Balloon-Assisted Stent Visualization: A Simple Technique for Precise Measurement of Previously Placed Stent Diameter.

Stent-assisted coil embolization is effective for treating intracranial aneurysms, improving outcomes and reducing recurrence rates. However, accurately measuring the diameter of a previously placed stent during imaging can be challenging due to coil artifacts. This poses difficulties in determining the coil packing and size of additional stents needed during retreatment. In a reported case, the use of a balloon enabled precise assessment of stent deployment. A 50-year-old male with a history of basilar artery-left superior cerebellar artery aneurysm underwent coil embolization, direct clipping, and stent-assisted coil embolization (SAC) over a span of 14 years. However, the aneurysm showed reenlargement over time. To address the recurrence, a balloon was used to assess the previously placed Neuroform Atlas stent. Additional coils were inserted outside the stent, and a Low-profile Visualized Intraluminal Support Blue stent was added. Postoperatively, there were no new neurological issues, and a follow-up magnetic resonance imaging showed no ischemic lesions . Balloon-assisted stent visualization (BASV) may be a useful method in the retreatment of SAC. It has the potential to provide valuable information for treatment planning.

Japan Trevo Registry: Real-world Registry of Stent Retriever Alone or in Combined Therapy with Aspiration Catheter for Acute Ischemic Stroke in Japan.

Endovascular therapy (EVT) for real-world patients after extended time frames is associated with concerns about its efficacy and safety. We conducted a prospective registry at 77 centers between November 2019 and October 2020. The registry criteria included patients treated with Trevo Retriever alone or in combined therapy with an aspiration catheter. The primary outcome was effective reperfusion (thrombolysis in cerebral infarction grade ≥ 2b), the secondary outcome was a modified Rankin scale 0-2 at 90 days, and the safety outcomes were worsening of neurologic symptoms within 24 h postoperatively, intracranial hemorrhage (ICH) within 24 h after EVT and mortality. We also exlpored the difference between patients whose last known well time (LKWT) to a puncture was less than 6 h (0-6 h) and those whose LKWT was 6 h or more but less than 24 h (6-24 h). Among the 1041 patients registered, 1025 patients were analyzed. The mean age was 76.9 years, and 53.6% of the participants were males. The 6-24 h group was 206/998 (20.6%), the median National Institute of Health Stroke Scale (NIHSS) score at admission was 18, and the median Alberta Stroke Program Early CT score was 8. Combined technique as the first pass was used on 817 (79.7%) patients. The primary outcome was 934 (91.1%). The secondary outcome was 433/1021 (42.4%). Symptomatic ICH, any ICH, and mortality were 10/1019 (1.0%), 311/1019 (30.5%), and 75 (7.3%). In the subanalysis, the 6-24 h group was lower in NIHSS (median;18 vs 16), and the secondary outcome was not significantly different in the <6 h group. Even after treatment time expansion, this result was comparable to other Trevo-based trials and nationwide registries.

Ultrasound localization of embolic material to guide resection of brain AVM: Report of two cases.

Background: The Spetzler-Martin Grade (SMG) is widely used to evaluate the risk of resection of cerebral arteriovenous malformation (AVM), and direct surgery is strongly recommended for low SMG lesions. Micro-AVMs are defined as AVMs with a nidus <1 cm in diameter, and sometimes, the challenge is identifying the exact lesion site during AVM resection, although identification of the site is very important in the procedure. Here, we present two cases in which the sites of micro-AVM were marked using presurgical embolization and easily confirmed by intraoperative ultrasonography (IUS) and discuss the benefits of IUS in combination with presurgical embolization for low-grade micro-AVM. Case Description: (Patient 1) A 30-year-old man was brought to our hospital and diagnosed with a micro-AVM, which was classified as SMG II AVM. He underwent evacuation of the intracerebral hematoma and subsequently underwent AVM resection. However, the lesion was not identified because it was not exposed in the cerebral cortex although we searched for the lesion. Therefore, endovascular embolization was performed before subsequent surgical resection. During AVM resection following embolization with Onyx, the IUS clearly demonstrated the Onyx-embolized lesion, and it was resected uneventfully. (Patient 2) A 46-year-old man with a ruptured SMG II AVM underwent AVM resection using a microsurgical technique with IUS after embolization for AVM preoperatively. IUS clearly showed abnormal vessels embolized with Onyx and indicated the correct location of the nidus, although the lesion was not observed directly from the brain surface. After identifying some embolized AVM constructions, we excised the entire AVM with ease and safety. Conclusion: The combined use of presurgical embolization, which focuses on marking the lesions and IUS, may contribute to improving surgical outcomes of low SMG micro-AVMs, which are not exposed on the brain surface.

Recurrence of internal carotid artery dissection associated with elongated styloid process: A case report.

BACKGROUND: An elongated styloid process is known to cause ischemic stroke. Previous reports claim that internal carotid artery (ICA) dissection due to the elongated styloid process has good outcomes when treated conservatively; however, long-term follow-up has not been attempted and recurrence in the later period has not been reported so far. We report a case of recurrence of symptoms over a decade after the initial onset. CASE DESCRIPTION: A 59-year-old man experienced a transient ischemic attack (TIA) 10 years ago. Six years ago, he experienced hemispheric TIA, and magnetic resonance angiography revealed a diminished signal of the left ICA; however, no further examination was performed. Four years ago, he experienced another transient amaurosis attack and was treated with antiplatelet therapy because no embolic source was detected using ultrasonography examination, and he was diagnosed with idiopathic ICA dissection. Recently, he experienced a third amaurosis fugax attack. Digital subtraction angiography and cone-beam computed tomography demonstrated left cervical ICA dissection due to elongated styloid process. He underwent surgical resection of the left styloid process and cervical stent placement. He had no ischemic attacks postoperatively. CONCLUSION: The elongated styloid process may cause recurrent ischemic attacks over a decade due to ICA dissection.

[A comparative study of three cases of neuronal intranuclear inclusion disease (NIID)].

All three patients were men in their 70s. All cases were solitary onset and the chief complaint was gait disturbance. All patients had miosis and limb and trunk ataxia, MMSE score was declined in two patients, and FAB score was declined in all patients. Head MRI showed leukoencephalopathy, cerebellar atrophy, and DWI high intensity signal in corticomedullary junction. However, two of the three patients were not followed up without further examination. Skin biopsies in all cases showed ubiquitin-positive and p62-positive intranuclear inclusions. Genetic testing showed CGG repeat expansion of NOTCH2NLC. The diagnosis of neuronal intranuclear inclusion disease (NIID) was made based on the above findings in all cases. Most patients are diagnosed with NIID due to memory loss, but sometimes they are diagnosed due to gait disturbance with ataxia. It is important to proceed with the diagnosis by skin biopsy and genetic diagnosis based on the characteristic MRI findings of the head.

Organized Chronic Subdural Hematoma Treated with Middle Meningeal Artery Embolization and Small Craniotomy: Two Case Reports.

The most preferred treatment for organized chronic subdural hematoma (OSDH) remains controversial. Although a large craniotomy has been reported to be necessary and effective for the treatment of an OSDH, a craniotomy is associated with postoperative hemorrhagic complications and recurrence. Although middle meningeal artery (MMA) embolization has been reported to be effective for a refractory chronic subdural hematoma (CSDH), its efficacy for an OSDH remains unclear. We report two cases of OSDH treated with MMA embolization followed by hematoma removal via a small craniotomy under local anesthesia with good progress. Case 1: A 71-year-old man underwent a single burr hole irrigation for a CSDH, which failed due to a solid hematoma. He underwent a small craniotomy under local anesthesia after an MMA embolization. During the craniotomy, a small hemorrhage from the hematoma and its outer membrane was observed. Postoperatively, the symptoms disappeared immediately, and the hematoma did not recur. Case 2: A 77-year-old man underwent a burr hole irrigation, but the hematoma was not evacuated because of an OSDH, and he remained in motor aphasia. After an MMA embolization, a craniotomy was performed under local anesthesia. Intraoperative hemorrhage was minimal, and after the craniotomy, his neurological symptoms improved without any recurrence. MMA embolization and hematoma removal with a small craniotomy could be a treatment option for an OSDH.

[Utility of transesophageal echocardiography for etiologic diagnosis of centrum ovale infarcts].

A small centrum ovale infarct in the territory of the white matter medullary artery can be caused not only by embolism but also small-vessel disease. In our study, thorough screening for emboligenic diseases was performed, including the modality of transesophageal echocardiography (TEE), in patients with an acute, isolated, small (less than 1.5 cm) infarct in the centrum ovale. Of 79 patients enrolled in this study, 45 had emboligenic diseases, in whom a patent foramen ovale was detected in 29 patients, complicated aortic arch lesion in 15, atrial fibrillation in 6, occlusive carotid disease in 2, and others in 2. The majority (80%) of the emboligenic diseases were diagnosed by TEE. Therefore, TEE may be mandatory for the etiologic diagnosis of centrum ovale infarcts.

[A case of myasthenia gravis developed during pembrolizumab administration, suggesting an excitation-contraction connection disorder].

The patient was a 50-year-old woman. Pembrolizumab was started for bladder cancer recurrence. From the day after the second administration, ptosis, diplopia, restriction of eye movement, muscle weakness, fatigue resistance, increase in serum creatine kinase (CK) level, and muscle pain were observed. Tests for anti-acetylcholine receptor (AChR) antibody and anti-muscle specific kinase (MuSK) antibody were negative. Electrophysiological examination of the neuromuscular junction showed negative results, and electromyography revealed no myogenic changes. We considered that the immune checkpoint inhibitor caused neuromuscular damage. The patient's symptoms were gradually improved by immunotherapy, such as steroid and plasma exchange. In this case, tests for the anti-titin antibody, an anti-striational antibody, were positive. We considered that myasthenia gravis-like symptoms and serum CK level elevation might have been caused by impairment of excitation-contraction coupling, and not the neuromuscular junction.

[Internal Carotid Artery-Cavernous Sinus Fistula in a Patient with Masked Hypertension Caused by Bilateral Subclavian Artery Stenosis:A Case Report].

We herein report a case of direct carotid-cavernous fistula(direct CCF)in a patient with masked hypertension caused by bilateral subclavian artery stenosis. A 74-year-old woman presented with headache, right-sided proptosis, double vision, and pulsatile tinnitus since past 10 days. The patient was diagnosed with direct CCF. Transarterial embolization in the region of the right internal carotid artery was performed, after which her symptoms resolved. However, additional interventions in the form of subclavian artery stenting were required, because of the complications of left subclavian artery occlusion and right subclavian artery stenosis. Satisfactory dilatations were achieved, and the angiographic 'steal' phenomenon disappeared. The patient had terminated antihypertensive treatment because of the normalization of her brachial blood pressure; however, this was merely pseudo-normalization due to subclavian artery insufficiency. We consider this a case of direct CCF occurring as a complication of masked hypertension caused by bilateral subclavian artery stenosis.

Case Report: Shortest Course of Pediatric Paroxysmal Hemicrania.

Paroxysmal hemicrania (PH) is a rare primary headache disorder, especially among children. We describe herein a case with the shortest course of pediatric PH among previously reported cases, and the first case report of Japanese pediatric PH. An 11-year-old boy was referred to our clinic by his primary care physician for a headache evaluation. He had been complaining of severe, sharp, pulsating headache for 5 days. Attacks were restricted to the left side with a duration ranging from 2 to 20 minutes, 20-30 times a day. Attacks were associated with left autonomic symptoms (conjunctival injection, lacrimation, nasal congestion, eyelid edema, and ptosis). Two days after we prescribed indomethacin at 0.9 mg/kg/day, the patient was headache free. He stopped taking indomethacin 14 days after consultation because of drug eruptions. As of the time of writing, more than 1 year later, he has experienced no recurrence of headache. This case indicates the importance of improving awareness among general doctors regarding PH in children, and of conducting further investigations about low-dose, short-term indomethacin treatment.

[Subarachnoid Hemorrhage of Unknown Origin at Initial Imaging Investigation].

In some patients with spontaneous subarachnoid hemorrhage(SAH), initial imaging investigations may not be able to detect a bleeding source;repeat imaging may be necessary to reveal these lesions. We reviewed a consecutive series of 45 patients with SAH and negative initial digital subtraction angiograms(DSA)during a 15-year period. The aims were to document the frequency and reason for the negative initial investigations, to determine the appropriate modality and timing of repeat examinations, and to investigate the identified bleeding sources. Twenty-eight(62%)patients underwent repeat DSA, 35(78%)underwent magnetic resonance imaging(MRI), and 33(73%)underwent computed tomography angiography(CTA). Nine lesions(5 small aneurysms, 2 craniocervical junction arteriovenous fistulas, 1 arteriovenous malformation, and 1 internal carotid artery dissection)were identified on subsequent DSA after 2-3 weeks. Most aneurysms were identified on an atypical vascular tree. CTA or MRI alone were unable to disclose the culprit lesions. In retrospect, human errors including oversight were the major reasons for the negative initial investigation results. It is, however, difficult to search for a tiny vascular lesion that might be anywhere in the cranium. Repeat DSA is still the gold standard for the inspection of hidden bleeding sources in patients with SAH of unknown origin.

Unusual Clinical Sequelae of Kawasaki Disease-Symptomatic Extracranial Internal Carotid Stenosis in Young Adult.

BACKGROUND: Kawasaki disease (KD) is an acute systemic vasculitis that primarily affects the coronary artery, but it does not commonly affect the carotid artery. Cerebral infarction (CI) with internal carotid artery stenosis (ICS) in patients with KD has not been reported until now. We report a patient with CI as a remote-phase complication of KD. CASE PRESENTATION: A 32-year-old man presented with impaired consciousness. Magnetic resonance imaging and digital subtraction angiography confirmed CI and ICS. He successfully underwent carotid endarterectomy. The resected plaque had pathologic findings of KD, which suggested that the internal carotid artery suffered from chronic inflammation. CONCLUSION: KD in childhood may cause symptomatic ICS as a sequela of a remote phase.

Microsurgical Removal of Snagged Stent Retriever During Endovascular Embolectomy for Acute Ischemic Stroke.

BACKGROUND: Catheter-based endovascular thrombectomy has gained popularity for use in patients with acute large-vessel occlusion; however, various complications have been reported. Herein, we present a unique, serious procedure-related complication. CASE DESCRIPTION: A 91-year-old woman with acute middle cerebral artery (MCA) occlusion underwent endovascular thrombectomy with a stent retriever, but the device could not be retrieved from the horizontal segment of MCA during the procedure. Subsequently, she underwent emergency craniotomy. The lodged stent was extracted with microforceps using a counter-stretch of the vessels, so as not to avulse the perforating arteries. The stent device was retrieved uneventfully through a sheath introducer that was inserted through the femoral artery. Postprocedural indocyanine green video angiography showed complete recanalization of the MCA and internal cerebral artery. CONCLUSIONS: This is a rare case in which successful open surgery was performed to retrieve a snagged stent retriever, with successful recanalization of the large cerebral artery occlusion.

[Multiple cerebral artery occlusion due to non-bacterial thrombotic endocarditis: an autopsy case report].

A 60-year-old man was admitted to our hospital because of vertigo and repeated vomiting, which suddenly occurred 25 hours before admission. Neurologic examination revealed Wallenberg syndrome on the left side, and brain MRI showed acute infarcts in the left lateral medulla as well as in the left internal carotid artery (ICA) territory. MR angiography did not depict the left vertebral artery (VA) and the left ICA. Despite antithrombotic treatment, he developed bulbar palsy, and then, brain herniation due to infarct growth in the left middle cerebral artery territory. He died on day 9. Histopathlogical examination found verruca involving the mitral leaflet, which was consistent with non-bacterial thrombotic endocarditis (NBTE). Atherosclerosis was also found in the systemic arteries, and there was sclerotic stenosis with calcification at the portion of piercing dulla matter in the left VA and at the cavernous segment of the left ICA. Because the cerebral emboli in the narrowed lumen presented a histologic appearance similar to that of the verruca, the diagnosis of brain embolism due to NBTE was confirmed.

The relationship between neurological worsening and lesion patterns in patients with acute middle cerebral artery stenosis.

BACKGROUND: Intracranial atherosclerotic disease is one of the most common causes of ischemic stroke especially in Asians, Hispanics and blacks. Although middle cerebral artery (MCA) stenosis is increasingly being recognized with the advent of magnetic resonance angiography (MRA) or transcranial Doppler ultrasonography, few studies have focused on acute neurological worsening (NW) in patients with MCA stenosis. We investigated the relationship between NW and lesion patterns detected by diffusion-weighted imaging (DWI). METHODS: We studied 44 consecutive patients out of a total of 2,863 consecutive patients who had symptomatic lesions in the territory of the MCA and in whom MRA and/or conventional angiography showed isolated MCA stenosis ≥50% in the MCA trunk. Acute DWI lesion patterns were classified as follows: (1) pial artery territory infarcts (PAI); (2) small cortical and/or subcortical infarcts (SCS); (3) deep penetrating artery territory infarcts (DPI); (4) cortical border zone infarcts (CBZ), and (5) internal border zone infarcts (IBZ). NW was defined as worsening by ≥2 points on the National Institutes of Health Stroke Scale (NIHSS) during the first 7 days. Functional outcome was assessed by the modified Rankin Scale (mRS) at 3 months after stroke onset. Poor outcome was defined as ≥3 on the mRS. The severity of MCA stenosis on MRA was further categorized as 50-75% (moderate) and >75% or focal signal loss with the presence of distal MCA signal (severe). RESULTS: There were 14 patients (31.8%) who showed NW and 16 patients (36.3%) who showed poor outcomes. Nine of the 14 patients with NW showed poor outcomes (64.2%). The most frequent lesions in the present study were SCS (n = 16, 36.3%), followed by IBZ (n = 12, 27.2%) and DPI (n = 11, 25.0%). Prevalence of IBZ was significantly higher in the group with NW compared to that without NW (p = 0.0081), while the prevalence of SCS, DPI, PAI and CBZ did not differ between the two groups. Logistic regression analysis showed significantly high age- and sex-adjusted odds ratios (ORs) for NW only for IBZ (OR 10.9, p = 0.0051). The degree of stenosis did not correlate with NW and lesion patterns. CONCLUSIONS: Only IBZ among various lesion patterns correlated strongly with NW. IBZ are considered to be more associated with hemodynamic compromise, while embolic pathogeneses contribute more to CBZ or SCS. Early interventional medical treatments such as thrombolytic or anti-platelet therapy or stenting should be considered in cases of IBZ in MCA stenosis.

Intensive blood pressure-lowering treatment in patients with acute lacunar infarction.

BACKGROUND: The optimal management of high blood pressure (BP) during the acute stage of stroke has yet to be established. To test the extent to which BP can be lowered without causing adverse effects and to determine the safety or efficacy of administration of antihypertensive agents in acute ischemic stroke, we performed ambulatory BP monitoring (ABPM) before and after administration of angiotensin receptor blockers (ARBs) with and without diuretics to monitor the ABPM profile after acute lacunar infarction. Patients with lacunar infarcts are presumed to be less vulnerable to reduced cerebral perfusion pressure in the ischemic tissue because of BP lowering. METHODS: We prospectively performed ABPM during the acute stage and around 3 weeks after ictus for 59 patients with lacunar infarction. As a historical control group, we selected 60 consecutive patients with acute lacunar infarction who were admitted during the period of 1 year before the present study and treated according to the guidelines. RESULTS: Baseline data, prevalence of progressive motor deficits, and modified Rankin Scale scores 3 months after ictus were not significantly different between both groups. ARB with or without diuretics lowered 24-hour systolic BP and diastolic BP by 27.8 and 12.7 mm Hg, daytime systolic BP and diastolic BP by 26.8 and 12.0 mm Hg, and nighttime systolic BP and diastolic BP by 30.2 and 12.0 mm Hg. The incidence of dippers tended to increase in the second measurement from 11 (18.6%) to 20 (33.8%; P=.093). CONCLUSIONS: Considerable reduction in 24-hour BP levels was attained around day 21. The limit of BP level to which BP can be safely lowered appears to be lower than that was previously considered.