[Selective coil embolization of a distal anterior choroidal artery aneurysm associated with moyamoya disease: a case report].

Intracranial hemorrhage in patients with moyamoya disease is often caused by rupture of the associated aneurysms. Of these aneurysms, distal anterior choroidal artery (AChoA) aneurysms are rare. In patients with moyamoya disease, the AChoA constitutes collateral vessels and the aneurysm requires careful treatment strategy. However, reported cases of distal AChoA aneurysms include various procedures including conservative therapy, direct surgery, and endovascular therapy. Herein, we report a case of coil embolization of a distal AChoA aneurysm associated with moyamoya disease and discuss the treatment strategy. A 39-year-old female presented with severe headache and subsequent deep coma. Computed tomography (CT) revealed thick intraventricular hemorrhage, and three-dimensional CT angiography revealed a right distal AChoA aneurysm. Bilateral ventricular drainage was performed and subsequent ventriculoperitoneal (VP)shunt was performed. The persisting distal AChoA aneurysm was coil embolized without any complication. Rebleeding did not occur during the 1-year follow-up period. Endovascular treatment is effective for distal AChoA aneurysms associated with moyamoya disease to preserve collateral circulation.

Evaluation of recurrence factors and Gorei-san administration for chronic subdural hematoma after percutaneous subdural tapping.

Recent reports have shown that administration of Gorei-san (Tsumura, Tokyo, Japan) can prevent recurrence of chronic subdural hematoma (CSDH). However, no report has shown its potential, including its correlation with other recurrent clinical factors. We retrospectively evaluated the recurrent factors and the effects of Gorei-san on CSDH using percutaneous subdural tapping. Between April 2009 and February 2012, we performed percutaneous subdural tapping on 160 patients with intact CSDH. Of this population, 125 patients with unilateral hematoma and measurable initial hematoma pressure were included in this study. From April 2010, Gorei-san was routinely administered to patients. Patient characteristics such as age, sex, neurological grading, alcohol, diabetes mellitus, antiplatelet agent, anticoagulant agent, trauma, midline shift on CT images, hematoma volume on CT images, initial hematoma pressure, volume of the removed hematoma, and administration of Gorei-san were analyzed. Recurrence was recognized in 35/125 (28.0%) patients. Multivariate analysis revealed that a greater midline shift on CT images (p = 0.033) and initial hematoma pressure (p = 0.031) predicted recurrence. Gorei-san was administered to 94/125 (75.2%) patients, but they showed no changes in recurrence (27.7% vs. 29.0%; p = 1.0). Among 13 patients for whom Gorei-san administration was started before surgery, CSDH recurrence was reported in only 1 (7.7%). However, the group showed a significantly lower number of recurrent factors. Patients with a greater midline shift in their CT images or higher initial hematoma pressure need close postsurgical observation. The potential of Gorei-san for preventing recurrence of CSDH needs further examination.

Y-configured double stent-assisted coil embolization with double microcatheter technique for complex basilar bifurcation aneurysm.

Y-configured double stent technique is useful for coil embolization of a bifurcation wide neck aneurysm while preserving the patency of the two important vessels. However, if the important vessels emanating directly from the aneurysm comprised four vessels, two vessels not deployed, Y-stents might not be preserved with the Y-stent technique by itself. We report a case treated with Y-configured double stent-assisted coil embolization with a double microcatheter technique for complex basilar bifurcation aneurysm. A 78-year-old woman presented with a subarachnoid hemorrhage (SAH) of poor grade. CT-angiography showed a wide neck and shallow aneurysm of complex basilar bifurcation involving both posterior cerebral arteries (PCAs) and superior cerebellar arteries (SCAs). In the chronic stage of SAH, Y-configured double stent-assisted coil embolization with a double microcatheter technique was performed. After Y-stent (two Enterprise) deployment from both the PCAs to the basilar artery, coil embolization of a basilar bifurcation aneurysm was performed using a double microcatheter technique to preserve both SCAs.

Effect of region-wide use of prehospital stroke triage scale on management of patients with acute stroke.

BACKGROUND: Prehospital stroke triage scales help with the decision to transport patients with suspected stroke to suitable hospitals. OBJECTIVE: To explore the effect of the region-wide use of the Japan Urgent Stroke Triage (JUST) score, which can predict several types of stroke: large vessel occlusion (LVO), intracranial hemorrhage (ICH), subarachnoid hemorrhage (SAH), and cerebral infarction other than LVO (CI). METHODS: We implemented the JUST score and conducted a retrospective and prospective multicenter cohort study at 13 centers in Hiroshima from April 1, 2018, to March 31, 2020. We investigated the success rate of the first request to the hospital, on-scene time, and transport time to hospital. We evaluated the door-to-puncture time, puncture-to-reperfusion time, and 90-day outcome among patients with final diagnoses of LVO. RESULTS: The cohort included 5141 patients (2735 before and 2406 after JUST score implementation). Before JUST score implementation, 1269 strokes (46.4%) occurred, including 140 LVO (5.1%), 394 ICH (14.4%), 120 SAH (4.4%), and 615 CI (22.5%). The JUST score was used in 1484 (61.7%) of the 2406 patients after implementation, which included 1267 (52.7%) cases of stroke (186 LVO (7.7%), 405 ICH (16.8%), 109 SAH (4.5%), and 567 CI (23.6%)). Success rate of the first request to the hospital significantly increased after JUST score implementation (76.3% vs 79.7%, p=0.004). JUST score implementation significantly shortened the door-to-puncture time (84 vs 73 min, p=0.03), but the prognosis remained unaltered among patients with acute LVO. CONCLUSIONS: Use of prehospital stroke triage scales improved prehospital management and preparation time of intervention among patients with acute stroke.

Nonfunctional pituitary macroadenoma manifested as muscular symptoms.

A 75-year-old man with a large pituitary adenoma presented with general muscular weakness, including difficulty in rising in the morning and forceless defecation and urination, and muscular pain, numbness and atrophy in the shoulder, neck and thigh. Testosterone replacement and subsequent resection of the pituitary tumor resulted in resolution of the symptoms. The value of pituitary imaging tests for men with hypogonadotropic hypogonadism is discussed.