Early Enhancement with Contrast-Enhanced Ultrasonography Relates to the Number of Small-Diameter Neovessels in the Carotid Plaque.

BACKGROUND AND PURPOSE: Intraplaque neovessels (INVs) have been recognized as a major cause of intraplaque hemorrhage and subsequent vulnerability of the carotid plaque. However, the exact mechanisms by which INVs cause intraplaque hemorrhage remain unclear. Various sizes of INVs coexist in carotid plaques pathologically, and we hypothesized that the size of INVs would be associated with carotid plaque histology, particularly in terms of intraplaque hemorrhage. Detection method of INV is important when determining whether carotid plaques are vulnerable, and contrast-enhanced ultrasonography (CEUS) is one of the most useful methods to detect them. The purpose of this study was to examine the relationship between findings from CEUS and vascular pathology obtained by carotid endarterectomy (CEA). We focused on associations between small and large INVs evaluated by CEUS and histologically defined intraplaque hemorrhage. METHODS: Participants comprised 115 patients (mean age, 73.0 ± 7.2 years; 96 men) who underwent preoperative CEUS and underwent CEA. CEUS findings were evaluated as vascular grade at 0 min (Vas-G0) and 10 min (Vas-G10) after contrast injection. Plaques were histologically evaluated quantitatively for the total area of intraplaque hemorrhage, cholesterol, and calcification and the thinnest fibrous cap. Immunohistochemical studies were conducted using anti-CD-34 antibody as a marker for endothelial cells. INVs were divided into two groups depending on diameter: small INVs, <50 µm; and large INVs, ≥50 µm. The numbers of small and large blood vessels in the plaque were quantified histologically. Associations of small and large INVs with CEUS, plaque histology, and clinical findings were assessed by uni- and multivariable analyses. RESULTS: Multivariable analyses indicated that CEUS Vas-G0 was associated with the 4th quartile of the number of small INVs compared with other quartiles, and Vas-G10 was associated with the 4th quartile of the number of large INVs. Histologically, the presence and area of intraplaque hemorrhage were associated with the number of small INVs, while the increased number of large INVs was associated with infrequent plaque disruption and thicker fibrous cap. CONCLUSIONS: Our study showed that early phase enhancement in the CEUS can help identify plaque vulnerability by predicting a larger number of small INVs. This information can also help determine treatment strategies for carotid plaque.

Detection and Differentiation of Dural Arteriovenous Fistulas in the Transverse Sinus/Sigmoid Sinus and Cavernous Sinus Using Carotid Ultrasound: Importance of Evaluation of the Occipital Artery.

OBJECTIVES: Dural arteriovenous fistula (DAVFs) in the transverse sinus (TS)/sigmoid sinus (SS) and cavernous sinus (CS) are observed frequently in the clinic. This study aimed to detect DAVFs with ultrasound and compare carotid ultrasound findings between these conditions. METHODS: We retrospectively reviewed 26 patients with either a TS/SS DAVF or a CS DAVF who were admitted to our hospital for evaluation of DAVFs from 2014 to 2018. The shunt site decision was made by neuroendovascular experts, whereas carotid ultrasound examinations were performed by ultrasound specialists. The flow velocity of the ipsilateral external carotid artery was reviewed in all 26 patients, whereas that of the occipital artery (OA) was examined in 20 patients. Blood flow velocities were compared between the TS/SS DAVF and CS DAVF groups. RESULTS: The study included 18 patients with a TS/SS DAVF (11 women and 7 men; mean age ± SD, 65.3 ± 18.6 years) and 8 patients with a CS DAVF (7 women and 1 man; mean age, 70.4 ± 9.3 years). Evaluations of feeder arteries on cerebral angiography showed that all patients had dural branches from the internal carotid and middle meningeal arteries as feeders of CS DAVFs, whereas the OA was the major feeder source of all TS/SS DAVF cases. The end-diastolic velocity (EDV) of the external carotid artery was significantly higher in patients with a TS/SS DAVF compared with those with a CS DAVF (P = .004). The EDV of the OA was significantly elevated in TS/SS DAVF cases compared with CS DAVF cases (P < .001). CONCLUSIONS: Duplex ultrasound parameters are significantly different between patients with TS/SS and CS DAVFs. An increased EDV of the OA can predict the presence of a TS/SS DAVF.

The Comparison of Clinical Findings and Treatment Between Unilateral and Bilateral Vertebral Artery Dissection.

BACKGROUND: There are limited clinical studies of bilateral vertebral artery dissection (VAD). OBJECTIVE: To compare the characteristics, imaging findings, and treatments between patients with bilateral and unilateral VAD. METHODS: Between February 2007 and May 2017, 31 (mean age: 53.0 years; 23 men, 8 women) out of 171 VAD patients were hospitalized because of bilateral VAD. Onset type, dissection site, dominant side of the VA, imaging features, treatments, and outcomes were investigated based on medical records. The dominant side of the VA was determined by basi-parallel anatomical scanning. RESULTS: Twenty (64.5%) of 31 patients exhibited bilateral VAD on both sides of V4. The dominant side of the VA was right in 16 patients and left in 15 patients. The pearl and string sign (an angiographical finding with both dilatation and stenosis) was frequently observed on the dominant VAD side, while a tapered occlusion and string sign were most common on the nondominant side. For clinical subtype of VAD, 6 (19.4%) patients had subarachnoid hemorrhage, 10 (32.3%) ischemic stroke, 3 (9.7%) infarction plus subarachnoid hemorrhage, and 12 (38.7%) only headache. The frequency of infarction was increased in bilateral VAD compared with unilateral (P < .05). Surgical intervention was performed in 3 cases, while 14 patients received endovascular intervention. CONCLUSIONS: Infarction occurred frequently in bilateral VAD patients, and 17 patients required an intervention (mainly endovascular) for VA. The treatment strategy varied depending on the clinical subtype, imaging findings of VAD, and morphology of the dominant VAD side.

Intra-Plaque Vessels on Contrast-Enhanced Ultrasound Sonography Predict Carotid Plaque Histology.

BACKGROUND AND PURPOSE: Although the echogenicity of carotid plaques on carotid enhanced ultrasound (CEUS) was reported to correlate with the historological density of intra-plaque neovessels, it is unclear whether the intra-plaque vessel size is associated with carotid plaque vulnerability. We evaluated the relationship of size of intra-plaque vessels on CEUS with carotid plaque histology. METHODS: We prospectively registered patients with carotid stenosis who were hospitalized to receive carotid endarterectomy between 2012 and 2016. CEUS was performed by ultrasound specialists using a 7-MHz linear transducer (GE LOGIQ7; GE Healthcare, Milwaukee, WN, USA). Sonazoid® was used for conducting CEUS. The sizes of microbubbles inside the plaques were scored at 0, 1, 3, and 5 min after the injection of contrast agent, and were categorized according to our defined vascular score (Vas-S; 0: the effect of contrast was not recognized; 1: the microbubbles were visible, but so blurred and vague that their shape could not be recognized; 2: dot or string-like microbubbles with movement, localized in part or the whole site of the plaque). At histological examination, we simplified the modified American Heart Association classification and defined as an atherosclerotic category (Ath-cat; 1: unruptured plaque; 2: ruptured plaque; 3: healed plaque). We then assessed the correlation of Vas-S with Ath-cat, which describes the process of rupture and restoration of carotid plaques. RESULTS: A total of 97 patients were included in this study. A higher Ath-cat was significantly associated with higher Vas-S at any time. Spearman signed-rank test indicated that Vas-S at 1 min was most strongly correlated with Ath-cat (ρ = 0.43, p = 0.001). Receiver operating curve analysis indicated that a Vas-S of 0 at 1 min was significantly associated with an unruptured plaque (area under curve [AUC] 0.72, p = 0.006), while a Vas-S of 2 at 1 min was significantly associated with a healed plaque (AUC 0.72, p = 0.001). CONCLUSION: Vas-S values of 0 and 2 at 1 min indicated unruptured and healed plaques respectively. Thus, a Vas-S of 1 at 1 min is an indicator of a ruptured plaque. The intra-plaque vessel size on CEUS was significantly associated with carotid plaque histology, and may predict the process of plaque rupture and restoration.

Safety and Feasibility of Carotid Artery Stenting with Dual-Echo Technique to Minimize Iodinated Contrast Dose.

BACKGROUND: The aim of this study was to evaluate the safety and feasibility of carotid artery stenting (CAS) employing dual-ultrasound technique and administering a minimal contrast agent in patients with renal insufficiency. METHODS: Between September 2009 and July 2013, 63 consecutive patients underwent CAS at our institution: dual-echo carotid artery stenting (DECAS) in 7 patients with renal insufficiency and standard carotid artery stenting (STCAS) in the remaining 56 patients. Periprocedural adverse events and outcomes were compared between the 2 groups. RESULTS: Technical success was achieved in all cases. The 3 procedure-related complications were 1 case of transient hemiparesis in the DECAS group and 1 transient and 1 permanent case of hemiparesis in the STCAS group. The rate of positive diffusion-weighted-imaging lesions did not differ significantly between the 2 groups (28.6% versus 12.5%, P = .26). A significantly smaller volume of contrast was used in DECAS (15 versus 163 mL, P < .01). The change in creatinine level remained stable after CAS and did not differ between the 2 groups (.02 versus .03 mg/dL, P = .96). CONCLUSIONS: DECAS is safe and feasible for patients with pre-existing renal insufficiency and can provide an alternative for patients with carotid stenosis and renal insufficiency.

Multiple Thrombi in the Heart in Trousseau Syndrome Caused by Pancreatic Carcinoma.

A 65-year-old woman presented to our emergency room because of sudden onset of right hemiparesis with severe fatigue. Neurological examination revealed right hemiparesis with right facial numbness and an extensor planter response on the right side.Magnetic resonance imaging with diffusion-weighted imaging revealed multiple highintensity areas in both cerebral hemispheres and the right cerebellum. A diagnosis of acute stage of multiple brain infarctions caused by emboli was made. An abdominal computed tomography showed a pancreatic tumor with multiple liver metastases. High D-dimer and serum carbohydrate antigen 19-9 concentration strongly suggested Trousseau syndrome associated with pancreatic cancer. The patient had another large embolic stroke and died on day 47. Autopsy was performed. There were large thrombi in the left ventricular apex and in the left atrial appendage There was also a papillary-shaped vegetation on the aortic valve that consisted mainly of fibrin without any inflammatory cells or destruction of the valve, these findings being characteristic of NBTE. This case is remarkable in that the patient had 3 different types of cardiac thrombi in her heart associated with Trousseau syndrome.

Evaluation of the Time-Dependent Changes and the Vulnerability of Carotid Plaques Using Contrast-Enhanced Carotid Ultrasonography.

BACKGROUND: The association of carotid plaque enhancement on contrast-enhanced carotid ultrasound (CEUS) and plaque vulnerability evaluated by magnetic resonance imaging (MRI) was to be determined. MATERIALS AND METHODS: The 103 patients underwent CEUS from May 2013 until June 2016. CEUS images of the carotid plaque were obtained offline. Plaque images obtained at 1, 3, 5, and 10 minutes were compared with the reference image, defined as the image obtained at 0 minute. Plaque brightness was assessed using the gray-scale median during contrast enhancement (GSM-C). Plaque vulnerability was evaluated using T1- and T2-weighted MRI and Volume ISotropic TSE Acquisition (VISTA), with a VISTA cutoff value for the plaque muscle ratio (PMR) of 1.5. Time-dependent changes in the GSM-C were evaluated, and those between 0 and 1 minute were compared with the PMR values determined on MRI. FINDINGS: GSM-C decreased significantly over time, from 32.0 at 0 minute to 28.0 at 1 minute, 25.0 at 3 minutes, and 19.0 at 10 minutes. The greater the increase in the changes in the GSM-C from 0 to 1 minute, the more significant the association with a PMR higher than the median on T1 (GSM-C: 0 minute: 29.0, 1 minute: 24.0, P = .015), a PMR less than or equal to the median on T2 (0 min: 35.0, 1 min: 28.0, P = .003), and a PMR more than 1.5 determined on VISTA (GSM-C: 0 minute: 29.0, 1 minute: 24.0, P = .005). CONCLUSIONS: Early changes in the GSM-C evaluated with CEUS indicate significant plaque vulnerability on MRI.

YAMATO Study (Tissue-Type Plasminogen Activator and Edaravone Combination Therapy).

BACKGROUND AND PURPOSE: We investigated whether administration of edaravone, a free radical scavenger, before or during tissue-type plasminogen activator (tPA) can enhance early recanalization in a major arterial occlusion. METHODS: The YAMATO study (Tissue-Type Plasminogen Activator and Edaravone Combination Therapy) is an investigator-initiated, multicenter (17 hospitals in Japan), prospective, randomized, and open-label study. Patients with stroke secondary to occlusion of the M1 or M2 portion of the middle cerebral artery and within 4.5 hours of the onset were studied. The subjects were randomly allocated to the early group (intravenous edaravone [30 mg] was started before or during tPA) and the late group (edaravone was started after tPA and the assessment of early recanalization). RESULTS: One-hundred sixty-five patients (96 men; median age [interquartile range], of 78 [69-85] years) were randomized 1:1 to either the early group (82 patients) or the late group (83 patients). Primary outcome, defined as an early recanalization 1.5 hour after tPA, was observed in 53% of the early group and in 53% of the late group (P=1.000). About secondary outcomes, the rate of significant recanalization of ≥50% was not different between the 2 groups (28% versus 34%; P=0.393). The symptomatic intracerebral hemorrhage has occurred in 4 patients (5%) in the early group and in 2 patients (2%) in the late group (P=0.443). The favorable outcome (modified Rankin Scale score of 0-2) at 3 months was also similar between the groups (53% versus 57%; P=0.738). CONCLUSIONS: The timing of edaravone infusion does not affect the rate of early recanalization, symptomatic intracerebral hemorrhage, or favorable outcome after tPA therapy. CLINICAL TRIAL REGISTRATION: URL: http://www.umin.ac.jp/ctr/index-j.htm. Unique identifier: UMIN000006330.

Patients' characteristics and outcomes depending on complete or incomplete unilateral spatial neglect.

Unilateral spatial neglect (USN) is known to depress the activities of daily living. The purpose of this study was to clarify that categorizing the type of USN using line cancelation and line bisection tests is important when evaluating patients with acute intracerebral hemorrhage (ICH). In this study, patients with ICH were prospectively evaluated for the presence of USN using line cancelation and line bisection tests. They were classified into an incomplete USN group (iUSN = abnormal results in either test) or a complete USN group (cUSN = abnormal findings in both tests). We compared the initial severity of ICH and the outcomes of USN in the two groups. We were able to assess 16 patients, among whom 10 showed USN. Seven were then categorized as having iUSN and three as having cUSN. The median hematoma volume was larger in the cUSN group than in the iUSN group. The USN symptoms of patients in the iUSN group disappeared during the chronic phase, whereas the symptoms of patients in the cUSN group continued. The type of USN was associated with the initial severity of ICH and the persistence of USN.

Early and noninvasive evaluation using superficial temporal artery duplex ultrasonography after indirect bypass for adult ischemic moyamoya disease.

BACKGROUND: The validity of indirect bypass for adult patients with moyamoya disease is still debatable. Some patients are poor responders to indirect bypass, and additive intervention is occasionally required in these cases. Therefore, it is necessary to evaluate the development of collateral circulation as early as possible postoperatively. METHODS: Fifteen adult patients (>17 years old) with moyamoya disease (22 affected sides) who underwent encephalo-duro-arterio-synangiosis (EDAS) at Fukuoka University Hospital from April 2008 to August 2014 were included. All patients had ischemic symptoms of at least one hemisphere. Superficial temporal artery duplex ultrasonography (STDU) was performed before and 3, 6, and 12 months postoperatively. Digital subtraction angiography was performed 1 year after the operation to evaluate the development of collateral circulation. Hemispheres exhibiting collateral formation of more than one-third of the MCA distribution were defined as good responders, and those with less than one-third were defined as poor responders. RESULTS: EDAS induced the formation of well-developed collaterals in 17 of 22 affected sides (77.3%) of adult patients with ischemic moyamoya disease. Regardless of the degree of collateral formation, the ischemic event subsided eventually with time in all patients. In good responders, the pulsatility index obtained by STDU showed a drastic decrease 3 months after the operation, while it did not change significantly in poor responders. Absence of this decrease in the pulsatility index along with no change in the flow velocity reliably indicated poor responders. CONCLUSIONS: Neovascularization after EDAS can be evaluated noninvasively in early phase using STDU.

Cognitive Change 1 Year after CEA or CAS Compared with Medication.

BACKGROUND: Whether improvement of cognitive function can be maintained remains controversial. AIMS: This study aimed to investigate cognitive changes between before carotid endarterectomy (CEA) or carotid artery stenting (CAS) and 1 year after intervention using cognitive evaluation tools. METHODS: Patients suspected as having carotid stenosis were prospectively registered for evaluation of cognitive function from October 2011 to December 2013 in the Department of Neurosurgery, Fukuoka University Hospital. Cognitive evaluation by the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) were performed before and 1 year after CEA or CAS. Cognitive changes were evaluated using the Wilcoxon signed rank test, whereas the subscores of MoCA and MMSE were also compared. RESULTS: The MoCA score was significantly ameliorated from 21 to 23 at 1 year after CEA (P = .003), but the MMSE score did not significantly change (24 to 25, P = .56). Additionally, the MoCA score was improved 1 year after CAS (P = .04), but it was unchanged in those who were treated medically (P = .15). Regarding the analyses of subscores, patients who had CEA improved in the areas of executive and memory functions, whereas those with medical treatment only showed improvement in memory. CAS did not improve any subscores. There was no significant improvement in the subscores of the MMSE in patients with CEA, CAS, or medical treatment 1 year after treatment compared with before treatment. CONCLUSIONS: CEA or CAS may be significantly associated with cognitive improvement as evaluated by the MoCA. However, patients treated medically do not show improvement in cognitive performance.

Contralateral Cerebral Hypometabolism After Cerebellar Stroke: A Functional Near-Infrared Spectroscopy Study.

INTRODUCTION: We report the changes in cortical activity evaluated using functional near-infrared spectroscopy (fNIRS) in 2 cases with cerebellar stroke. METHODS: Using an fNIRS imaging system, changes in the oxygenated hemoglobin concentration (ΔOxy-Hb) from baseline were estimated. Design and verbal fluency tasks were conducted for evaluation of visuospatial and language functions, respectively. RESULTS: The contralateral prefrontal area showed limited activation compared with the ipsilateral one in the case with either cerebellar stroke. CONCLUSIONS: A negative impact of cerebellar stroke on the multimodal association of cortex, regardless of the type of stroke (infarct or hemorrhage).

Tailor-made rehabilitation approach using multiple types of hybrid assistive limb robots for acute stroke patients: A pilot study.

This article investigated the feasibility of a tailor-made neurorehabilitation approach using multiple types of hybrid assistive limb (HAL) robots for acute stroke patients. We investigated the clinical outcomes of patients who underwent rehabilitation using the HAL robots. The Brunnstrom stage, Barthel index (BI), and functional independence measure (FIM) were evaluated at baseline and when patients were transferred to a rehabilitation facility. Scores were compared between the multiple-robot rehabilitation and single-robot rehabilitation groups. Nine hemiplegic acute stroke patients (five men and four women; mean age 59.4 ± 12.5 years; four hemorrhagic stroke and five ischemic stroke) underwent rehabilitation using multiple types of HAL robots for 19.4 ± 12.5 days, and 14 patients (six men and eight women; mean age 63.2 ± 13.9 years; nine hemorrhagic stroke and five ischemic stroke) underwent rehabilitation using a single type of HAL robot for 14.9 ± 8.9 days. The multiple-robot rehabilitation group showed significantly better outcomes in the Brunnstrom stage of the upper extremity, BI, and FIM scores. To the best of the authors' knowledge, this is the first pilot study demonstrating the feasibility of rehabilitation using multiple exoskeleton robots. The tailor-made rehabilitation approach may be useful for the treatment of acute stroke.

Do octogenarians still have a high risk of adverse outcomes after carotid endarterectomy in the era of a super-aged society? A single-center study in Japan.

BACKGROUND: The aim of this study was to evaluate the safety and feasibility of carotid endarterectomy (CEA) in Japanese octogenarians. METHODS: This study prospectively included 157 consecutive CEA procedures in 145 patients treated at Fukuoka University Hospital between May 2008 and April 2013. Clinical and radiologic findings were obtained from the medical records and by telephone interview. Major events and outcomes were compared between patients 80 years of age or older (octogenarians) and those less than 79 years of age (nonoctogenarians). RESULTS: The rate of major adverse events (major stroke, myocardial infarction, or death) in the perioperative period was 1.2%. Follow-up data were available for 142 patients (97.9%). Only 1 case (.7%) of ipsilateral stroke occurred during the follow-up period. Thirteen patients died of causes other than stroke. The estimated 1-, 3-, and 5-year overall survival rates were 98.5%, 96.9%, and 93.1%, respectively. Nineteen (13.4%) of the patients were octogenarians. There were no significant differences in baseline characteristics between octogenarians and nonoctogenarians, except for age. In octogenarians, there were no major adverse events during the perioperative period and no cases of stroke or stroke-related death during the follow-up period. The estimated 1-, 3-, and 5-year overall survival rates in octogenarians were 92.9%, 92.9%, and 61.9%, respectively. There was no significant difference in overall survival between octogenarians and nonoctogenarians (P = .371). CONCLUSIONS: The results of this study suggest that CEA can be safely performed in Japanese octogenarians. Midterm outcomes were relatively good, but long-term outcomes require further study.

Features of brain magnetic resonance imaging diffusion-weighted images of aortogenic embolic stroke.

BACKGROUND: The features of acute aortogenic embolic stroke on magnetic resonance diffusion-weighted imaging (DWI) have not been fully elucidated, so we compared patients with acute aortogenic embolic stroke and those with acute cardioembolic stroke. METHODS AND RESULTS: This study included 40 consecutive patients with acute aortogenic embolic stroke, and 40 age- and sex-matched patients with acute cardioembolic stroke. The diagnosis of aortogenic embolic stroke was made when patients met 5 criteria: (1)acute neurologic event lasting >24h; (2) positive signals on DWI; (3) atherosclerotic lesions ≥3.5-mm thick at the aortic arch on transesophageal echocardiography; (4) neuroradiologic features suggesting embolic stroke, such as lesions involving the brain cortex or the re-opening phenomenon of previously occluded vessels on Magnetic Resonance Angiography (MRA); and (5) absence of other embolic sources, including heart disease and carotid stenosis. The number, site, and maximal diameter of the infarct lesions on DWI were compared between the aortogenic and cardiogenic groups. The aortogenic patients more frequently had ≥3 lesions (25.0% vs. 2.5%, P<0.01), lesions with a maximal diameter <30mm (77.5% vs. 20.0%, P< 0.001), and vertebrobasilar system lesions (55.0% vs. 10.0%, P< 0.001) than the cardiogenic patients. CONCLUSIONS: Acute aortogenic embolic stroke is characterized by multiple (≥3) and small lesions, and involvement of the vertebrobasilar system.

Outcome of 312 Japanese patients with carotid endarterectomy and factors associated with cardiovascular events--a single-center study in Japan.

BACKGROUND: There have only been a few reports regarding the outcomes and risk factors after CEA. To clarify the factors associated with outcome in patients with carotid stenosis who underwent carotid endarterectomy (CEA), we investigated cardiovascular events and mortality in the Kyushu Medical Center in Japan. METHODS: We consecutively registered patients with significant carotid stenosis who had CEA performed over 10 years and compared the incidences of stroke, myocardial infarction, and death. On admission, we evaluated medical records for stroke risk factors, including hypertension, diabetes mellitus, hypercholesterolemia, atrial fibrillation, and current smoking habits. When performing CEA, blood pressure, heart rate, blood gases, and Doppler flow parameters in the carotid artery, and an electroencephalogram, were continuously monitored during the procedure. A shunt tube was inserted into both ends of the carotid artery, and a microscope was used. Although it was recommended that patients be evaluated by magnetic resonance imaging and ultrasound after the operation, we attempted to obtain information from the patient or a family member through a questionnaire or telephone survey if a patient did not come for assessment. We determined the factors associated with stroke, myocardial infarction, and death using Kaplan-Meier analyses. RESULTS: Of 312 CEA patients, 302 (96.8%) with confirmed outcomes were analyzed. We found that a factor associated with stroke was a history of ischemic stroke (P = .028). A history of myocardial infarction (P = .009) and the presence of peripheral arterial disease (PAD) (P = .001) were factors related to the future occurrence of myocardial infarction. Perioperative complications occurred in 6 patients (1.99%) including 1 death because of sepsis and 1 major ipsilateral stroke. Of the 302 patients who underwent CEA, 43 patients died in the follow-up period, and the 5-year survival rate was 83.9%. The number of patients who died because of myocardial infarction and cancer was 9 for each, and they were the leading causes of their death. Only 1 patient died because of stroke (2.3%). Patients with PAD had a significantly high mortality (P < .001). CONCLUSIONS: In patients who underwent CEA, a risk factor of future stroke was a history of stroke. A history of myocardial infarction or PAD was strongly associated with future occurrence of myocardial infarction or high mortality.

Long-term morbidity and mortality of carotid endarterectomy in patients with end-stage renal disease receiving hemodialysis.

BACKGROUND AND PURPOSE: Renal insufficiency is a known risk factor for stroke. However, the impact of carotid endarterectomy (CEA) on stroke incidence in patients requiring dialysis remains controversial. We hypothesized that patients undergoing dialysis have no greater risk for periprocedural adverse events. METHODS: We performed a retrospective chart review of 12 CEA patients who were on dialysis at the time of CEA. The charts were reviewed for patient demographics, systemic vascular disease, perioperative morbidity and mortality rates, and long-term outcome. Outcomes were recorded in terms of modified Rankin Scale (mRS). RESULTS: The mean patient age at the time of CEA was 66.9 ± 7.3 years, with 1 patient having received carotid artery stenting for restenosis. Of the 12 patients undergoing 15 CEAs while being dialysis dependent, none exhibited periprocedural complications including stroke and myocardial infarction. During the follow-up period (mean, 56.1 ± 38.8 months), 3 patients had strokes unrelated to the target vessels for CEA, and 3 patients died from acute myocardial infarction, congestive heart failure, and sepsis. The calculated 5-year survival rate in our series was 58.3% in all cases, 40.0% in symptomatic patients, and 71.4% in asymptomatic patients. Eight patients (66.6%) had a good outcome. CONCLUSIONS: These data suggest that patients undergoing dialysis were at no greater risk for periprocedural complications when undergoing CEA. Thus, CEA may be effective for stroke prevention in hemodialysis patients.

Do characteristics of dissection differ between the posterior inferior cerebellar artery and the vertebral artery?

OBJECTIVE: The purpose of this study was to clarify the features of posterior inferior cerebellar artery (PICA) dissection. MATERIALS AND METHODS: We prospectively registered 93 consecutive patients and 108 arteries with confirmed diagnoses of dissection in the vertebral artery (VA) or PICA between February 2007 and January 2014. Patients were diagnosed with arterial dissection when they had both acute symptoms and radiological characteristics in magnetic resonance imaging or digital subtraction angiography. Patients were divided into 2 groups depending on whether the site of dissection was VA (VA group) or PICA (PICA group). We compared the clinical and radiological characteristics and clinical outcomes of PICA versus VA dissection. RESULTS: Of the 93 patients included in this study, 83 were in the VA group, and 10 had arterial dissection in the PICA. Patients with PICA dissection more frequently suffered from SAH (P < .001), whereas nonstroke symptom was often the initial symptom in the VA group. Pearl sign was seen most frequently at the dissection site of PICA. Surgical or endovascular treatment was performed in 9 of 10 PICA dissections, whereas more than half of the VA dissections were treated conservatively (P < .001). SAH was significantly more severe in the patients with PICA dissection compared with those in the VA group (P = .049). CONCLUSION: Patients with PICA dissection suffered from subarachnoid hemorrhage more frequently than those with VA dissection. PICA dissection was treated with surgical intervention, whereas VA dissection was treated conservatively.

Revascularization for acute ischemic stroke is safe for rivaroxaban users.

BACKGROUND: The safety of recombinant tissue plasminogen activator (rt-PA) and/or endovascular therapy for patients using the novel oral anticoagulant (NOAC) for atrial fibrillation remains unclear. METHODS: We report a patient who was treated by both rt-PA and endovascular thrombectomy who suffered from acute ischemic stroke under treatment with NOAC. RESULTS: An 83-year-old woman had a medical history with ischemic stroke due to paroxysmal atrial fibrillation and was then administered 10 mg of rivaroxaban daily. Although she took rivaroxaban in the morning, ischemic stroke recurred at midnight of that day. Soon after transferring to our hospital, we confirmed right middle cerebral artery (MCA) occlusion in the patient and then initiated treatment with intravenous rt-PA. Although no hemorrhagic complication occurred, recovery of her symptoms was not seen, and endovascular thrombectomy was performed. Although the inferior branch of the MCA was recanalized, an infarct was seen in her left frontal lobe. Hemorrhagic transformation was not observed during or after these combined treatments. CONCLUSIONS: Thrombolysis and/or endovascular thrombectomy might be safe for patients treated with the new anticoagulant rivaroxaban.

Improvement of cognitive function after carotid endarterectomy--a new strategy for the evaluation of cognitive function.

Significant carotid stenosis is known to cause ischemic stroke and cognitive impairment. However, it remains controversial whether carotid endarterectomy (CEA) can improve cognitive function in patients with carotid stenosis. We used the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) to compare cognitive function between before and after CEA. Patients were prospectively registered to evaluate cognitive function from October 2011 to December 2012 after we determined them to have significant carotid stenosis. Patients were examined by 3-dimensional computed tomographic angiography or digital subtraction angiography. Although symptomatic cases were included, their modified Rankin Scale was grade 0 or 1 before CEA. All CEA procedures were performed by the same neurosurgical team. Cognitive function was evaluated by MoCA and MMSE performed before and after surgery. Data were analyzed statistically using the Wilcoxon signed rank test. Thirty-six patients were included in this study. The MoCA score after surgery, whereas the MMSE score was not. After surgery, the MoCA score improved in patients who were 73 years or younger, who underwent CEA in the left side of their carotid lesion, who had severe carotid stenosis of more than 80%, who had bilateral lesion, who did not have abnormal lesion on diffusion-weighted imaging after surgery, or who had cerebral blood flow of pre-CEA over 34.5 mL. In conclusion, MoCA was feasible in patients soon after undergoing CEA. Using MoCA not MMSE, CEA may improve cognitive function in patients with significant carotid stenosis.