Alternative Proximal Protection Method during Carotid Artery Stenting Using Combined Transbrachial and Transradial Artery Approaches.

Herein, we report a case of carotid artery stenting with proximal flow protection for severe stenosis of the left internal carotid artery using transbrachial and transradial artery approaches. Because an abdominal aortic aneurysm was present, we avoided the transfemoral approach. The procedure was successfully performed with a combination of an 8-Fr balloon guide catheter and microballoon catheter on separate axes. No complications such as pseudoaneurysm, thrombosis, or dissection were observed at the puncture site. The patient was discharged without complications and showed good outcomes at 3 months. This technique may offer a useful alternative for patients with severe stenosis who cannot be treated using a femoral artery approach.

Enhancement of the Ivy Sign during an Ischemic Event in Moyamoya Disease.

We herein report a case of increased and expanded ipsilateral ivy sign paralleling the expansion of cerebral infarction in a patient with moyamoya disease. A 67-year-old woman visited our hospital with symptoms of left hemiplegia, left homonymous hemianopia, and left unilateral spatial neglect. Magnetic resonance imaging of the head showed cerebral infarction in the right parietal lobe. In addition, ivy signs were evident on fluid-attenuated inversion recovery imaging. These findings were enhanced by the expansion of cerebral infarction and disappeared once the ischemia resolved, implying hemodynamic changes. As a result of continuing medical treatment without antithrombotic therapy, the patient obtained a good outcome. Treatment for moyamoya disease in the acute phase is considered to require complex knowledge of multiple factors, such as the anatomical background of the individual patient and the progression grade of ischemia.

Plaque Protrusion in a Patient with Left Common Carotid Artery Stenting after Radiation Therapy: A Case Report.

Objective: We report a case of additional carotid artery stenting (CAS) for plaque protrusion occurring after initial CAS for radiation-induced common carotid artery (CCA) stenosis. Case Presentation: A 69-year-old man with a history of radiotherapy for laryngeal cancer presented to our hospital with sudden-onset right hemiparesis. Since vulnerable plaque of the left CCA was considered the embolic source for ischemic stroke, CAS was performed for left CCA stenosis. No perioperative complications were observed and the patient was discharged with a modified Rankin Scale score of 0. However, 1 month after CAS, cerebral embolism recurred. As protruding plaque was found on CTA, additional endovascular treatment was performed with intravascular ultrasonography. He was discharged without complications and showed a good outcome at 3 months. Conclusion: In CCA stenosis after radiotherapy, accelerated arteriosclerosis may cause drug-resistant cerebral embolism and plaque protrusion after CAS, making determination of the treatment strategy difficult. Appropriate treatment options need to be based on individual underlying diseases and plaque instability.

The application of shotgun metagenomics to the diagnosis of granulomatous amoebic encephalitis due to Balamuthia mandrillaris: a case report.

BACKGROUND: Granulomatous amoebic encephalitis (GAE) is an infrequent and fatal infectious disease worldwide. Antemortem diagnosis in this condition is very difficult because clinical manifestations and neuroimaging are nonspecific. CASE PRESENTATION: A 60-year-old Japanese woman was admitted with a chief complaint of left homonymous hemianopsia. Brain-MRI showed extensive necrotizing lesions enhanced by gadolinium, in the right frontal lobe, right occipital lobe, and left parietal lobe. Epithelioid granulomas of unknown etiology were found in the biopsied brain specimens. Shotgun metagenomic sequencing using a next-generation sequencer detected DNA fragments of Balamuthia mandrillaris in the tissue specimens. The diagnosis of granulomatous amoebic encephalitis was confirmed using an amoeba-specific polymerase chain reaction and immunostaining on the biopsied tissues. CONCLUSIONS: Shotgun metagenomics is useful for the diagnosis of central nervous system infections such as GAE wherein the pathogens are difficult to identify.

[A 74-year-old man who underwent carotid artery stenting with symptomatic right internal carotid artery stenosis with congenital agenesis of the left internal carotid artery].

A 74-year-old man visited our hospital with a 1-month history of awareness of wobbling while walking. Head MRI revealed fresh cerebral infarction in the territory of the right middle cerebral artery, and cervical carotid ultrasonography revealed severe stenosis at the origin of the right internal carotid artery. No left internal carotid artery could be confirmed, and no carotid canal was evident on CT of the head, suggesting congenital agenesis of the left internal carotid artery. Carotid artery stenting was performed for the stenosed right internal carotid artery that was refractory to medical treatment, obtaining a good outcome. Patients with congenital internal carotid artery agenesis show unique hemodynamics and anatomical features. Particularly in cases with cerebral infarction, an understanding of the etiology and complicated classification of disease types is needed, in addition to familiarity with comorbidities.