 days. The favorable outcome rate was 21.7%, and mortality was 39.1%. In multi-variate analysis, timing of idarucizumab administration was associated with a favorable outcome. There were ischemic complications in 3 cases (13.1%), and all three events occurred ≥7 days after administration of idarucizumab. These findings suggest that in cases that develop hematoma during treatment with dabigatran, it is important to administer idarucizumab early and restart dabigatran after conditions stabilize.

Angiographic Characteristics of Pseudo-occlusion of the Internal Carotid Artery Before and After Stenting.

BACKGROUND: Various definitions of pseudo-occlusion and clinical outcomes after various treatments have been reported, but reports discussing the stenotic characteristics of pseudo-occlusion are rare. OBJECTIVE: To analyze the angiographic characteristics of pseudo-occlusion of the internal carotid artery (ICA) before and after carotid artery stenting (CAS). METHODS: We retrospectively reviewed the angiographic characteristics of 56 patients with pseudo-occlusion of the ICA treated with CAS. Angiographic changes were evaluated from digital subtraction angiography in terms of lesion characteristics of the stenosis and the diameter changes in the distal ICA before and after CAS. RESULTS: Fifty-six patients were successfully treated. Based on angiographic findings of ICA stenosis, 33 and 23 patients were classified into the single-channel and multiple-channel group, respectively. Regarding the diameter changes in the distal ICA after CAS, 31 cases were classified as immediate dilatation and the other 25 as restricted dilatation. Immediate dilatation of the distal ICA beyond the stent and that at a follow-up examination were observed significantly less frequently in the multiple-channel group than in the single-channel group. The use of multiple stents and stent occlusion at a follow-up examination were significantly more prevalent in the multiple-channel group than in the single-channel group. CONCLUSION: Stenotic lesions of pseudo-occlusion of the ICA were classified as single channel and multiple channel. Restricted dilatation of the distal ICA after CAS was more prevalent in the multiple-channel group. Because adverse events tended to be more frequent in the multiple-channel group than in the single-channel group, the indications for CAS should be determined carefully in multiple-channel patients. ABBREVIATIONS: CAS, carotid artery stentingICA, internal carotid artery.

The clinical results of transcervical carotid artery stenting and frequency chosen as the approach route of carotid artery stenting in 1,067 consecutive cases.

BACKGROUND: Carotid artery stenting (CAS) is generally performed via a transfemoral approach. A transbrachial approach is usually chosen as an alternative when CAS via a transfemoral approach is difficult. At our institutions, a transcervical approach is chosen when the previous two approach routes are not available. We reviewed CAS cases treated via the transcervical route in our 1,067 CAS series to investigate the safety, feasibility, and frequency of this procedure as an approach route of CAS. METHODS: We performed 1,067 CAS procedures in 1,067 consecutive cases between December 2002 and June 2011. Initially, a transfemoral route was chosen, and secondarily a transbrachial route, the last choice was a transcervical route. A transbrachial approach was chosen in 96 (9.0%) cases and a transcervical approach in ten (0.9%). We reviewed the characteristics and outcomes of CAS performed via a transcervical approach. RESULTS: CAS was successfully performed on all ten transcervical-approach patients. Eight procedures were performed under local anesthesia and two under general anesthesia. Perioperative morbidity and mortality were both 0%. The modified Rankin scale (mRS) showed no deterioration at 3 months except for one case whose mRS became five because of an embolic stroke after aortic valve replacement. CONCLUSIONS: CAS via a transcervical approach was safe and feasible, and its frequency chosen as an approach route was 0.9%. This procedure can be an alternative to transfemoral or transbrachial approaches when CAS via either of these approaches is too difficult.

A polyvinyl alcohol core coil containing basic fibroblast growth factor evaluated in rabbits with aneurysms induced by elastase.

OBJECTIVE: The present study evaluates the effect of a novel coil with a polyvinyl alcohol (PVA) core that delivered basic fibroblast growth factor (bFGF) to aneurysms in rabbits induced by elastase. METHODS: PVA was processed to form small threads and inserted into the central core of a primary coil (PVA-core coil). After immersion in saline or bFGF (500 or 2000 mug/ml), PVA-core coils were implanted into elastase-induced aneurysms in rabbits in vivo. Follow-up angiography was performed 4 and 8 weeks after embolization, and the effects were histologically semiquantified according to a grading scale. RESULTS: Follow-up angiography showed that the coils did not compact or protrude and that clots did not form in any group. The score of gross neck healing was significantly higher in the 8-week 2000 bFGF group than in the 8-week PVA coil group (2.7 +/- 0.6 versus 0.0 +/- 0.0, P < 0.05). The dome healing score was significantly higher in the 4-week 2000 bFGF group than that of the 4-week PVA coil group (4.0 +/- 0.0 versus 2.7 +/- 0.6, P < 0.05). Cells positive for alpha-smooth muscle actin densely accumulated in the dome of the aneurysm embolized with PVA-core coils containing bFGF. CONCLUSION: Implantation of the PVA-core coil containing bFGF accelerated tissue growth at the neck as well as in the dome of aneurysms induced by elastase in rabbits. These results suggested that PVA-core coils could prevent the recanalization of embolized aneurysms.

[Carotid artery stenting via a transbrachial artery: techniques and problems].

Recently, carotid artery stenting (CAS) has been reported to be an alternative of carotid endarterectomy (CEA) for internal carotid artery (ICA) stenosis due to the improvement of protection devices. In general, the transfemoral approach has been chosen for CAS because of the sizes of the devices. However, the transfemoral route seems to be unavailable or at high risk, in cases of severe atherosclerotic changes or aneurysm of the femoral, iliac artery or aorta, or after bypass graft placement. In this report, we presented 5 patients who underwent CAS using the transbrachial approach. The mean stenotic rate of 84% before treatment was reduced to 14% after the procedures. The 30-day morbidity and mortality were both 0%. Major local complications at the puncture site were not encountered. There has been no stroke nor death during a mean follow-up period of 6 months. We suggest that CAS via transbrachial route is an effective and safe treatment for ICA stenosis, by use of low-profile devices and bi-plane DSA equipment, especially in patients who are not eligible for the transfemoral access.

Endovascular treatment for pseudo-occlusion of the internal carotid artery.

OBJECTIVE: The surgical benefit to pseudo-occlusion of the internal carotid artery (ICA) is controversial. Because the benefit of carotid endarterectomy for pseudo-occlusion of the ICA remains uncertain, we examined the use of carotid stenting as a possible alternative treatment for this condition. METHODS: Twenty cases of carotid pseudo-occlusion (17 symptomatic, three asymptomatic) were treated with carotid artery stenting. Nineteen patients were treated with various embolic protection techniques. Our clinical results, including angiographic follow-up data, perioperative complications, and data on the effectiveness of the embolic protection methods were studied for ICA pseudo-occlusion. RESULTS: All pseudo-occlusions were successfully dilated, and the stenotic ratio was reduced from 95 to 6.7% on average. No neurological deterioration was encountered in any of the cases, although one patient died of cardiac event 1 day after treatment. None of the patients experienced stroke during the mean 24.8 month follow-up period, although one patient died from myocardial infarction. Among the 17 cases in which follow-up angiography was performed at 6 months after stenting, only one patient demonstrated restenosis. This patient was successfully treated with repeated percutaneous transluminal angioplasty. The rate of restenosis in our series was 5.9%, and the morbidity/mortality rate within 30 days was 5%. CONCLUSION: The clinical results of carotid stenting for ICA pseudo-occlusion under embolic protection were fairly good from the viewpoints of periprocedural neurological morbidity, angiographic follow-up results, and stroke prevention. Carotid stenting can be considered an alternative to carotid endarterectomy in patients with ICA pseudo-occlusion.

Hemorrhagic complications after endovascular therapy for atherosclerotic intracranial arterial stenoses.

OBJECTIVE: Hemorrhagic complications were analyzed in 106 procedures of 99 patients treated with percutaneous transluminal angioplasty (PTA) or stenting for intracranial arterial stenoses. METHODS: Ninety-nine patients with intracranial arterial stenosis were treated with PTA or stenting 106 times from January 1995 to December 2003. Fifty-seven patients had intracranial internal carotid artery stenosis, 23 had middle cerebral artery stenosis, and 19 had vertebrobasilar stenosis. Evaluation of hemodynamic compromise via single-photon emission computed tomography was performed 50 times for 50 patients before the treatment. RESULTS: Four hemorrhagic complications occurred in 106 procedures. Two of these cases involved intracerebral hemorrhage after PTA or stenting in the treated vascular territory 30 minutes and 16 hours after the treatment, respectively. One case showed subarachnoid hemorrhage, which appeared 6 hours after treatment. Hemodynamic compromise was found on single-photon emission computed tomography in these three cases. The last case with a hemorrhagic complication was a hemorrhagic infarction after recanalization of stent thrombosis, which appeared 3 days after stenting. Hyperperfusion syndrome was strongly suggested as the cause of hemorrhage in the two cases associated with intracerebral hemorrhage. CONCLUSION: The rate of hemorrhagic complication directly related to the procedure of PTA or stenting was 3%, and hyperperfusion syndrome was suggested as the cause of hemorrhage in two cases (2%), from the perspective of clinical characteristics and single-photon emission computed tomographic findings.

Carotid artery stenting for stenosis with intraluminal thrombus.

Since intraluminal thrombus in the context of carotid artery stenosis is rarely encountered, treatment for this condition remains controversial. The present paper describes six cases of carotid artery stenosis with thrombus and discusses the efficacy and complications of carotid artery stenting (CAS). From April 2002 to May 2004, six patients with carotid artery stenosis and intraluminal thrombus receiving medical therapy underwent CAS at our institution. CAS was performed with distal protection alone (method 1) in three patients, and three other patients underwent CAS with reversed-flow system and distal protection (method 2). Two of six patients experienced worsening neurologic symptoms despite medical therapy. All six patients were successfully treated with CAS and showed satisfactory patency of the artery. Embolic lesions were detected on diffusion-weighted MRI after the procedure in all patients treated with method 1 but not in patients treated with method 2. Complications included stent thrombosis (n=1) and in-stent thrombus (n=1). All six patients achieved a modified Rankin Scale 1 or 2 classification at 30 days after stenting. In conclusion, CAS was feasible for stenosis even with intraluminal thrombus. Use of method 2 for this condition may reduce the incidence of thromboembolic events although our series was small in number.

Patency of perforating arteries after stent placement? A study using an in vivo experimental atherosclerosis-induced model.

BACKGROUND AND PURPOSE: The recent advent of flexible stents has enabled their application in intracranial atherosclerotic disease. However, it is unclear whether perforating artery occlusion occurs after stent placement in atherosclerotic stenotic vessels. We investigated this issue by using experimental atherosclerosis-induced rabbits. METHODS: A stainless steel balloon-expandable stent was deployed into the atherosclerosis-induced abdominal aorta across the lumbar artery in six New Zealand white rabbits. This model system is suitable because the diameter of the abdominal aorta is similar to that of human intracranial arteries. We evaluated the patency of the lumbar artery by using angiography and scanning electron microscopy (SEM) 3 months after stent placement. Histopathologic evaluation also was performed in one rabbit. RESULTS: The lumbar artery was patent in five of six rabbits per angiography. The lumbar artery was occluded with an intraluminal thrombus in one rabbit. However, SEM findings demonstrated that the stent struts were covered completely with a thick neointima and the ostium of the lumbar artery became narrowed in all cases. In the one lumbar artery that was occluded at angiography, histopathologic findings confirmed that intraluminal thrombus surrounded the stent struts crossing the ostium. CONCLUSION: We observed luminal narrowing after stent placement in an atherosclerotic stenotic vessel, although patency of the perforating arteries was generally maintained.

Endovascular therapy for acute thrombotic occlusion of the intracranial artery.

The goal of this study was to evaluate the efficacy of endovascular therapy for acute thrombotic occlusion. Six patients with acute thrombotic occlusion in the middle cerebral or basilar arteries underwent treatment with intra-arterial thrombolysis, followed by assessment of residual stenosis. If residual stenosis was greater than 70%, percutaneous transluminal angioplasty (PTA) was performed in the same session; otherwise, patients were anticoagulated, and PTA was performed several days later. Successful recanalization was achieved in five of six patients. One patient died of massive infarction, because of the failure of recanalization of the M1 segment. At discharge, modified Rankin scale distribution of the patients was: grade 0, one patient; grade 1, one patient; grade 2, two patients; grade 3, one patient; grade 6, one patient. Retreatment was required via PTA or stenting in two patients in which type C stenosis was present. In conclusion, endovascular therapy for acute thrombotic occlusion of an intracranial artery appears to be effective compared to conservative therapy. However, further refinement of the technique is required to prevent various complications, including vessel perforation, dissection, perforating artery occlusion and restenosis.

Basic fibroblast growth factor released from a platinum coil with a polyvinyl alcohol core enhances cellular proliferation and vascular wall thickness: an in vitro and in vivo study.

OBJECTIVE: We developed a new type of platinum coil that has a polyvinyl alcohol (PVA) core to absorb and release various biologically active materials for the endovascular treatment of intracranial aneurysms. We evaluated its efficacy as an embolic material with basic fibroblast growth factor (bFGF) in an in vitro and in vivo study. METHODS: A small PVA thread was inserted into the central space of the primary coil. This coil was named the PVA-core coil. Ten-millimeter segments of the PVA-core coil were used in this study. PVA-core coils were immersed in a bFGF solution for 1 hour. The PVA-core coil, which absorbed bFGF in the PVA-core, was named the FGF-core coil. Initially, the dose of bFGF released from the PVA core into saline was measured by performing an enzyme-linked immunosorbent assay. In the in vitro study, FGF-core coils, PVA-core coils, and unmodified coils were cultured with fibroblasts (NIH3T3), and then their surfaces were observed with electron microscopy. In the in vivo study, each coil was implanted into a rat common carotid artery. The rats were killed, and the arterial lumen was histologically examined at 14 and 28 days after coil implantation. RESULTS: BFGF was released from the PVA core into saline within 24 hours by performing an enzyme-linked immunosorbent assay. Electron microscopic findings demonstrated remarkable cellular adhesion to the surfaces of the FGF-core coils, but no adhesion to the surfaces of the PVA-core coils and the unmodified coils was found. Histologically, remarkable cell proliferation in the vascular lumen was demonstrated in the common carotid arteries of the FGF-core coil implantation group at the 14th and 28th days. Cellular components proliferated around the implanted coil, and these components mainly stained blue with Masson trichrome. These changes did not occur in the PVA-core coil group and the unmodified coil group. CONCLUSION: We suggest that FGF-core coils may be effective in inducing fibrotic changes inside aneurysms. These coils may be used as an embolic material to cure cerebral aneurysms.

Results of endovascular treatment of internal carotid artery stenoses with a newly developed balloon protection catheter.

OBJECTIVE: A new balloon protection catheter to prevent distal emboli during internal carotid artery percutaneous transluminal angioplasty and stenting was developed, and its efficacy was evaluated in both an experimental model and clinical cases. METHODS: The balloon protection catheter was navigated over a steerable 0.014-inch guidewire to negotiate tight stenoses and sharp bends, which would cause difficulties for the passage of a flow-directed balloon catheter. Percutaneous transluminal angioplasty and stenting were performed for 85 consecutive patients with 87 stenotic lesions of the cervical internal carotid artery, with two different methods using this protection system. Distal protection was provided only after dilation for the initial 38 lesions (Group I), but the latter 49 lesions were treated in both the pre- and postdilation periods (Group II). The effects of using the balloon protection catheter with the embolic debris clearance technique were evaluated with pre- and postoperative magnetic resonance imaging for each group. RESULTS: The balloon protection catheter was introduced beyond the stenosis in all cases. In Group I, one symptomatic embolic stroke was caused by distal embolization resulting from atheromatous plaque, and high-intensity areas appeared on diffusion-weighted magnetic resonance imaging scans in 47% of cases. In contrast, in Group II, there were no strokes related to the procedure, although one patient with multiple risk factors died suddenly on the second day after stenting. Diffusion-weighted imaging scans demonstrated small, high-intensity areas in 19% of cases in Group II. The overall morbidity/mortality rate in our series was 2.3%. CONCLUSION: Our new balloon protection catheter was reliably navigated across internal carotid artery stenoses and reduced distal embolism in clinical cases.

Endovascular therapy for stenosis of the petrous or cavernous portion of the internal carotid artery: percutaneous transluminal angioplasty compared with stent placement.

OBJECT: The effects of percutaneous transluminal angioplasty (PTA) and stent placement for stenosis of the petrous or cavernous portion of the internal carotid artery (ICA) were compared. METHODS: Twenty-four patients with symptomatic, greater than 60% stenosis of the petrous or cavernous portion of the ICA were treated using PTA or stent placement; 15 were treated with PTA and nine with stent insertion. Initial and follow-up results (> 3 months posttreatment) were compared in each group. Stenotic portions of the ICA were successfully opened in 13 of 15 patients in the PTA group, and in all nine patients in the stent-treated group. In one case in the PTA group stent delivery was attempted; however, the device could not pass through the vessel's tortuous curve, and PTA alone was performed in this case. Postoperatively, the mean stenotic ratio decreased from 72.1 to 29.6% in the PTA group, and from 75.6 to 2.2% in the stent-treated group. In four patients in the PTA group, stenoses greater than 50% were demonstrated on follow-up angiography performed at 3 to 6 months after PTA. In the stent-treated group, no restenosis was encountered, although in one case acute occlusion of the stent occurred; the device was recanalized with PTA and infusion of tissue plasminogen activator. This case was the only one of the 24 in which any neurological deficits related to the endovascular procedure occurred. Stent placement brought a greater gain in diameter than did PTA at the initial and late follow-up period; this gain was statistically significant. CONCLUSIONS: Stent placement is more effective than PTA for stenosis of the petrous or cavernous portion of the ICA from the viewpoint of initial and late gain in diameter.

Study of the patency of small arterial branches after stent placement with an experimental in vivo model.

BACKGROUND AND PURPOSE: The patency of intracranial perforating arteries after stent placement is unknown despite the general clinical use of intracranial arterial stenting. METHODS: We deployed stainless steel stents in the abdominal aorta across the lumbar artery in eight normal rabbits in which the diameters of the abdominal arterial vessels were similar to those of human intracranial arteries. We evaluated the patency via angiographic and scanning electron microscopic methods 3 months after stent placement. Histopathologic evaluation was also performed for one rabbit. RESULTS: The lumbar arteries were patent, even when stent struts crossed the ostium, except in one rabbit in which intimal dissection occurred intraoperatively. The scanning electron microscopy showed that the regenerative endothelium had grown onto the strut at the ostium of the lumbar artery. CONCLUSION: We confirmed the patency of the lumbar arteries in this study by using normal rabbits. Thus, intracranial stenting may not pose a risk of occluding perforating arteries of the same diameter of the lumbar artery, even if stent struts cover the ostium.

Transient aphasia and persistent amnesia after surgery for internal carotid artery--posterior communicating artery aneurysm.

We report a case of transient aphasia and persistent amnesia after clipping of a ruptured cerebral aneurysm to treat a subarachnoid hemorrhage. Postoperatively, aphasia was identified and magnetic resonance imaging (MRI) showed an abnormal intensity area in the left anterior thalamus. Single photon emission computed tomography (SPECT) revealed a wider area of low perfusion surrounding the left thalamus and left frontotemporal lobe than that shown by the MRI. His aphasia resolved over the subsequent 12-week period. He was left with an isolated disturbance of memory; in the absence of any dementia, aphasia or disturbance of consciousness, his condition was classified as one of amnesia. SPECT 14 weeks after admission revealed an area of low perfusion limited to the left thalamus. These findings suggest that the persistence of amnesia in this case was caused by the infarction of the mammillothalamic tract, and the recovery from aphasia may have resulted from the disappearance of surrounding edema.