Optimizing shunt integrity during acute subdural hematoma evacuation.

Background: Even mild head trauma can cause severe intracranial hemorrhage in patients with cerebrospinal fluid (CSF) shunts for hydrocephalus. CSF shunts are considered a risk factor for subdural hematoma (SDH). The management of acute SDH (ASDH) in shunted patients with normal pressure hydrocephalus can be challenging. Addressing the hematoma and the draining function of the shunt is important. To preserve the shunt, we set the shunt valve pressure to the highest and perform hematoma evacuation for ASDH. In this study, we report the surgical cases of ASDH in patients with shunts. Methods: Between 2013 and 2019, five patients with ASDH and CSF shunts underwent hematoma evacuation at our hospital. We retrospectively analyzed data regarding their clinical and radiological presentation, hospitalization course, the use of antithrombotic medications, and response to different treatment regimens. Results: The patients presented with scores of 5-14 in the Glasgow coma scale and severe neurological signs, consciousness disturbance, and hemiparesis. Most patients were elderly, taking antithrombotic medications (four of five cases), and had experienced falls (4 of 5 cases). All patients underwent hematoma evacuation following resetting their programmable shunt valves to their maximal pressure setting and shunt preservation. ASDH enlargement was observed in only one patient who underwent burr-hole drainage. Glasgow outcome scale scores at discharge were 1 and 3, respectively. Conclusion: In hematoma evacuation, increasing the valve pressure may reduce the bleeding recurrence. To preserve the shunt, setting the shunt valve pressure to the highest level and performing endoscopic hematoma evacuation with a small craniotomy could be useful.

Delayed Diagnosis of Temporomandibular Joint Dislocation in Severe Stroke Patients.

A 79-year-old woman with a history of left cerebral infarction developed altered consciousness and left hemiplegia. CT of the head revealed a putaminal hemorrhage. She underwent tracheal intubation followed by a tracheostomy for long-term airway management. Despite improved consciousness, the patient continued to experience dysphagia and was fed via a nasal tube. Subsequent axial CT and 3D CT scans revealed an empty glenoid fossa in both temporomandibular joints (TMJs) with the condyles positioned anteriorly, consistent with chronic bilateral anterior TMJ dislocation. After an unsuccessful attempt at manual reduction, closed manual reduction was successfully performed under general anesthesia with muscle relaxants, allowing the patient to resume oral feeding. This case underscores the importance of considering TMJ dislocation in stroke patients with persistent dysphagia. Early diagnosis and timely intervention are crucial for improving patient outcomes in such cases.

One Puncture, Two Solutions: Simultaneous Carotid and Iliac Artery Stenting.

An 81-year-old man with asymptomatic severe carotid artery stenosis and symptomatic iliac artery stenosis underwent simultaneous carotid artery stenting (CAS) and iliac artery percutaneous transluminal angioplasty and stenting. The procedure involved transfemoral access, balloon angioplasty, and stenting of the right iliac artery, followed by CAS of the right carotid artery. Similar procedures were performed later on the left iliac and carotid arteries. The patient was discharged with no neurological deficits and remained asymptomatic at a six-month follow-up. Simultaneous CAS and iliac artery stenting were feasible and effective in patients with concurrent severe carotid and iliac artery stenosis, providing a comprehensive revascularization strategy for patients with complex atherosclerotic disease.

Delayed Rupture from a Pseudoaneurysm after Mechanical Thrombectomy: A Case Report.

Pseudoaneurysm following mechanical thrombectomy (MT) is a rare but possible complication associated with endovascular procedures. This report presents a case of delayed rupture of a pseudoaneurysm after MT with a stent retriever, which was confirmed by open surgery. During hospitalization, an 85-year-old woman had right hemiplegia and aphasia. Magnetic resonance imaging and angiography revealed acute ischemic changes in the left middle cerebral artery because of M2 segment occlusion. MT was performed to address persistent M2 occlusion. Retrieving from distal vessels with the fully deployed Solitaire 4 × 20 mm stent retriever was considered dangerous, we resheathed the stent, but the microcatheter jumped distally. Angiography through microcatheter revealed contrast leakage into the subarachnoid space. The diagnosis was vessel perforation caused by the microcatheter. The lesion was treated with temporary balloon occlusion for 5 minutes using a balloon-guiding catheter, combined with the reversal of heparin anticoagulation by protamine, and a systolic blood pressure reduction to below 120 mm Hg. Anticoagulation was initiated after confirming that postprocedural subarachnoid hemorrhage (SAH) decreased 1 day after the procedure. Fourteen days after the procedure, computed tomography and angiography revealed a massive hematoma with a newly formed small pseudoaneurysm at the site of vessel rupture. Open surgery was performed to close the small artery rupture using a clip. Delayed rupture of the pseudoaneurysm occurred after MT using a stent retriever. If SAH is observed after MT, performing follow-up computed tomography angiography or magnetic resonance angiography is recommended to consider pseudoaneurysm formation.

A Case of Two-stage Surgery Using Intracranial Pressure Monitoring for Hemorrhagic Infarction during Direct Oral Anticoagulant Medication.

Direct oral anticoagulants (DOACs) are considered to cause a few hemorrhagic complications, including hemorrhagic infarction; these are administered in the acute phase of cerebral infarction for secondary prevention of cerebral embolism. Hemorrhagic infarction with cerebral herniation requires urgent decompressive craniectomy and can become fatal. Perioperative management is challenging because patients are often on antithrombotic therapy. In this study, we report on a case of a 61-year-old man with left-sided hemiparesis and impaired consciousness; he suffered from a hemorrhagic infarction with cerebral herniation during oral DOAC treatment after endovascular recanalization for the middle cerebral artery occlusion. As the patient was on apixaban for <3 h, performing decompressive craniectomy was considered difficult to stop hemostasis. We then opted to perform a small craniotomy to remove the hematoma, control the intracranial pressure (ICP), and administer fresh frozen plasma. We waited for the effect of apixaban to diminish before performing decompressive craniectomy. Gradually, his level of consciousness was noted to improve. Hemorrhagic cerebral infarction while on DOAC medications can be safely treated with small craniotomy and ICP monitoring followed by decompressive craniectomy. Thus, this case highlights the value of staged surgery under ICP monitoring in the absence of an immediate administration of DOAC antagonists.

Endoscopic-assisted removal of bilateral traumatic intracerebral hemorrhage: A case report.

Background: Decompressive craniectomy or craniotomy is an effective method for reducing intracranial pressure in patients with traumatic brain injury. However, contralateral intracranial hematoma is a rare but serious complication. Recently, the endoscopic technique has been described as a minimally invasive, safe, and effective treatment for intracranial hematoma evacuation. To the best of our knowledge, no technical report has described bilateral traumatic intracerebral hemorrhage (TICH) evacuation using a neuroendoscope. Case Description: A 62-year-old man was admitted to the hospital after a fall due to intoxication. His initial Glasgow Coma Scale (GCS) score was 14. Initial computed tomography (CT) revealed a right temporal skull fracture, bilateral frontal and right temporal tip contusions, and acute subdural hematoma. During admission, his condition deteriorated to a GCS score of 6 points, and follow-up CT showed hemorrhagic progression of left frontal and right temporal contusion with midline shift and brainstem compression. Emergency surgery was performed for TICH in the left frontal lobe and right temporal lobe. A burr hole was made in each of the left frontal and right temporal regions, and we used a neuroendoscope to assist in the evacuation of the hematoma. Postoperative CT showed adequate evacuation of the hematoma. The patient regained consciousness and was discharged after 2 months. Conclusion: Bilateral TICH was rapidly and sequentially removed by burr-hole craniotomy and endoscopic hematoma evacuation without rapid decompression by craniotomy. The hematoma did not increase. This report demonstrates that the endoscopic-assisted technique allows the safe treatment of bilateral TICH.

Endoscopic hematoma evacuation for acute subdural hematoma with improvement of the visibility of the subdural space and postoperative management using an intracranial pressure sensor.

Background: The first choice to treat acute subdural hematoma (ASDH) is large craniotomy under general anesthesia. However, increasing age or the comorbid burden of patients may render invasive treatment strategy inappropriate. These medically frail patients with ASDH may benefit from a combination of small craniotomy and endoscopic hematoma removal, which is less invasive. We proposed covering with protective sheets to prevent brain injury due to contact with the endoscope and suction cannula and improve visualization of the subdural space. Moreover, we placed an intracranial pressure (ICP) sensor after endoscopic hematoma removal. In this article, we attempted to clarify the use of small craniotomy evacuation with endoscopy for ASDH. Methods: Between January 2015 and December 2019, nine patients with ASDH underwent hematoma evacuation with endoscopy at our hospital. ASDH was removed using a suction tube with the aid of a rigid endoscope through the small craniotomy (5-6 cm). Improvement of the clinical symptoms and procedure-related complications was evaluated. Results: No procedure-related hemorrhagic complications were observed. The outcomes of our endoscopic surgery were satisfactory without complications or rebleeding. The outcomes were not inferior to those of other reported endoscopic surgeries. Conclusion: The results suggest that small craniotomy evacuation with endoscopy and postoperative management using an ICP sensor is a safe, effective, and minimally invasive treatment approach for ASDH in appropriately selected cases.

Prevalence of idiopathic normal pressure hydrocephalus in patients with vertebral compression fractures.

Background: Patients with idiopathic normal pressure hydrocephalus (iNPH) may be more prone to all fracture types due to falls. Vertebral compression fractures (VCFs) are a global burden that temporarily or permanently affects millions of elderly people. This study aimed to investigate the prevalence of iNPH in patients with VCFs. Methods: We retrospectively reviewed 128 patients aged 60-102 years who underwent balloon kyphoplasty (BKP) for VCFs between November 1, 2017, and March 31, 2020. We also assessed the presence of the iNPH triad (i.e., gait disturbance, cognitive impairment, and urinary incontinence). Patients with Evans' index (EI) >0.3 and the iNPH triad were defined as having possible iNPH, those with clinical improvement after a cerebrospinal fluid tap test were defined as having probable iNPH, and those with clinical improvement after a shunt surgery were defined as having definite iNPH. Results: Of the 128 patients, seven were excluded due to a history of intracranial disease that could cause ventricular enlargement or gait disturbance. Another 70 patients who did not undergo head computed tomography or magnetic resonance imaging one year before or after BKP were excluded from the study. Finally, 51 patients with a mean age of 78.9 years were enrolled. The mean EI value of these 51 patients was 0.28, with 18 patients showing EI >0.3. Moreover, 18 had possible iNPH, one had probable iNPH, and one had definite iNPH. Conclusion: Screening for iNPH in elderly patients with VCFs can allow early diagnosis of iNPH and benefit them more from surgical treatment.

Creating of "fascial sheath" around subcutaneous lumboperitoneal shunt catheters largely prevents postoperative subcutaneous shunt catheter migration.

Background: Spinal catheter migration into the subcutaneous tissue is common after lumboperitoneal shunt (LPS) placement. This study proposed a new method (i.e., wrapping fascia around the catheter like a sheath) to prevent LPS spinal catheter migration. Methods: After a LPS spinal catheter was inserted under routine fluoroscopic guidance, and the paravertebral muscle fascia was closed, the fascia was sutured to wrap the catheter like a sheath using intermittent sutures. Results: Before the introduction of this technique, the rate of LPS spinal catheter subcutaneous migration was 4.6%. In this study, following LPS shunt placement in 18 consecutive patients with normal pressure hydrocephalus, no further spinal catheter migrations were observed. Conclusion: This novel method of "wrapping the LPS catheter with intermittent suture like a sheath" was found to be safe and effective for preventing further spinal catheter subcutaneous migration.

Incidence of radiculopathy following lumboperitoneal shunt placement without fluoroscopy for normal pressure hydrocephalus.

Background: Spinal catheter insertion in lumboperitoneal shunt (LPS) surgery for normal pressure hydrocephalus (NPH) can result in radiculopathy due to mechanical irritation of the nerve roots of the cauda equina. Here, we analyzed the position of LPS shunts placed without portable fluoroscopy in 72 patients, a subset of whom developed postoperative radiculopathy. Methods: We retrospectively analyzed how frequently 72 consecutive NPH patients experienced radiculopathy following LPS catheter placement performed without intraoperative fluoroscopy. Results: The rate of incorrect catheter placement was 15.3% (11/72 cases). We observed that is, downward placement in 6.9% (5/72 cases), hyperflexion in 6.9% (5/72 cases), and subcutaneous migration in 1.4% (1/72 cases) patients. One patient with initial correct LPS placement developed radicular pain 5-day postoperatively attributed to 1-cm of catheter movement; they recovered simply by utilizing oral analgesics for 1-month duration. Conclusion: LPS insertion without fluoroscopic guidance resulted in a 15.3% risk of spinal catheter displacement. We suggest, therefore, that intraoperative imaging guidance be utilized for the placement of LPS in patients with NPH and/or for other pathology to avoid the 15.3% risk of postoperative radiculopathy.

Rapid Change in Shape of Unruptured Intracranial Aneurysm with Acute Perforating Infarction.

Acute ischemic stroke is a rare complication resulting from an unruptured intracranial aneurysm (UIA). Ischemic stroke adjacent to the aneurysms is considered the risk of rupture of aneurysms. However, there is presently no consensus on the optimal strategy for the management of UIAs with ischemic stroke. A 27-year-old woman presented with sudden onset left hemiparesis. Acute infarction of the right basal ganglia and an aneurysm of the right middle cerebral artery were discovered on brain imaging. Antiplatelet therapy was used to treat her. The diagnosis revealed ischemic stroke caused by a thrombosed aneurysm due to the change in the shape of the aneurysm on day 4. The UIA clipping procedure was performed on day 21 due to the risk of subarachnoid hemorrhage (SAH). The findings of the surgery and indocyanine green imaging revealed a partially thrombosed aneurysm and occlusion of a perforating artery. As is well known, enlargement of aneurysm size indicates increasing rupture risk. In the present case, after ischemic events developed, magnetic resonance angiography revealed enlargement of the aneurysm. The findings of the surgery revealed possible pathogenic mechanisms were perforating artery occlusion due to local extension of the luminal thrombus. Clinicians should be aware of the risk of ischemic stroke due to luminal thrombosis of the UIA and SAH and should consider urgent treatment of the UIA even immediately after ischemic stroke.

[Lumbo-peritoneal Shunt Ventral Catheter Placement Using the Lateral Approach without Repositioning].

We reported 10 cases of lumbo-peritoneal(L-P)shunt placement using the lateral approach without repositioning. Each patient was placed in a left lateral position under general anesthesia and fixed so that the spine did not rotate. The skin incision on the flank was made at the height of the L4 vertebral body, 4 cm in the left-right direction and 3cm in front of the vertebral body. The external oblique, internal oblique, and transverse abdominal muscles were dissected to reach the peritoneum and confirm that the intestinal tract was peristaltic below the peritoneum. The peritoneum was lifted with hooked tweezers in order to separate them from the intestinal tract, and the peritoneum was incised with a scalpel to reach the peritoneal cavity. Using a finger and a shunt passer, the ventral catheter was guided between the muscle layers. Preoperative abdominal CT showed that all 10 kidneys in this case series were cephalic from the predicted approach route. The ascending colons of three patients were partially in contact with the predicted approach route. During surgery, a ventral catheter could be inserted in all 10 cases. Postoperative abdominal CT showed no intraperitoneal hemorrhage or invasion into the retroperitoneal cavity of the ventral catheter. During the follow-up period, no invasion into the abdominal wall or infection was observed. The average operation time was 52.2 minutes. In order to avoid invasion into the retroperitoneal cavity, a surgical incision was performed without complications by incising the outer side of the lower abdomen and approaching via the external oblique aponeurosis.

Association between Pericytes in Intraplaque Neovessels and Magnetic Resonance Angiography Findings.

(1) Background: Pericytes are involved in intraplaque neovascularization of advanced and complicated atherosclerotic lesions. However, the role of pericytes in human carotid plaques is unclear. An unstable carotid plaque that shows high-intensity signals on time-of-flight (TOF) magnetic resonance angiography (MRA) is often a cause of ischemic stroke. The aim of the present study is to examine the relationship between the pericytes in intraplaque neovessels and MRA findings. (2) Methods: A total of 46 patients with 49 carotid artery stenoses who underwent carotid endarterectomy at our hospitals were enrolled. The patients with carotid plaques that were histopathologically evaluated were retrospectively analyzed. Intraplaque hemorrhage was evaluated using glycophorin A staining, and intraplaque neovessels were evaluated using CD34 (Cluster of differentiation) stain as an endothelial cell marker or NG2 (Neuron-glial antigen 2) and CD146 stains as pericyte markers. Additionally, the relationships between the TOF-MRA findings and the carotid plaque pathologies were evaluated. (3) Results: Of the 49 stenoses, 28 had high-intensity signals (TOF-HIS group) and 21 had iso-intensity signals (TOF-IIS group) on TOF-MRA. The density of the CD34-positive neovessels was equivalent in both groups. However, the NG2- and CD146-positive neovessels had significantly higher densities in the TOF-HIS group than in the TOF-IIS group. (4) Conclusion: The presence of a high-intensity signal on TOF-MRA in carotid plaques was associated with intraplaque hemorrhage and few pericytes in intraplaque neovessels. These findings may contribute to the development of new therapeutic strategies focusing on pericytes.

Possible involvement of pericytes in intraplaque hemorrhage of carotid artery stenosis.

OBJECTIVEIntraplaque hemorrhage (IPH) is most often caused by the rupture of neovessels; however, the factors of intraplaque neovessel vulnerability remain unclear. In this study, the authors focused on pericytes and aimed to investigate the relationship between IPH and pericytes.METHODSThe authors retrospectively analyzed the medical records of all patients with carotid artery stenoses who had undergone carotid endarterectomy at their hospitals between August 2008 and March 2016. Patients with carotid plaques that could be evaluated histopathologically were eligible for study inclusion. Intraplaque hemorrhage was analyzed using glycophorin A staining, and patients were divided into the following 2 groups based on the extent of granular staining: high IPH (positive staining area > 10%) and low IPH (positive staining area ≤ 10%). In addition, intraplaque neovessels were immunohistochemically evaluated using antibodies to CD34 as an endothelial cell marker or antibodies to NG2 and CD146 as pericyte markers. The relationship between IPH and pathology for intraplaque neovessels was investigated.RESULTSSeventy of 126 consecutive carotid stenoses were excluded due to the lack of a specimen for histopathological evaluation; therefore, 53 patients with 56 carotid artery stenoses were eligible for study inclusion. Among the 56 stenoses, 37 lesions had high IPH and 19 had low IPH. The number of CD34-positive neovessels was equivalent between the two groups. However, the densities of NG2- and CD146-positive neovessels were significantly lower in the high IPH group than in the low IPH group (5.7 ± 0.5 vs. 17.1 ± 2.4, p < 0.0001; 6.6 ± 0.8 vs. 18.4 ± 2.5, p < 0.0001, respectively).CONCLUSIONSPlaques with high IPH are associated with fewer pericytes in the intraplaque neovessels. This finding may help in the development of novel therapeutic strategies targeting pericytes.

[Non-cirrhotic Portal-systemic Encephalopathy with Total Aphasia and Right Hemiplegia Following Transient Right Hemiparesis: A Case Report].

A 77-year-old right-handed woman without any liver diseases was admitted to our hospital because of transient right hemiparesis. She developed total aphasia with right hemiplegia on the third hospital day. We suspected that she had a cerebral infarction following a transient ischemic attack. However, brain diffusion-weighted images revealed no abnormal-intensity lesions, and cerebral angiography showed patent arteries. Additionally, her serum ammonia level was elevated. Theta waves without triphasic waves were detected by electroencephalogram. T1-weighted magnetic resonance brain images revealed high-intensity signals in the bilateral globus pallidus. Enhanced abdominal computed tomography showed a portal-systemic shunt from the splenic and inferior mesenteric veins into the left renal vein via the left ovarian vein. The administration of branched-chain amino acids and lactulose improved her clinical symptoms. We confirmed the diagnosis of non-cirrhotic portal-systemic encephalopathy (NCPSE), therefore balloon-occluded retrograde transvenous obliteration of the shunt vessel was performed. The recognition of NCPSE on the examination of a suspected stroke patient is important, as patients with NCPSE can present as stroke mimics. (Received June 26, 2017; Accepted August 22, 2017; Published February 1, 2018).