Rigid but nonmetallic cranioplasty after pterional craniotomy: Technical note.

Background: Given the popularity of pterional craniotomy, numerous modifications have been made to prevent postoperative deformities. With the advent of titanium plates, fixation has become both simple and excellent. However, titanium plates can cause skin problems, infection, or cause skull growth to fail. Methods: To develop a simple, cost-effective, and esthetically satisfactory fixation method, without the use of non-metallic materials, six young and older patients underwent pterional craniotomy. CranioFix Absorbable clamps were used to fix the bone flap in the frontal and temporal regions such that the frontal part was in close contact with the skull. After fixation, the bone chips and bone dust were placed in the bone gap and fixed with fibrin glue. We measured the computed tomography values of the reconstructed area and thickness of the temporal profiles postoperatively over time. Results: Bone fusion was achieved in all patients by 1 year after surgery. Both the thickness of the temporalis muscle and the thickness of the temporal profile had changed within 2 mm as compared with the preoperative state. Conclusion: Our simple craniotomy technique, gentle tissue handling, and osteoplastic cranioplasty yielded satisfactory esthetic results and rigidness in pterional craniotomy.

Safety of Apixaban Monotherapy for Non-Valvular Atrial Fibrillation-Related Acute Stroke with Intra-/Extracranial Artery Stenosis.

INTRODUCTION: We investigated whether apixaban is safe for the prevention of further adverse events in non-valvular atrial fibrillation (NVAF) patients with intra-/extracranial artery stenosis (Stenosis group) compared with acute large vessel occlusion without intra-/extracranial artery stenosis (No stenosis group). We also examined whether combination therapy using apixaban and antiplatelet is safe. METHODS: ALVO (Apixaban on clinical outcome of patients with Large Vessel Occlusion [LVO] or stenosis) was a historical and prospective multicenter registry at 38 centers in Japan. Patients with NVAF and acute LVO or stenosis who received apixaban within 14 days after onset were included. We conducted the post hoc analysis using the ALVO dataset. We compared patients with stenosis versus those without stenosis in terms of the primary outcome, which was defined as a composite of all-cause death, major bleeding events, and ischemic events 365 days after onset. RESULTS: Of the 662 patients, 54 (8.2%) patients were classified into the Stenosis group, and 104 patients of the total (16%) reached the primary outcome. The cumulative incidence of primary outcome was not significantly different between the No stenosis and the Stenosis groups (hazard ratio [HR] 1.2, 95% confidence interval [CI]: 0.64-2.4; p = 0.52). Even after adjustment for predictive clinical variates, no significant difference in the primary endpoint between the No stenosis and the Stenosis groups was shown (adjusted HR 1.2, 95% CI: 0.59-2.5; p = 0.60). Fifty patients (7.6%) used an antiplatelet with apixaban. Among the Stenosis group patients, the cumulative incidence of the primary outcome was significantly higher among patients treated with an antiplatelet and apixaban (HR 3.5, 95% CI: 1.0-12; p = 0.048). CONCLUSION: Apixaban monotherapy appears safe for the prevention of further adverse events in the Stenosis group patients similar to the No stenosis group patients. Concomitant use of an antiplatelet might not be favorable in patients with stenosis.

Task-specific dystonia in hairdressers: a questionnaire survey and review of the literature.

Hairdresser dystonia is one of the occupational dystonias and task-specific movement disorders occurring as a result of long-term repetitive cutting with scissors. The task-specific dystonia manifests itself as a loss of voluntary motor control during extensive practice of cutting requiring a high level of technical proficiency. The prevalence rate of hairdresser dystonia is not well-known worldwide. A questionnaire regarding dystonia was prepared for hairdressers. After sending the questionnaires to 800 hairdressers by direct mail, 134 answers were received by mail. Five of the 134 were suspected to have hairdresser-associated focal dystonia. Thus, 3.7% of hairdressers might have task-specific dystonia. This report was limited because of the small number of participants. However, this research is valuable because it was difficult to find a patient with suspected dystonia due to concerns related to job security.

Reperfusion Therapy Brings Apixaban Administration Forward in Patients with Nonvalvular Arterial Fibrillation with Anterior Circulation Large Vessel Occlusion or Stenosis.

OBJECTIVE: The initiation of anticoagulant administration after large vessel occlusion (LVO) or stenosis with nonvalvular arterial fibrillation (NAVF) is controversial. We evaluate the timing of anticoagulation and its relationship with clinical factors. METHODS: We enrolled 595 anterior circulation LVO or stenosis with NAVF cases from 38 stroke centers. Laboratory data; activities of daily living; the Alberta Stroke Program Early CT Score (ASPECTS); the National Institutes of Health Stroke Scale (NIHSS) score; occluded artery; treatment methods; date of the initiation of apixaban administration and outcome were recorded. Multivariate analyses were performed after univariate analysis. RESULTS: The median start of apixaban administration after the stroke was 2 days (interquartile range, 1-5; range, 0-14). Multivariate analysis of variance showed that non-internal carotid artery occlusion (F value 4.60), reperfusion therapy (31.1), high ASPECTS (6.27) before anticoagulant intake, and absence of intracranial hemorrhage (12.9) were significantly correlated with early apixaban administration. Multiple logistic regression analysis for independent living at 90 days after the stroke showed significant factors: aging (odds, 0.94; 95% confidence interval [CI], 0.91-0.97); male (odds, 0.46; 95% CI, 0.26-0.79); prestroke independence (odds, 20.7; 95% CI, 6.48-93.9); number of white blood cells (odds, 0.99; 95% CI, 0.97-1.00); non-internal carotid artery occlusion; NIHSS score at 72 hours after the stroke (odds 0.92; 95% CI, 0.89-0.96); ASPECTS before apixaban intake (odds, 1.15; 95% CI, 1.00-1.31) and initiation of apixaban (odds, 0.91; 95% CI, 0.83-0.99). CONCLUSIONS: Early administration of apixaban is induced by nonsevere infarction, reperfusion therapy or none of intracranial hemorrhage and it correlates with an independent long-term outcome.

Evaluation of the Safety and Effectiveness of Coil Embolization for Anterior Communicating and Anterior Cerebral Artery Aneurysms.

Objective: Endovascular coil embolization for anterior communicating artery (ACoA) and anterior cerebral artery (ACA) aneurysms is associated with high total and near-total occlusion rates, but the complication rate is high. The development of newer endovascular technologies may improve the clinical outcomes. This study investigated the status of endovascular treatment of ACoA and ACA aneurysms by comparing our results with past reports. Methods: Between January 2006 and December 2018, we investigated 50 patients who were followed for 12 months or longer to clarify the outcomes of coil embolization. The outcomes of embolization were evaluated using time-of-flight MRA. The safety was evaluated based on procedure-related complications that affected clinical outcomes. Results: Initial assessments demonstrated complete obliteration in 84% (42 of 50 patients) and a residual neck in 14% (7 of 50 patients). Procedure-related complications developed in 12% (6 of 50 patients). The procedure-related morbidity rate was 2% (1 of 50 patients) and there was no procedure-related death. Recanalization was noted in 14% (7 of 50 patients, median follow-up period, 57 months). The recanalized aneurysms were significantly smaller than the stable aneurysms in maximum size (4.3 mm vs. 5.8 mm; p = 0.017) and height (3.7 mm vs. 4.3 mm; p = 0.035). Conclusion: We demonstrated the safety and effectiveness of endovascular coil embolization for ACoA and ACA aneurysms. The small size of aneurysms may be related to recanalization.

Transarterial and Transvenous Coil Embolization of Direct Carotid-Cavernous Fistulas.

Objective: Transvenous embolization (TVE) is typically used in combination with the residual shunt of transarterial embolization (TAE) for the treatment of direct carotid-cavernous fistulas (direct CCFs). This report is about our additional embolization method using combination therapy. Case Presentation: Five consecutive cases of direct CCF were presented; two were caused by aneurysms and three by head injuries. The treatment for each was started with TAE, with the addition of TVE if a shunt remained. At the time of TVE, a microcatheter positioned in the internal carotid artery passing from the cavernous sinus through the aneurysm neck or fistula was pulled back (pull-back method). It was then placed in the coil mass with TAE, and additional coils were filled. In two cases, the shunt disappeared by using only TAE, whereas it disappeared after being additionally embolized by the pull-back method in the remaining cases. All patients recovered with no postoperative complications. Conclusion: The TAE and TVE combination therapy with the pull-back method could efficiently embolize the residual shunt after TAE.

Effect of prior antiplatelet therapy on large vessel occlusion in patients with non-valvular atrial fibrillation newly initiated on apixaban.

INTRODUCTION: We evaluated the effect of prior antiplatelet therapy on large vessel occlusion (LVO) in patients with non-valvular atrial fibrillation (NVAF) newly initiated on apixaban. METHODS: Patients with acute LVO with acute stroke due to NVAF or stenosis with NVAF started on apixaban within 14 days of onset were enrolled. We compared incidence of major bleeding, cerebral hemorrhage, ischemic events, cerebral infarction, and all-cause mortality between patients with and without prior antiplatelet therapy for acute LVO. We also compared these events between patients who continued antiplatelet therapy after onset (continued group) and those who discontinued it (discontinued group). Hazard ratios were estimated after adjusting for confounders; interaction was evaluated considering intravenous thrombolysis (IVT) or endovascular treatment (EVT) according to major bleeding. RESULTS: The study comprised 686 eligible patients (excluded [n = 194]; enrolled [n = 492]). The antiplatelet group consisted of older patients (mean: 79 vs. 76 years; p = 0.006) and had a higher cumulative incidence of major bleeding (7.3% vs. 2.9%, p = 0.003). The incidence of ischemic events and all-cause mortality was similar between the groups. Among the 109 patients in the antiplatelet group, the cumulative incidence of major bleeding, ischemic events, and all-cause mortality was comparable between continued group (n = 26) and discontinued group (n = 83). There were no significant differences between groups with and without IVT/EVT. However, major bleeding occured more frequently in the antiplatelet group without IVT. CONCLUSION: Prior antiplatelet therapy for LVO in patients with NVAF newly initiated on apixaban was associated with major bleeding, which was more frequent in the antiplatelet group without IVT.

Vascular Endothelial Repair and the Influence of Circulating Antiplatelet Drugs in a Carotid Coil Model.

BACKGROUND: Clinicians may choose to administer antiplatelet medications to patients with cerebral aneurysms following endovascular coiling to prevent thrombus formation and vascular occlusion, if they fear a thrombus will form on the platinum wire where it diverges into the vessel from the aneurysm sac. However, the mechanism by which vascular endothelial cells repair a vessel in the living body in the event of a coil deviation and the effects of antiplatelet drugs on these cells have not been fully elucidated. We aimed to investigate the association between endothelial progenitor cells (EPCs) and endothelium formation at the surface of the platinum coils deployed in the carotid artery of rats, and to determine the effects of different antiplatelet drugs on this process. SUBJECTS AND METHODS: We established an experimental model using normal and diabetic rats at 12 months of age. The diabetic rats were assigned to 4 different diet groups, distinguished by whether they were fed plain rat feed, or the same feed supplemented by 1 of 3 antiplatelet drugs (cilostazol, aspirin, or clopidogrel: all 0.1%) for 2 weeks, and the carotid artery was perforated by an embolization coil ("carotid coil model"). We monitored the process by which vascular endothelial cells formed the new endothelium on the surface of the coil by sampling and evaluating the region at 1, 2, and 4 weeks after placement. This repair process was also compared among 3 groups treated with different antiplatelet drugs (i.e. aspirin, clopidogrel, and cilostazol). One-way analysis of variance tests were performed to evaluate the differences in vascular thickness between groups, and P < .05 was considered statistically significant. RESULTS: The diabetic rats showed delayed neoendothelialization and marked intimal hyperplasia. Cilostazol and clopidogrel effectively counteracted this delayed endothelial repair process. Flk1 immunostaining revealed greater expression in the diabetic rats administered cilostazol, second only to normal rats, suggesting that this agent acted to recruit EPCs. CONCLUSION: Neoendothelialization is delayed when vascular endothelial cells fail to function normally, which consequently leads to the formation of hyperplastic tissue. Cilostazol may remedy this dysfunction by recruiting EPCs to the site of injury.

Safety of Early Administration of Apixaban on Clinical Outcomes in Patients with Acute Large Vessel Occlusion.

Early administration of direct oral anticoagulants in patients with acute large vessel occlusion (LVO) and nonvalvular atrial fibrillation (NVAF) is a concern, as endovascular therapy (EVT) became highly utilized. We conducted a historical and prospective multicenter registry at 38 centers in Japan from July 2016 to February 2018. Patients aged ≥ 20 years with NVAF and acute LVO or stenosis who received apixaban within 14 days from onset were included. We compared patients who received apixaban < 48 h (Early group) and ≥ 48 h (Late group) after onset in terms of the primary outcome (a composite of ischemic events, major bleeding events, and all-cause deaths). The secondary outcomes were each component of the primary outcome. Among the 686 patients, the median time from onset to administration was 2.5 days (range, 0-14; Early 263, Late 423). The Alberta Stroke Program Early CT Score (ASPECTS) and diffusion-weighted imaging (DWI)-ASPECTS) were significantly higher in the Early group than in the Late group. Recombinant tissue plasminogen activator (rt-PA) and EVT were more utilized in the Early group (rt-PA 46% vs. 35%, p = 0.003; EVT 62% vs. 46%, p < 0.0001). The cumulative incidence of primary outcome was similar between groups (ischemic events: Early 1.9% vs. Late 0.5% at 30 days; 3.5% vs. 0.7% at 90 days, major bleeding 3.4% vs. 2.9% at 30 days; 5.0% vs. 3.4% at 90 days). Early administration of apixaban (< 48 h), after onset of acute LVO in patients with NVAF, was generally safe compared with those who received it Late (≥ 48 h). http://www.clinicaltrials.gov . Unique identifier: NCT02818868 (June 30, 2016).

Usefulness of contralateral carotid angiography in revascularization therapy of acute internal carotid artery occlusion.

OBJECTIVE The vascular lumen of an acutely occluded internal carotid artery (ICA) generally contains numerous thrombi. Therefore, carotid angiography on the affected side during revascularization therapy of acute ICA occlusion has a potential risk of causing distal embolization. In this study the authors propose the use of contralateral carotid angiography. METHODS Six patients with acute ICA occlusion underwent revascularization therapy using a stent retriever or Penumbra system. Revascularization therapy was performed with placement of a 9-Fr balloon-guiding catheter (BGC) in the affected ICA and a 4-Fr diagnostic catheter in the contralateral ICA. During the procedure, the 9-Fr BGC was kept inflated, and all control angiography was performed from the 4-Fr diagnostic catheter. After thrombectomy, contralateral carotid angiography combined with manual aspiration from the 9-Fr BGC was performed to assess the presence or absence of residual thrombi in the affected ICA. The 9-Fr BGC was deflated only after the complete absence of residual thrombi in the affected ICA was confirmed. RESULTS The time required for introducing the 4-Fr diagnostic catheter into the contralateral ICA was within a few minutes in all patients. Residual thrombi in the affected ICA were found in 3 of 6 patients. The residual thrombi in these 3 patients were completely removed; thus, distal embolization was prevented. CONCLUSIONS Contralateral carotid angiography is useful for avoiding distal embolization during revascularization therapy of acute ICA occlusion. Further studies involving a larger number of patients are warranted to verify the clinical efficacy of this contralateral carotid angiography.

Urgent Carotid Artery Stenting for Carotid-Related Stroke-in-Evolution.

BACKGROUND: Stroke-in-evolution (SIE) is a major outcome determinant in patients with acute ischemic stroke. The benefit of surgery for treatment of carotid artery-related SIE remains controversial. OBJECTIVE: To retrospectively evaluate the use of carotid artery stenting (CAS) as a possible alternative treatment in patients with carotid-related SIE. METHODS: Ten patients with carotid-related SIE were treated with CAS from May 2005 to December 2014. The mean initial National Institutes of Health Stroke Scale (NIHSS) score was 5.4 ± 4.4. Two patients had total occlusion of the internal carotid artery, and 8 had severe stenosis. The mean interval from symptom onset to clinical deterioration was 2.9 ± 2.9 d. The mean NIHSS score after deterioration was 14.3 ± 4.5. In the hemodynamic assessment using perfusion imaging, the ipsilateral cerebral hemodynamics was impaired in 7 of 8 patients. RESULTS: All patients underwent urgent CAS in the acute phase of SIE. Seven patients underwent CAS using flow reversal with or without distal protection. No procedure-related complications occurred in any patients, although 1 patient developed aspiration pneumonia. The mean NIHSS score 7 d after CAS was 4.8 ± 2.3. Six patients (60%) had a modified Rankin scale score of 0 to 2 at discharge. CONCLUSION: Urgent CAS for carotid-related SIE with hemodynamic impairment appears to be an effective method for achieving good clinical outcomes.

Transfemoral Stenting of Stenoses at the Common Carotid Artery Origin Using an Anchoring Technique With a Balloon Protection Device.

BACKGROUND: Transfemoral stenting of stenoses at the common carotid artery (CCA) origin is technically difficult because of poor stability of the guiding catheter. OBJECTIVE: To describe an anchoring technique using a balloon protection device that provides excellent stability of the guiding catheter. METHODS: Four patients (5 stenotic lesions) with stenosis of the CCA origin underwent transfemoral stenting with a balloon protection device (PercuSurge GuardWire; Medtronic, Santa Rosa, California). These 5 stenotic lesions of the CCA origin included 1 on the right side and 4 on the left side. Two of the stenoses were symptomatic, and 3 were asymptomatic. A balloon-expandable stent (Express LD stent; Boston Scientific, Natick, Massachusetts) was used in all patients. RESULTS: All stenoses were successfully dilated. With the balloon protection device as an anchor in all patients, the guiding catheter was highly stable during the procedure. There were no intraprocedural or periprocedural ischemic complications in any patients. None of the patients developed a stroke during a mean follow-up period of 8.4 months. CONCLUSION: The anchoring technique using a balloon protection device is useful for transfemoral stenting of stenoses at the CCA origin. ABBREVIATIONS: CCA, common carotid arteryECA, external carotid arteryICA, internal carotid arteryPTA, percutaneous transluminal angioplasty.

A novel technique for identifying the fistulous point in a direct carotid-cavernous fistula.

The fistulous point in a direct carotid-cavernous fistula (CCF) can often be difficult to identify because of high-flow shunting. A novel technique that is useful for identifying the fistulous point is reported. A 71-year-old woman underwent endovascular therapy for a left direct CCF that presented with sudden diplopia and tinnitus. To identify the fistulous point, vertebral angiography with manual compression of the left carotid artery was attempted, as was slow injection of a contrast agent from a balloon guiding catheter, closing off the left internal carotid artery; however, the shunt flow was very rapid, and identification was not possible. Therefore, three-dimensional digital subtraction angiography of the vertebral artery was performed while also performing manual aspiration from the balloon guiding catheter, closing off the left internal carotid artery. This reduced early visualization of the cavernous sinus and enabled an aneurysm in the cavernous sinus to be clearly visualized. Embolization was performed transarterially and transvenously, and the shunt flow disappeared completely. Vertebral angiography combined with manual aspiration from a balloon guiding catheter closing off the internal carotid artery is useful for identifying the fistulous point in a direct CCF.

Overlapped Stenting for Treatment of an Extracranial Carotid Artery Aneurysm.

Extracranial carotid artery aneurysms (ECAAs) are rare, and their treatment is very difficult and challenging. The case of a 59-year-old woman who presented with a pulsatile mass on the left side of her neck, was diagnosed with a left-sided giant thrombosed common carotid artery aneurysm, and underwent definitive treatment by overlapped stenting, is presented. Overlapped stenting is a safe and an effective treatment procedure for ECAA. A covered stent would theoretically be reasonable and immediately effective, but its long-term patency remains unknown. Therefore, in patients lacking ischemic tolerance and those not requiring urgent intervention, overlapped stenting using uncovered stents is preferable.

Spontaneous closure of a dural arteriovenous fistula immediately after cerebral angiography using a gadolinium contrast agent.

Gadolinium (Gd) contrast agents have been used instead of iodinated contrast agents in patients in whom iodine is contraindicated, but cerebral angiography of a dural arteriovenous fistula (dAVF) using a Gd contrast agent has not previously been reported. We recently performed cerebral angiography using a Gd contrast agent in a patient with an anterior condylar confluence dAVF who was allergic to iodine. To our surprise, there was spontaneous closure of the dAVF immediately after angiography. We now report what we believe is the first such case report.

Endovascular microcatheter provocation test for the diagnosis of glossopharyngeal neuralgia.

OBJECTIVE: Glossopharyngeal neuralgia (GN) is a rare disease often clinically misdiagnosed as trigeminal neuralgia. An endovascular provocative test has been applied to assist in making the diagnosis of GN caused by vascular compression. We similarly used endovascular provocative techniques to identify the causative vessel and to evaluate the indication for microvascular decompression (MVD) in two patients. METHODS: Two patients had severe retroauricular and pharyngeal pain that could not be controlled by medical therapy. Magnetic resonance imaging and magnetic resonance angiography showed a high-riding right posterior inferior cerebellar artery (PICA). We decided to apply the endovascular provocation test to prove the assumed GN and identify potential indications for MVD. RESULT: A loop of the PICA appeared to compress the glossopharyngeal nerve in the first patient. In this patient, a microcatheter was inserted into the right PICA, decreasing the GN. The patient underwent MVD, resulting in complete pain relief. In the second patient, a microcatheter was inserted into the right PICA, and an attack of typical GN occurred, with pain in the posterior region of the tongue, tonsils, oropharynx, and larynx. The patient's severe pain was clearly different from this typical GN caused by the microcatheter provocation test, and MVD was not performed. CONCLUSION: The diagnosis of GN is sometimes complex. The endovascular provocative technique may allow identification of GN caused by vascular compression.

Neuromodulation using intrathecal baclofen therapy for spasticity and dystonia.

Intrathecal baclofen (ITB) therapy is a treatment for intractable spasticity due to a variety of causes. Continuous intrathecal administration of baclofen, an agonist of the inhibitory neurotransmitter γ-aminobutyric acid, inhibits excitation of motor neurons at the spinal level and thus suppresses spasticity. This therapy was introduced clinically in the Europe and the United States in the 1990s, and was finally approved by the Japanese Ministry of Health, Labour and Welfare in Japan in 2005. Clinical use has been permitted since 2006, and reports of therapeutic efficacy are now appearing in Japan. ITB therapy is a non-destructive treatment that enables administration of baclofen from an implantable pump under the control of a programmer, and represents an outstanding treatment method offering both reversibility and adjustability. Indications for ITB therapy have been expanding in recent years to include not only spasticity, but also various causes dystonia. And ITB therapy can greatly improve activities of daily living and quality of life, and this treatment is attracting attention as a neuromodulatory therapy that also affects metabolic and respiratory functions and even state of consciousness. We here report the surgical methods and therapeutic outcomes for 22 patients who underwent ITB therapy for spastic and dystonic patients in our hospital, together with an investigation of the effects on metabolic and respiratory functions.

Spinal syringomyelia following subarachnoid hemorrhage.

Subarachnoid blood has been reported as a cause of chronic spinal arachnoiditis. Although syringomyelia has been thought to be caused by spinal arachnoiditis, reports of syringomyelia following aneurysmal subarachnoid hemorrhage (SAH) are very rare. We describe two patients with syringomyelia associated with chronic spinal arachnoiditis following SAH. From January 2001 to December 2010, 198 patients with aneurysmal SAH were treated at Kinki University School of Medicine. Two of the 198 patients had syringomyelia following aneurysmal SAH; thus the rate of syringomyelia associated with aneurysmal SAH was 1.0%. Patient 1 was a 54-year-old woman who presented with back pain, back numbness and gait disturbance 20 months after SAH. Her MRI revealed syringomyelia of the spinal cord from C2 to T10. She underwent shunting of the syrinx to the subarachnoid space. Patient 2 was a 49-year-old man, who was admitted to the hospital with headache, diplopia, hoarseness, dysphagia and ataxia five months after SAH. MRI revealed syringomyelia from the medulla oblongata to C6, and an enlargement of the lateral and fourth ventricles. After foramen magnum decompression and C1 laminectomy, a fourth ventricle-subarachnoid shunt was placed by insertion of a catheter. Spinal arachnoiditis and spinal syringomyelia are rare but important chronic complications after SAH.