Use of n-butyl-2-cyanoacrylate for microvascular decompression in a Jehovah's witness patient.

OBJECTIVE: We report the application of n-butyl-2-cyanoacrylate (n-BCA) in microvascular decompression (MVD) surgery for a Jehovah's Witness patient. To our best knowledge, this is the first case wherein n-BCA has been employed as an adhesive to the offending artery. CASE PRESENTATION: A 55-year-old female Jehovah's Witness patient was suffering from serious right hemifacial spasm. Although MVD surgery was needed, the patient resisted any curative medical treatment involving the application of whole blood products, including fibrin glue. Thus, we proposed several choices using artificial materials, including n-BCA as an adhesive, and received informed consent from the patient. RESULT: MVD was performed on the dolichoectatic right vertebral artery and right posterior inferior cerebellar artery. The abnormal vessel response disappeared during the procedure and transposition using n-BCA of the concerned vessels was successful. The patient experienced a favorable postoperative clinical course and has been free from the spasm for a year. No abnormal findings were detected in the radiological examination during the follow-up period. CONCLUSION: Although careful follow-up is mandatory, n-BCA is a possible alternative option in MVD surgery.

Effect of Mechanical Thrombectomy Without vs With Intravenous Thrombolysis on Functional Outcome Among Patients With Acute Ischemic Stroke: The SKIP Randomized Clinical Trial.

IMPORTANCE: Whether intravenous thrombolysis is needed in combination with mechanical thrombectomy in patients with acute large vessel occlusion stroke is unclear. OBJECTIVE: To examine whether mechanical thrombectomy alone is noninferior to combined intravenous thrombolysis plus mechanical thrombectomy for favorable poststroke outcome. DESIGN, SETTING, AND PARTICIPANTS: Investigator-initiated, multicenter, randomized, open-label, noninferiority clinical trial in 204 patients with acute ischemic stroke due to large vessel occlusion enrolled at 23 hospital networks in Japan from January 1, 2017, to July 31, 2019, with final follow-up on October 31, 2019. INTERVENTIONS: Patients were randomly assigned to mechanical thrombectomy alone (n = 101) or combined intravenous thrombolysis (alteplase at a 0.6-mg/kg dose) plus mechanical thrombectomy (n = 103). MAIN OUTCOMES AND MEASURES: The primary efficacy end point was a favorable outcome defined as a modified Rankin Scale score (range, 0 [no symptoms] to 6 [death]) of 0 to 2 at 90 days, with a noninferiority margin odds ratio of 0.74, assessed using a 1-sided significance threshold of .025 (97.5% CI). There were 7 prespecified secondary efficacy end points, including mortality by day 90. There were 4 prespecified safety end points, including any intracerebral hemorrhage and symptomatic intracerebral hemorrhage within 36 hours. RESULTS: Among 204 patients (median age, 74 years; 62.7% men; median National Institutes of Health Stroke Scale score, 18), all patients completed the trial. Favorable outcome occurred in 60 patients (59.4%) in the mechanical thrombectomy alone group and 59 patients (57.3%) in the combined intravenous thrombolysis plus mechanical thrombectomy group, with no significant between-group difference (difference, 2.1% [1-sided 97.5% CI, -11.4% to ∞]; odds ratio, 1.09 [1-sided 97.5% CI, 0.63 to ∞]; P = .18 for noninferiority). Among the 7 secondary efficacy end points and 4 safety end points, 10 were not significantly different, including mortality at 90 days (8 [7.9%] vs 9 [8.7%]; difference, -0.8% [95% CI, -9.5% to 7.8%]; odds ratio, 0.90 [95% CI, 0.33 to 2.43]; P > .99). Any intracerebral hemorrhage was observed less frequently in the mechanical thrombectomy alone group than in the combined group (34 [33.7%] vs 52 [50.5%]; difference, -16.8% [95% CI, -32.1% to -1.6%]; odds ratio, 0.50 [95% CI, 0.28 to 0.88]; P = .02). Symptomatic intracerebral hemorrhage was not significantly different between groups (6 [5.9%] vs 8 [7.7%]; difference, -1.8% [95% CI, -9.7% to 6.1%]; odds ratio, 0.75 [95% CI, 0.25 to 2.24]; P = .78). CONCLUSIONS AND RELEVANCE: Among patients with acute large vessel occlusion stroke, mechanical thrombectomy alone, compared with combined intravenous thrombolysis plus mechanical thrombectomy, failed to demonstrate noninferiority regarding favorable functional outcome. However, the wide confidence intervals around the effect estimate also did not allow a conclusion of inferiority. TRIAL REGISTRATION: umin.ac.jp/ctr Identifier: UMIN000021488.

BC-Box Motif-Mediated Neuronal Differentiation of Somatic Stem Cells.

Von Hippel-Lindau tumor suppressor protein (pVHL) functions to induce neuronal differentiation of neural stem/progenitor cells (NSCs) and skin-derived precursors (SKPs). Here we identified a neuronal differentiation domain (NDD) in pVHL. Neuronal differentiation of SKPs was induced by intracellular delivery of a peptide composed of the amino-acid sequences encoded by the NDD. Neuronal differentiation mediated by the NDD was caused by the binding between it and elongin C followed by Janus kinase-2 (JAK2) ubiquitination of JAK2 and inhibition of the JAK2/the signal transducer and activator of transcription-3(STAT)3 pathway. The NDD in pVHL contained the BC-box motif ((A,P,S,T)LXXX (A,C) XXX(A,I,L,V)) corresponding to the binding site of elongin C. Therefore, we proposed that other BC-box proteins might also contain an NDD; and subsequently also identified in them an NDD containing the amino-acid sequence encoded by the BC-box motif in BC-box proteins. Furthermore, we showed that different NDD peptide-delivered cells differentiated into different kinds of neuron-like cells. That is, dopaminergic neuron-like cells, cholinergic neuron-like cells, GABAnergic neuron-like cells or rhodopsin-positive neuron-like cells were induced by different NDD peptides. These novel findings might contribute to the development of a new method for promoting neuronal differentiation and shed further light on the mechanism of neuronal differentiation of somatic stem cells.

Neuroprotection conferred by post-ischemia ethanol therapy in experimental stroke: an inhibitory effect on hyperglycolysis and NADPH oxidase activation.

Ethanol provides neuroprotection following ischemia/reperfusion. This study assessed ethanol's effect on hyperglycolysis and NADPH oxidase (NOX) activation. Adult, male Sprague-Dawley rats were subjected to middle cerebral artery occlusion (MCAO) for 2 h. Three sets of experiments were conducted to determine ethanol's effect on (i) conferring neuroprotection by measuring infarct volume and neurological deficits 24 h post reperfusion; (ii) cerebral glucose metabolism and lactic acidosis by measuring brain and blood glucose concentrations and protein expression of glucose transporter 1 and 3 (GLUT1, GLUT3), phosphofructokinase (PFK), as well as lactic acidosis by measuring lactate dehydrogenase (LDH), and lactate; and (iii) nicotinamide adenine dinucleotide phosphate (NADPH) oxidase (NOX) activation by detecting enzymatic activity and subunit expression at 3 h after reperfusion. When administered upon reperfusion, ethanol (1.5 g/kg) reduced infarct volume by 40% (p < 0.01) and neurological deficits by 48% at 24 h post reperfusion while reducing (p < 0.01) elevations in glycolytic protein expression and lactate levels during early reperfusion (3 h). Ethanol increased the reductions in cerebral glucose concentration at 3 h post reperfusion by 64% (p < 0.01) while enhancing (p < 0.01) post stroke blood glucose concentration, suggesting a reduced cellular glucose uptake and utilization. Ethanol decreased (p < 0.01) stroke-induced NOX activation by reducing enzymatic activity and gp91(phox) expression by 45% and 38%, respectively. Post-ischemia ethanol treatment exerts neuroprotection through attenuation of hyperglycolysis and associated NOX activation. Because of the lack of associated hypoglycemia and selectivity toward decreasing cerebral metabolism, further investigation of ethanol's use as a post-stroke therapy, especially in the context of hyperglycemia, seems warranted.

Endovascular Embolization of Femoral Pseudoaneurysm Associated with Therapeutic and Diagnostic Neuroendovascular Procedures.

Objective: We aimed to evaluate the usefulness of endovascular embolization for femoral iatrogenic pseudoaneurysms (PAs) following therapeutic and diagnostic neuroendovascular procedures. Methods: This study included 12 patients with femoral PA due to femoral puncture at our department between May 2014 and April 2021. We performed an analysis of baseline characteristics, treatment, and outcome of these cases. Results: Endovascular embolization was performed in 10 of the 12 PAs using coils and/or N-butyl-2-cyanoacrylate. Of these, 10 PAs were treated with endovascular embolization and 9 were successfully occluded, whereas complete occlusion was not achieved in 1 case of PA (success rate: 90%). No new intraoperative or postoperative complications or postoperative recurrences occurred. Conclusion: Endovascular embolization for PA can be immediately performed under local anesthesia without discontinuation of antithrombotic therapy and may be a safe and effective option for access site complication treatment.

Importance of preoperative coronary artery examination before performing procedures for carotid artery stenosis.

Background: Carotid artery stenosis and coronary artery disease (CAD) often occur simultaneously, with one being an important risk factor in the treatment of the other. This study aimed to perform coronary computed tomography angiography (CTA) as a preoperative evaluation for carotid artery stenosis treatment. Methods: We retrospectively reviewed cases of carotid endarterectomy (CEA) and carotid artery stenting (CAS) performed at our hospital as well as CAD complications. Results: Among the 54 and 166 CEA and CAS cases from May 2014 to February 2022, 53 and 148 cases were analyzed for atherosclerotic stenosis, respectively. Among those who underwent CEA and CAS, 7 (13.2%) and 17 (11.5%) received percutaneous coronary intervention (PCI), 44 (83%) and 97 (65.5%) received symptomatic carotid stenosis treatment and 43 (81.1%) and 110 (74.3%) received preoperative coronary CTA, respectively. Coronary artery stenosis was noted in 14 (32.6%) and 46 (41.8%) patients who had undergone CTA in the CEA and CAS groups, respectively. PCI before carotid treatment was performed in two cases in the CEA group (3.8% of all patients who had undergone CEA) and eight cases in the CAS group (5.4% of all patients who had undergone CAS). Conclusion: Screening may detect asymptomatic coronary artery lesions in carotid artery stenosis even in patients without chest symptoms and suspicion of ischemic heart disease. Preoperative coronary artery screening is important considering that pre and postoperative coronary artery treatment may improve long-term prognosis.

Some technical options for successful PulseRider procedures.

Background: Unlike other conventional neck bridge stents, when using the PulseRider (PR), it is not necessary to introduce a microcatheter for stent delivery into the daughter branches from the neck, and it has less intraluminal metal. However, in some cases, securely introducing both leaflets into daughter vessels may be difficult, leading to coil herniation. This study aimed to present some technical issues in PR deployment. Methods: Fourteen PR procedures were performed in our institution between August 2021 and June 2023, and T-type PRs were used in all procedures. Four technical points during PR procedures are presented from our experience, as "technical options (Options 1-4)". All procedures were carried out with T-type PR implants. Results: The PR was successfully placed in all interventions; however, in seven cases (50%), some technique trials were necessary because the leaflets did not unfold in the optimal directions. In Option 1, an introduction procedure with transposition of the daughter artery using a microcatheter is presented. In Option 2, the method for correction of the unfolded leaflet angle is demonstrated. In Option 3, another method for correction of the leaflets is shown. In Option 4, an effective method for neck protection during PR procedures is shown. Conclusion: Various options should be considered to achieve appropriate apposition of PR leaflets. These technical options may be safe and effective for successful PR deployment.

Thromboembolic complications during and after embolization of unruptured aneurysms: A chronological outcome in periprocedural thromboembolic events.

Background: Ischemic complications develop after elective coil embolization procedures at a certain rate. The prevention of these events has been a longstanding issue for many interventional neuroradiologists. This study aimed to clarify whether procedural ischemic events after unruptured aneurysm embolization decrease over time with perioperative anti-thromboembolic treatment or surgical experience. Methods: This study included patients with cerebral aneurysms in our institution between July 2012 and June 2020. Dual-antiplatelet therapy (DAPT) was performed (Phase 1). Thromboembolic events developed at a certain rate; thus, rivaroxaban was administered with single-antiplatelet therapy (SAPT) to improve thromboembolic results (Phase 2), showing better outcomes than in Phase 1. Subsequently, DAPT was administered again (Phase 3). Ischemic complications were evaluated in each phase or compared between the DAPT group and the direct oral anticoagulant (DOAC) with the clopidogrel (DOAC+SAPT) group. Results: Relatively, fewer symptomatic ischemic events were noted in Phase 2 or the DOAC+SAPT group, but the outcome was not better in Phase 3 than in Phase 2. Symptomatic complications were more common in Phase 3 than in Phases 1 and 2. Conclusion: Ischemic complications occurred at a certain rate after endovascular procedures for unruptured aneurysms. The incidence did not decrease over time; particularly, standard DAPT plus postoperative anti-thromboembolic medication did not adequately decrease complications in Phase 3 compared to Phases 1 and 2. Therefore, accumulated experience or a learning curve could not explain the results. DOAC administration might decrease the risk of these events, but further accumulation of evidence or prospective investigation is warranted.

The impact of SAH finding on CT to the clinical outcome after mechanical thrombectomy for large vessel occlusion.

BACKGROUND AND PURPOSE: Whether subarachnoid haemorrhage (SAH) after mechanical thrombectomy affects the clinical outcomes of patients with acute large-vessel occlusion remains unclear. This study aimed to investigate the clinical impact of SAH on computed tomography (CT) after mechanical thrombectomy. METHODS: The SKIP study was an investigator-initiated, multicentre, randomised, open-label clinical trial. This study was performed in 23 hospital networks in Japan from January 1, 2017, to July 31, 2019. Among the 204 patients, seven were excluded because they did not undergo mechanical thrombectomy (MT) and had a modified Rankin scale (mRS) score > 2. The main outcome was the association between SAH within 36 h after mechanical thrombectomy and the clinical outcome at 90 days. RESULTS: Among 197 patients, the median age was 74 (67-79) years, 62.9% were male. Moreover, 26 (13.2%) patients had SAH (seven isolated SAH) on CT within 36 h. The SAH rate did not differ according to IV rt-PA administration (p = 0.4). The rate of favourable clinical outcomes tended to be lower in patients with SAH rather than patients without SAH (11 [42%] vs. 106 [62%], p = 0.08). Among the seven patients with isolated SAH, 6 showed favourable outcomes at 90 days. In the multivariate regression analysis, the presence of SAH within 36 h from onset was not associated with clinical outcome (Odd ratio, 0.59; 95% confidence interval, 0.18-1.95; p = 0.38). CONCLUSIONS: Among patients with acute stroke treated with MT, SAH, especially isolated SAH findings on CT, were not associated with poor clinical outcomes after 90 days. TRIAL REGISTRATION NUMBER: UMIN000021488.

Ultra-early rt-PA administration should improve patient outcome on mechanical thrombectomy: Post hoc analysis of SKIP.

BACKGROUND: To investigate whether ultra-early recombinant tissue-plasminogen activator (rt-PA) administration can improve patient outcomes on mechanical thrombectomy (MT) in patients with large vessel occlusion (LVO). METHODS: Participants comprised rt-PA-eligible 204 patients with internal carotid artery or middle cerebral artery occlusion in the SKIP trial, who were randomly assigned to receive mechanical thrombectomy alone or combined intravenous thrombolysis (rt-PA: alteplase at 0.6 mg/kg) plus mechanical thrombectomy. We assessed associations between onset-to-puncture time and onset-to-rt-PA administration time and frequency of favorable outcome at 90 days and any intracerebral hemorrhage (ICH) at 36 h after onset. RESULTS: As a cut-off onset-to-puncture time for favorable outcome, receiver operating characteristic curves defined 2.5 h (57% sensitivity, 62% specificity). For onset-to-puncture times ≤2.5 h and > 2.5 h, frequencies of favorable outcomes were 72% and 63% (p = 0.402) in patients with rt-PA therapy and 44% and 58% (p = 0.212) in patients without rt-PA therapy, respectively. In terms of onset-to-rt-PA administration time, frequencies of favorable outcomes among patients with ultra-early rt-PA administration at ≤100, >100 min after onset, and without rt-PA therapy with onset-to-puncture time ≤ 2.5 h, and with and without rt-PA therapy with onset-to-puncture time > 2.5 h were 84% and 64%, 63%, and 44% and 58%, respectively (p = 0.025). Frequencies of any ICH among those patients were 37% and 32%, 32%, and 63% and 40%, respectively (p = 0.006). CONCLUSION: Ultra-early rt-PA administration should improve patient outcomes on mechanical thrombectomy among patients with LVO. Relatively late rt-PA administration might increase the frequency of any ICH.

Carotid endarterectomy with stent removal for recurring in-stent restenosis: A case report and literature review.

Background: Percutaneous transcatheter angioplasty (PTA) and carotid artery stenting (CAS) are often performed repeatedly for in-stent restenosis (ISR) after CAS. Only a few reports describe the treatment for repeated ISR. Furthermore, only a few reports describe carotid endarterectomy (CEA) after CAS; thus, the evidence for this procedure is insufficient. Case Description: Herein, we describe a case in which CEA with stent removal was performed in a patient with repeated ISR after CAS. A 78-year-old man presented with dysarthria and slight left limb weakness. CAS was performed for the right internal carotid artery stenosis. ISR occurred again and PTA and stenting were performed. After the second CAS, ISR occurred again. CEA with stent removal was performed. After the CEA with stent removal, the patient experienced no restenosis or other complications. Conclusion: CEA with stent removal can be a good option for treating repeated ISR after CAS.

Long-Term Patency and Final Structure After Superficial Temporal Artery-Middle Cerebral Artery Bypass Surgery: A Retrospective Study.

OBJECTIVE: To investigate long-term bypass patency and final structure for patients who underwent superficial temporal artery (STA)-middle cerebral artery (MCA) bypass. METHODS: This study retrospectively evaluated 20 patients who underwent STA-MCA bypass and had 2-year follow-up with cerebral angiography. Patients were divided into internal carotid artery occlusion (n = 11) and MCA occlusion or stenosis (n = 9) groups, and diagnosis was either arteriosclerotic (n = 14) or nonarteriosclerotic (n = 6) disease. Final bypass formation was examined with cerebral angiography at 2 years postoperatively. Diameters of the STA, middle meningeal artery (MMA), and deep temporal artery (DTA) were measured at preoperative angiography and at 2-year follow-up. RESULTS: No significant differences in STA, MMA, and DTA diameters were reported between the internal carotid artery versus MCA group. For patients with arteriosclerotic disease, thicker STA diameters were noted on preoperative angiography. For patients with nonarteriosclerotic disease, MMA and DTA dilatation was noted on 2-year follow-up imaging. For patients with arteriosclerotic disease, all direct bypasses were patent at 2 years. For patients with nonarteriosclerotic disease, remarkable angiogenesis was demonstrated. CONCLUSIONS: Long-term patency of a direct bypass may be correlated with arteriosclerotic or nonarteriosclerotic etiology. An indirect bypass route may develop in patients with nonarteriosclerotic disease; therefore, it is important to create a foundation for an indirect bypass with MMA and DTA preservation during craniotomy. In 2 patients with nonarteriosclerotic disease, STA remained the primary bypass foundation; however, the technique resembled novel angiogenesis after encephaloduroarteriosynangiosis and not direct STA-MCA bypass. Therefore, final bypass structure might be affected by disease etiology.

Improvement of Cerebrovascular Reserve by Percutaneous Transluminal Angioplasty for Symptomatic Middle Cerebral Artery Stenosis.

Objective: The purpose of this study was to investigate the efficacy of percutaneous transluminal angioplasty (PTA) for symptomatic middle cerebral artery stenosis by analyzing cerebral blood flow (CBF). Methods: Between January 2016 and December 2018, six patients with symptomatic middle cerebral artery stenosis underwent CBF analysis by single-photon emission computed tomography (SPECT) with acetazolamide challenge before and after PTA for stenosis. They were retrospectively reviewed, and the blood flow in the area of the affected middle cerebral artery before and after angioplasty was compared. Results: The mean stenosis rate and length of lesion before angioplasty were 76.4 ± 5.4% and 6.5 ± 2.1 mm, respectively. Balloon angioplasty without stenting was performed on all patients. The mean residual stenosis rate just after angioplasty was 45.4 ± 9.3%. No periprocedual complications developed, and there were no notable cerebral ischemic events during the postprocedural follow-up period. One patient underwent repeat angioplasty for restenosis. Although there was only a mild decrease in blood flow at rest, the cerebrovascular reserve (CVR) in the area of the affected middle cerebral artery was markedly decreased before angioplasty (mean, 3.6 ± 4.3%). After angioplasty, the CVR was significantly improved (mean, 18.0 ± 4.7%, p <0.01). Conclusions: PTA for symptomatic middle cerebral artery stenosis can be safely performed using appropriate interventional techniques for select patients. Reduced CVR due to stenosis can be improved after angioplasty, which may reduce the risk of cerebral ischemic events.

Short-Vessel Occlusion Might Indicate Higher Possibility of Success in Reperfusion following Mechanical Thrombectomy in Acute Middle Cerebral Artery Occlusion.

BACKGROUND: The impact of the length of the occluded vessel in acute large-vessel occlusion on successful reperfusion by mechanical thrombectomy remains unclear. This study evaluated whether diameter and length of the occluded vessel in acute middle cerebral artery (MCA) occlusion might relate to successful reperfusion following mechanical thrombectomy. METHODS: This retrospective study included patients with acute MCA occlusion who underwent intra-aortic injection of contrast medium to obtain maximum intensity projection (MIP) images acquired by flat-panel detector computed tomography (FD-CT) equipped with an angiographic system. All patients received mechanical thrombectomy and were divided into two groups: those with successful reperfusion (Thrombolysis in Cerebral Infarction [TICI] 2b/3) and those without. We compared the diameter and length of the occluded vessel between the groups. In the sub-analysis of patients with stent retriever use, ratio of length of occluded vessel to length of the active zone was compared. RESULTS: We enrolled 29 patients (median age: 73, M1 occlusion: 51%, stent retriever use: 72%). Eighteen patients achieved TICI 2b/3 with significantly larger distal end diameter (1.7 [interquartile range: 1.5-1.9] vs. 1.2 [1.2-1.5] mm, p = 0.007) and shorter length (7.1 [4.9-9.7] vs. 12.3 [7.2-15.8] mm, p = 0.043) of the occluded vessel. Sub-analysis of 21 patients showed that the cut-off value for TICI 2b/3 reperfusion was 0.32 as the ratio between the occluded vessel and stent retriever active zone (receiver operating characteristic area under the curve: 0.90). CONCLUSION: In acute MCA occlusion, larger diameter of the distal end and shorter length of the occluded vessel on FD-CT MIP images might indicate a higher possibility of achieving TICI 2b/3 following mechanical thrombectomy.

Difference of Thrombus Location between Initial Noninvasive Vascular Image and First DSA Findings in Mechanical Thrombectomy for Intracranial Large Vessel Occlusion: Post Hoc Analysis of the SKIP Study.

In patients who undergo mechanical thrombectomy for intracranial large vessel occlusion, the occluded site is sometimes distal to the site shown in the initial vascular imaging. We investigated the factors related to the change in the occluded site between the sequential imagings. The 203 patients in the SKIP study were reviewed retrospectively. Magnetic resonance angiography (MRA) or computed tomography angiography (CTA) was used to assess the occluded site. The occluded site shown in the cerebral angiography appeared to be distal to the occluded site shown in the initial vascular imaging in 55 patients (group A). The location of the occluded site in the remaining 148 patients did not change between the sequential imagings (group B). MRA was used more often than CTA in group A (54 MRA, 1 CTA; P <0.01). Patients with middle cerebral artery (M1) occlusion were more likely to show change of the occluded site than patients with internal carotid artery (ICA) occlusion (M1: 38%, ICA: 9%; P <0.01). The number of patients who received intravenous recombinant tissue plasminogen activator did not differ between the two groups (group A: 54%, group B: 49%; P = 0.5). In patients with acute intracranial large vessel occlusion who require mechanical thrombectomy, physicians should be aware that the location of the thrombus may be distal to the occluded site shown in the initial vascular imaging, particularly in patients with M1 occlusion shown by MRA.

Efficacy of a 14-coil for Framing in Coil Embolization of Small Cerebral Aneurysms.

Objective: The purpose of this study was to demonstrate the efficacy of a 14-coil (Target XL) for framing in coil embolization of small cerebral aneurysms. Methods: Between January 2017 and December 2018, 46 patients underwent coil embolization of a small cerebral aneurysm that was less than 5 mm in maximum diameter. They were categorized into 26 patients in whom only 10-coils were used and 20 in whom Target XL was used for framing. The volume embolization rate (VER) and recanalization rate were compared between the two groups. Results: Although there were two patients in whom Target XL was replaced with a 10-coil for framing, no adverse events associated with the use of Target XL were noted. The mean VER of the first framing coil was significantly higher in aneurysms that were framed with Target XL than in those framed with a 10-coil (Target XL 22.6 ± 4.5%, 10-coil 17.9 ± 8.4%; p = 0.03). Furthermore, the mean VER at the end of the procedure was significantly higher in aneurysms with Target XL used for framing than in those embolized using only 10-coils (14-coil: 36.8 ± 7.8%, 10-coil: 32.0 ± 6.5%; p = 0.03). No recanalization was observed in aneurysms for which Target XL was used for framing, whereas five aneurysms embolized using only 10-coils were recanalized. Conclusion: Target XL may be safe and feasible as a framing coil in coil embolization of small cerebral aneurysms, which may result in a high VER, low recanalization rate, and good outcome.

Strategies to Prevent Ischemic Complications after Stent-assisted Coil Embolization of Cerebral Aneurysms.

Objective: There have been no delayed ischemic complications related to stent-assisted coil embolization (SACE) of cerebral aneurysms at our institution. We demonstrate our strategies for stent placement and postoperative management of antiplatelet therapy to reduce the risk of ischemic complications. Methods: We analyzed 57 cases of SACE retrospectively. In the procedure, an appropriate stent was selected and placed to fit the arterial wall without impeding on small arterial branches. Two different antiplatelet drugs, including clopidogrel, were used. Six to twelve months after surgery, follow-up angiography was performed to assess the safety of terminating antiplatelet therapy. In cases in which antiplatelet therapy was tapered, the two antiplatelet drugs were switched to clopidogrel alone, and it was subsequently tapered and finally discontinued. Results: There were 49 cases of SACE in which postoperative antiplatelet therapy was tapered. Among these cases, antiplatelet therapy was discontinued in 35 cases. The mean duration of dual antiplatelet therapy was 10.6 ± 2.8 months, and the mean duration of total antiplatelet therapy was 15.0 ± 2.1 months. Three patients developed SACE-related ischemic stroke, which developed in the early phase after surgery in all. Conclusion: Antiplatelet therapy can safely be terminated in most cases of SACE. In order to reduce the risk of ischemic complications, stent selection, stent placement, and management of antiplatelet therapy should be performed appropriately. Furthermore, careful follow-up should be continued even after the termination of antiplatelet therapy.

Expression of hypoxia-inducible angiogenic proteins (hypoxia-inducible factor-1alpha, vascular endothelial growth factor, and E26 transformation-specific-1) and plaque hemorrhage in human carotid atherosclerosis.

OBJECT: Plaque hemorrhage in carotid atherosclerosis promotes plaque progression, resulting in cerebrovascular disease. Hypoxia inducible factor-1alpha (HIF-1alpha) induces angiogenesis via the expression of vascular endothelial growth factor (VEGF) and E26 transformation-specific-1 (Ets-1). The authors investigated human carotid plaques to determine whether these hypoxia-inducible angiogenic proteins play a major role in intraplaque angiogenesis and hemorrhage. METHODS: The expression of HIF-1alpha, VEGF, and Ets-1 was analyzed using immunohistochemistry and Western blotting in 29 human carotid plaques obtained at carotid endarterectomy. The authors investigated the relationship between plaque characteristics and clinical symptoms. RESULTS: A higher incidence of plaque hemorrhage was observed in plaques associated with symptoms than in those without symptoms (p = 0.03). Hypoxia-inducible factor-1alpha, VEGF, and Ets-1 coexisted in the deep layer of plaque, where angiogenesis was remarkably developed; the expression levels of HIF-1alpha, VEGF, and Ets-1 were significantly enhanced in the main lesion of the plaque (p < 0.01). Symptomatic plaques showed higher expression of VEGF (p = 0.04) than asymptomatic plaques. Plaques with hemorrhage showed a higher incidence of plaque ulcer (p = 0.001) and higher expression of Ets-1 (p = 0.03) than those without hemorrhage. Moreover, significantly increased expressions of VEGF (p = 0.01) and Ets-1 (p = 0.006) were observed in plaques with not only hemorrhages but also ulcers and severe stenosis. CONCLUSIONS: The findings in this study suggest that hypoxia-inducible angiogenic proteins in human carotid atherosclerosis promote intraplaque angiogenesis, which can induce plaque hemorrhage and progression.

Hemangioblastoma of the optic nerve--case report.

A 64-year-old man presented with a rare sporadic hemangioblastoma arising in the left optic nerve manifesting as left visual disturbance gradually progressive over 5 years. Magnetic resonance imaging revealed a well-enhanced mass in the left optic nerve. Partial resection of the tumor was performed via the frontoorbital approach. The histological diagnosis was optic nerve hemangioblastoma. Hemangioblastoma must be considered in the differential diagnosis of optic nerve tumors even in the absence of other lesions associated with von Hippel-Lindau disease.

Acute lymphocytic leukemia recurring in the spinal epidural space.

A 27-year-old man presented with a very rare spinal epidural mass associated with recurrence of acute lymphocytic leukemia (ALL) manifesting as acute progressive neurological deficits. The patient presented with shoulder pain and ambulatory difficulties 3 years after remission of ALL treated by bone marrow transplantation. Magnetic resonance imaging revealed an epidural mass extending from C-7 to T-3, which compressed the cord and extended to the intervertebral foramen along the roots. After decompression surgery, the symptoms dramatically improved. Histological examination showed clusters of immature lymphocytes consistent with recurrence of leukemia, so chemotherapy and radiation therapy were carried out. At 1 year after the operation, no local mass expansion or systemic progression of leukemia had occurred. Leukemic mass must be considered in the differential diagnosis of spinal epidural mass, even in patients with ALL.