Internal carotid artery-persistent primitive anterior choroidal artery aneurysms: report of two cases and literature review.

PURPOSE: Persistent primitive anterior choroidal artery (PPAChA) is a rare vascular anomaly. The clinical course of internal carotid artery (ICA)-PPAChA aneurysms has not been well described. CASE REPORTS: We report two patients with an ICA-PPChA aneurysm and summarize previously reported cases. RESULTS: Including our two, a total of 10 patients with an ICA-PPAChA aneurysm have been reported. Data were not described for one. Among the remaining nine, five patients (56%) experienced aneurysmal rupture. Five patients underwent surgical clipping and four underwent endovascular coiling. The procedure was completed in all but one patient who had a tiny branch artery adherent to the aneurysm; this patient was converted from clipping to aneurysm coating with a cotton sheet. Among the other eight patients, one who underwent coiling experienced an internal capsule infarction. The remaining seven had a satisfactory postoperative course; however, an asymptomatic occlusion of the PPAChA at its origin was noted on postoperative angiography in one. CONCLUSION: PPChA is associated with a high incidence of aneurysm formation and rupture. During treatment of ICA-PPAChA aneurysms, obstruction of the PPAChA and any surrounding perforating arteries should be avoided to prevent ischemic stroke.

Five-Year Stroke Risk and Its Predictors in Asymptomatic Moyamoya Disease: Asymptomatic Moyamoya Registry (AMORE).

BACKGROUND: Long-term outcomes are unknown in patients with asymptomatic moyamoya disease. In this report, we aimed to clarify their 5-year risk of stroke and its predictors. METHODS: We are conducting a multicenter, prospective cohort study (Asymptomatic Moyamoya Registry) in Japan. Participants were eligible if they were 20 to 70 years, had bilateral or unilateral moyamoya disease, experienced no episodes suggestive of TIA and stroke; and were functionally independent (modified Rankin Scale score 0-1). Demographic and radiological information was collected at enrollment. In this study, they are still followed up for 10 years. In this interim analysis, we defined the primary end point as a stroke occurring during a 5-year follow-up period. Independent predictors for stroke were also determined, using a stratification analysis method. RESULTS: Between 2012 and 2015, we enrolled 109 patients, of whom 103 patients with 182 involved hemispheres completed the 5-year follow-up. According to the findings on DSA and MRA, 143 hemispheres were judged as moyamoya disease and 39 hemispheres as questionable manifestations (isolated middle cerebral artery stenosis). The patients with questionable hemispheres were significantly older, more often male, and more frequently had hypertension than those with moyamoya hemisphere. Moyamoya hemispheres developed 7 strokes, including 6 hemorrhagic and 1 ischemic stroke, during the first 5 years. The annual risk of stroke was 1.4% per person, 0.8% per hemisphere, and 1.0% per moyamoya hemisphere. Independent predictor for stroke was Grade-2 choroidal anastomosis (hazard ratio, 5.05 [95% CI, 1.24-20.6]; P=0.023). Furthermore, microbleeds (hazard ratio, 4.89 [95% CI, 1.13-21.3]; P=0.0342) and Grade-2 choroidal anastomosis (hazard ratio, 7.05 [95% CI, 1.62-30.7]; P=0.0093) significantly predicted hemorrhagic stroke. No questionable hemispheres developed any stroke. CONCLUSIONS: The hemispheres with asymptomatic moyamoya disease may carry a 1.0% annual risk of stroke during the first 5 years, the majority of which are hemorrhagic stroke. Grade-2 choroidal anastomosis may predict stroke, and the microbleeds and Grade-2 choroidal anastomosis may carry the risk for hemorrhagic stroke. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: UMIN000006640.

Increased Piezo1 expression in myofibroblasts in patients with symptomatic carotid atherosclerotic plaques undergoing carotid endarterectomy: A pilot study.

OBJECTIVES: We aimed to investigate Piezo1 expression in myofibroblasts in symptomatic and asymptomatic patients undergoing carotid endarterectomy and its relationship with atherosclerotic plaque formation. METHODS: This cross-sectional study analyzed carotid plaques of 17 randomly selected patients who underwent carotid endarterectomy from May 2015 to August 2017. In total, 51 sections (the most stenotic lesion, and the sections 5-mm proximal and distal) stained with hematoxylin-eosin and elastica-Masson were examined. Immunohistochemistry was performed using antibodies to Piezo1. The Piezo1 score of a section was calculated semiquantitatively, averaged across 30 randomly selected myofibroblasts in the fibrous cap of the plaque. RESULTS: Of 17 patients (mean age: 74.2 ± 7.1 years), 15 were men, 9 had diabetes mellitus, and 13 had hypertension. Symptomatic patients had higher mean Piezo1 score than asymptomatic patients (1.78 ± 0.23 vs 1.34 ± 0.17, p < .001). Univariate linear regression analyses suggested an association between plaque rupture, thin-cap fibroatheroma and microcalcifications and the Piezo1 score (p = .001, .008, and 0.003, respectively). CONCLUSIONS: Increased Piezo1 expression of myofibroblasts may be associated with atherosclerotic carotid plaque instability. Further study is warranted to support this finding.

[Emergency Superficial Temporal Artery-Middle Cerebral Artery Bypass for Atherosclerotic Ischemic Stroke].

Endovascular recanalization is the primary strategy for the treatment of acute embolic stroke. However, atherosclerotic occlusions are often challenging to recanalize, and only medical therapy can be performed. In these cases, even the best medical treatment may not be effective, and the cerebral infarction progressively worsens. We believe that an emergency superficial temporal artery-middle cerebral artery(STA-MCA)bypass could be effective in these situations, after careful case selection. We use the following eligibility criteria: (1)atherosclerotic infarction; (2)cerebral ischemia with blood flow < 70% of the contralateral side; (3)progressively worsening symptoms or widening of the subcortical infarction despite medical treatment; and(4)surgery availability < 72 h from symptom onset. Among the 35 patients who underwent urgent STA-MCA bypass from 2014 to 2020, 27(77.1%)gained gait independence, and the National Institutes of Health Stroke Scale(NIHSS)scores improved from a preoperative median of 8 to 3 at discharge. The modified Rankin score(mRS)improved from a preoperative median of 5 to 2 at discharge. No intracerebral hemorrhages occurred due to hyper-perfusion syndrome. When we match it with other reports, this emergency surgery allows 76-90% of patients with progressive stroke to achieve gait independency.

Development of Quality Indicators of Stroke Centers and Feasibility of Their Measurement Using a Nationwide Insurance Claims Database in Japan　­ J-ASPECT Study ­

BACKGROUND: We aimed to develop quality indicators (QIs) related to primary and comprehensive stroke care and examine the feasibility of their measurement using the existing Diagnosis Procedure Combination (DPC) database. METHODS AND RESULTS: We conducted a systematic review of domestic and international studies using the modified Delphi method. Feasibility of measuring the QI adherence rates was examined using a DPC-based nationwide stroke database (396,350 patients admitted during 2013-2015 to 558 hospitals participating in the J-ASPECT study). Associations between adherence rates of these QIs and hospital characteristics were analyzed using hierarchical logistic regression analysis. We developed 17 and 12 measures as QIs for primary and comprehensive stroke care, respectively. We found that measurement of the adherence rates of the developed QIs using the existing DPC database was feasible for the 6 QIs (primary stroke care: early and discharge antithrombotic drugs, mean 54.6% and 58.7%; discharge anticoagulation for atrial fibrillation, 64.4%; discharge antihypertensive agents, 51.7%; comprehensive stroke care: fasudil hydrochloride or ozagrel sodium for vasospasm prevention, 86.9%; death complications of diagnostic neuroangiography, 0.4%). We found wide inter-hospital variation in QI adherence rates based on hospital characteristics. CONCLUSIONS: We developed QIs for primary and comprehensive stroke care. The DPC database may allow efficient data collection at low cost and decreased burden to evaluate the developed QIs.

[Preventing Crying after Revascularization Surgery in Pediatric Patients with Moyamoya Disease:Sedation with Dexmedetomidine].

BACKGROUND: Hyperventilation is a well-known risk factor of ischemic events in pediatric patients with moyamoya disease. For young children, it is important to avoid crying to prevent ischemic events because of their unstable postoperative hemodynamics. To prevent crying in pediatric patients, we used dexmedetomidine(DEX)for sedation immediately after revascularization surgery. OBJECTIVE: We investigated the effects of postoperative DEX use on hemodynamic changes and the avoidance of crying and hypocapnia in pediatric patients with moyamoya disease. CASE: Ten consecutive patients(5 boys and 5 girls)who underwent surgical revascularization were enrolled, and 16 hemispheres(8 boys and 8 girls)were sedated with DEX postoperatively between August 2011 and August 2016. METHODS: During extubation after revascularization, DEX was started at 0.4µg/kg/hr under spontaneous breathing and its dose was increased depending on the degree of consciousness, to maintain sedation of at least 3 on the Ramsay scale. DEX administration was terminated the next morning. RESULTS: Sedation was maintained well in all patients without hypocapnia, and no ischemic complications were observed. One patient cried and needed additional intravenous DEX injections and was immediately re-sedated;no hypocapnia developed. Respiratory depression did not occur and changes in respiratory rate and decreases in SpO2 were not observed. No significant changes in systolic blood pressure and heart rate were observed. CONCLUSION: Dexmedetomidine is safe and useful for postoperative sedation in children with moyamoya disease.

[Treatment Strategy and Results of Carotid Endarterectomy in Chronic Renal Failure Patients].

INTRODUCTION: The number of patients receiving chronic dialysis treatment in Japan currently exceeds 300,000 people. Few reports have described carotid endarterectomy(CEA)for chronic renal failure patients because of the unacceptable rate of perioperative stroke and other morbidities. A strategy for and treatment results of CEA for chronic renal failure patients in our hospital are described herein. METHODS: The present study included 6 patients who underwent CEA while receiving dialysis treatment between April 2011 and November 2014. RESULTS: Dialysis treatment was initiated due to diabetes in 4 patients and renal sclerosis in 2 patients. All the patients were men, with a mean age of 74.0 years. Two patients were symptomatic, and four were asymptomatic. In all the patients, heart vascular lesions and arteriosclerosis risk factors were present. Postoperatively, pneumonia transient cranial neuropathy, heart failure, and pneumonia in 1 case required extensive treatment. However, by the time of discharge from hospital, no cases had deteriorated compared with their pre-CEA state. The modified Rankin scale score on discharge was 0-2 for all the patients. CONCLUSION: CEA can be performed safely in patients receiving dialysis, but further operative procedures and careful postoperative management are likely to be needed for patients with CEA who are receiving dialysis.

Fatal stroke with acute simultaneous bilateral common carotid artery occlusion presenting as sudden coma: A case report.

Common carotid artery occlusion is rare. Bilateral common carotid artery occlusion is extremely rare and, to our knowledge, has hardly ever been reported. This report describes a case of fatal stroke with acute simultaneous bilateral common carotid artery occlusion presenting as sudden coma. A 90-year-old woman was transferred to our hospital by ambulance with a sudden coma. She had a history of atrial fibrillation but had not taken any oral antithrombotic medication in recent years. She had been receiving house calls for dehydration in the previous week. Magnetic resonance imaging showed extensive cerebral infarcts in both cerebral hemispheres, and magnetic resonance angiography revealed bilateral common carotid artery occlusion. Acute recanalization therapy was not performed because of the extensive cerebral infarction, the patient's advanced age, and her poor ability to perform activities of daily living. On the day after onset, she died of massive cerebral infarction and marked brain swelling.

Endovascular treatment of acute atherothrombotic internal carotid artery occlusion associated with persistent primitive hypoglossal artery.

Persistent primitive hypoglossal artery is a relatively rare anatomical variation and a type of persistent carotid-basilar anastomosis. Acute internal carotid artery occlusion associated with persistent primitive hypoglossal artery is rare, and atherothrombotic occlusion is extremely rare. We present a case of acute atherothrombotic internal carotid artery occlusion associated with persistent primitive hypoglossal artery that was successfully treated by endovascular treatment. A 70-year-old male with a history of left internal carotid artery stenosis was transferred to our hospital by ambulance because of abnormal behaviors and aphasia. He was diagnosed with cerebral infarction and left internal carotid artery occlusion. Left carotid angiography revealed the persistent primitive hypoglossal artery arising from the cervical internal carotid artery and complete internal carotid artery occlusion distal to the origin of the persistent primitive hypoglossal artery. Therefore, we performed endovascular treatment. Mechanical thrombectomy was performed under minimal flow arrest with consideration of brain ischemia causing coma. After additional balloon angioplasty, recanalization was achieved, and the patient's symptoms improved. During the 1.5-year follow-up period, no recurrence or restenosis was observed. This report provides evidence that atherosclerotic internal carotid artery stenosis associated with persistent primitive hypoglossal artery can occur even distal to the origin of the persistent primitive hypoglossal artery and that the lesion may become acutely occluded, leading to acute stroke. Endovascular treatment considering brain ischemia was effective in this case.

Significant Correlation between Structural Changes in the Net-like Appearance on Postoperative Cranial Magnetic Resonance Images and Hematoma Recurrence in Cases of Chronic Subdural Hematoma.

Organized hematoma, which exhibits a net-like appearance on imaging studies, is one of the predisposing factors for the recurrence of chronic subdural hematoma. Patients who are positive for the net-like appearance are often treated with only burr hole surgery. We investigated the relationship between postoperative structural changes in the net-like appearance and the recurrence rate of chronic subdural hematoma. Of the 949 patients with chronic subdural hematoma treated with primary burr hole surgery between January 2010 and April 2021 at our hospital, 268 who were considered positive for the net-like appearance on T2- and T2 star-weighted magnetic resonance images were extracted. We followed the structural changes in the net-like appearance postoperatively and subsequently classified the patients into three groups: decreasing type, shifting type, and no change and deterioration type. The relationship between each structural change and the recurrence rate in the three groups was investigated. Postoperative recurrence requiring surgery occurred in 3.5% of the subjects with decreasing type, 0% with shifting type, and 100% with deterioration type of the net-like appearance (P < 0.05), indicating differences in the recurrence rates according to postoperative structural changes in the magnetic resonance images (MRI) features of chronic subdural hematoma. Our results indicate that the risk of postoperative chronic subdural hematoma recurrence can be predicted by focusing on the structural changes in the postoperative net-like appearance on MRI.

Long insular artery damage might be a key sign for predicting functional prognosis of putaminal hemorrhage.

OBJECTIVE: Although the putamen is the most common area of spontaneous intracerebral hemorrhage, previous reports about the effects of surgery are limited. We sometimes experience a poor prognosis in patients in whom there is no damage to the internal capsule, but with injury in the long insular artery (LIA) region. The purpose of this study was to confirm the relationship between LIA damage and patient prognosis following surgery for putaminal hemorrhage. METHODS: We retrospectively collected data of 287 surgical cases who presented with putaminal hemorrhage between January 2004 and March 2022. Among them, we chose patients without initial damage to the posterior limb of the internal capsule, and divided these patients into two groups, those without (Group A) and with (Group B) final damage in the LIA region. We compared positivity rates of final manual muscle test (MMT) scores≥3 and related factors. RESULTS: Sixty-three of the 287 patients were included in this study. Of them, 11 cases in Group A were positive for MMT scores≥3 (68.8%) and 9 cases (19.1%) in Group B had MMT scores≥3 seven days after surgery. Group A thus had a significantly higher rate of MMT scores≥3 than group B (p=0.00). CONCLUSION: In patients without initial damage to the internal capsule, LIA injury might be a key sign for predicting the functional prognosis of putaminal hemorrhage.

National trends in the outcomes of subarachnoid haemorrhage and the prognostic influence of stroke centre capability in Japan: retrospective cohort study.

OBJECTIVES: To examine the national, 6-year trends in in-hospital clinical outcomes of patients with subarachnoid haemorrhage (SAH) who underwent clipping or coiling and the prognostic influence of temporal trends in the Comprehensive Stroke Center (CSC) capabilities on patient outcomes in Japan. DESIGN: Retrospective study. SETTING: Six hundred and thirty-one primary care institutions in Japan. PARTICIPANTS: Forty-five thousand and eleven patients with SAH who were urgently hospitalised, identified using the J-ASPECT Diagnosis Procedure Combination database. PRIMARY AND SECONDARY OUTCOME MEASURES: Annual number of patients with SAH who remained untreated, or who received clipping or coiling, in-hospital mortality and poor functional outcomes (modified Rankin Scale: 3-6) at discharge. Each CSC was assessed using a validated scoring system (CSC score: 1-25 points). RESULTS: In the overall cohort, in-hospital mortality decreased (year for trend, OR (95% CI): 0.97 (0.96 to 0.99)), while the proportion of poor functional outcomes remained unchanged (1.00 (0.98 to 1.02)). The proportion of patients who underwent clipping gradually decreased from 46.6% to 38.5%, while that of those who received coiling and those left untreated gradually increased from 16.9% to 22.6% and 35.4% to 38%, respectively. In-hospital mortality of coiled (0.94 (0.89 to 0.98)) and untreated (0.93 (0.90 to 0.96)) patients decreased, whereas that of clipped patients remained stable. CSC score improvement was associated with increased use of coiling (per 1-point increase, 1.14 (1.08 to 1.20)) but not with short-term patient outcomes regardless of treatment modality. CONCLUSIONS: The 6-year trends indicated lower in-hospital mortality for patients with SAH (attributable to better outcomes), increased use of coiling and multidisciplinary care for untreated patients. Further increasing CSC capabilities may improve overall outcomes, mainly by increasing the use of coiling. Additional studies are necessary to determine the effect of confounders such as aneurysm complexity on outcomes of clipped patients in the modern endovascular era.

Development of transdural anastomosis after craniotomy in a patient with atherothrombotic carotid occlusion.

Development of transdural anastomosis is extremely rare in the patients with atherosclerotic cerebrovascular disease. We report a rare case of development of transdural anastomosis after craniotomy in the patient with atherothrombotic carotid occlusion.

Mechanical Thrombectomy Making Practical Use of an Aspiration Catheter While Selecting the Retrieval Technique during the Procedure.

Objective: To report the outcomes of thrombectomy for arterial occlusion involving the major arteries of the cerebral anterior circulation when an aspiration catheter (AC) was used in all cases, with the retrieval technique chosen during the procedure. Methods: Of the 126 patients who underwent endovascular thrombectomy during the 2-year period of 2018-2019, the study subjects were 102 patients with arterial occlusion involving the major arteries of the cerebral anterior circulation. Patients were divided into two groups depending on when the procedure was performed. In the earlier group (January 2018-March 2019), treatment was performed using only a stent retriever (SR), whereas an AC was used for all cases in the later group (April-December 2019). Outcomes between groups were retrospectively compared. In the later group, the treatment strategy was to use the SR in combination with the AC (combined technique) for retrieval if the microcatheter reached the distal side of the occlusion site without difficulty. If the microcatheter did not easily reach the distal side, we did not stick to penetrating the occlusion site, and contact aspiration was performed. Results: Thrombolysis in cerebral infarction (TICI) grade 2b-3 was achieved in 85% of patients in the earlier group and 95% in the later group. TICI grade 3 was achieved in 52% of the earlier group and 54% of the later group, showing no significant difference. TICI grade 2b-3 was achieved at first pass in 46% of patients in the earlier group, significantly lower than the 71% in the later group (P = 0.013). The mean number of passes decreased significantly from 1.84 in the earlier group to 1.32 in the later group (P = 0.002). Conclusion: Using an AC from the start, and using a combined technique when the microcatheter reached the distal side of the occlusion site, the frequency of first-pass TICI grade 2b-3 increased, and the mean number of passes decreased in comparison with the SR-alone group.

Predictors of a Good Outcome in Endovascular Treatment for Basilar Artery Occlusion with a Direct Aspiration First-Pass Technique.

Objective: There is limited evidence for mechanical thrombectomy in patients with basilar artery occlusion. Despite recanalization, there are several reports on poor outcomes. Therefore, we retrospectively evaluated the outcomes and examined the predictors of mechanical thrombectomy in patients with basilar artery occlusion. Methods: We recruited 22 consecutive patients who had received mechanical thrombectomy for basilar artery occlusion with a direct aspiration first-pass technique at our hospital between January 2016 and April 2020. The subjects were divided into good (modified Rankin Scale [mRS] ≤2) and poor outcome groups (mRS ≥3) and compared with one another. We conducted ROC analysis to identify the cut-off value that revealed a statistically significant difference in the univariate analysis. Results: Of the 22 patients, the average age ± standard deviation (SD), median pretreatment NIHSS (interquartile range [IQR]), and median pretreatment posterior circulation acute stroke progression early CT score (pc-ASPECTS) (IQR) were 76 ± 10 years, 21 (8-31), and 8 (5-9), respectively. The predictors that showed statistically significant differences in the univariate analysis were age, pretreatment NIHSS score, and pretreatment pc-ASPECTS. Based on the ROC analysis, age (area under the curve [AUC] of 0.782, cutoff <74, and P = 0.028), pretreatment pc-ASPECTS (AUC of 0.850, cutoff ≥7, and P = 0.006), and pretreatment NIHSS (AUC of 0.803, cutoff <19, and P = 0.018) were significant prognostic factors. Conclusion: In this study, aged <74 years, pc-ASPECTS ≥7, and NIHSS <19 were significant prognostic factors in endovascular treatment for basilar artery occlusion with a direct aspiration first-pass technique.

Vertebral artery stump syndrome: A 7-year follow-up case report.

Vertebral artery stump syndrome is rare, but one of the most important causes of posterior circulation stroke. To our knowledge, no optimal treatment for vertebral artery stump syndrome has been established, and there are no reports of long-term follow-up. We describe a 69-year-old man with vertebral artery stump syndrome who attended our hospital because of vertigo. Magnetic resonance imaging detected right cerebellar infarcts. Digital subtraction angiography revealed severe stenosis (functional obstruction) at the origin of the right vertebral artery, with distal antegrade collateral flow from the deep cervical artery. We started him on argatroban and cilostazol, but symptoms recurred after 1 month. We changed from cilostazol to aspirin and clopidgrel, then terminated aspirin 1 month after recurrence. He continued on clopidgrel, and follow-up after 7 years showed no recurrence, including asymptomatic lesions.

Separate origins of the left internal and external carotid arteries from the aorta in a patient with intracerebral hemorrhage.

Agenesis of the left common carotid artery with separate origins of the left internal and external carotid arteries from the aorta is an extremely rare anomaly. This anomaly is typically asymptomatic unless associated with other conditions. We report a case of separate origins of the left internal and external carotid arteries from the aorta in a patient with intracerebral hemorrhage. A 42-year-old man was transferred to our hospital by ambulance because of left hemiparesis. Computed tomography scan revealed right putaminal hemorrhage. Computed tomography angiography and digital subtraction angiography demonstrated independent origins of the left internal carotid artery and external carotid artery from the aortic arch. Right internal carotid angiography revealed blood supply to the left anterior cerebral artery and middle cerebral artery via the anterior communicating artery. The separate origins of the left internal and external carotid arteries from the aorta may cause hemodynamic stress to the contralateral side, leading to right intracerebral hemorrhage.

A Case of Internal Carotid Artery Occlusion Caused by En Bloc Distal Embolization of Carotid Free-Floating Thrombus Treated by Mechanical Thrombectomy.

Objective: We report a case of internal carotid artery (ICA) occlusion caused by en bloc distal embolization of carotid free-floating thrombus (FFT) treated by mechanical thrombectomy. Case Presentation: A 57-year-old woman was brought to our hospital with dysarthria, right hemiparesis, and motor aphasia. MRI and MRA revealed acute infarction due to middle cerebral artery occlusion. Carotid ultrasonography demonstrated a pedunculated mobile plaque in the left ICA. We diagnosed embolic infarction due to the carotid FFT and started medical treatment. However, on the second hospital day, the carotid FFT detached from the arterial wall en bloc, resulting in left ICA occlusion. The occluded ICA was successfully recanalized by mechanical thrombectomy. Conclusion: FFT is associated with a high risk of embolic ischemic stroke and the primary treatment strategy must be carefully considered.

Target Embolization of Dilated Post-PICA Segment for Ruptured PICA-Involved Type Vertebral Artery Dissecting Aneurysm.

Objective: In parent artery occlusion (PAO) for ruptured vertebral artery dissecting aneurysms (RVADA), target embolization using coils in a short segment to occlude only the vasodilated area containing the rupture point is selected as a first-choice procedure at our institute. We focused on RVADA involving the posterior inferior cerebellar artery (PICA) and evaluated the treatment results. Methods: This study consisted of eight cases with RVADA involving the PICA which were treated between October 2007 and January 2020. Based on radiological findings such as the bleb, the rupture points were located at the affected vertebral artery (VA) distal to PICA in all cases. Target embolization, by which only coiling at the dilated segment distal to the VA was performed. We aimed to preserve blood flow to the PICA. The incidence and extent of medullary infarctions, and neurological outcome were retrospectively assessed. Results: Regarding the diameter of bilateral VA, there were no differences in six cases while the affected VA with RVADA were larger in the remaining two cases. PICA was preserved in all cases but one in which occlusion of complementary PICA was observed. Postoperative medullary infarction was not noted. There was no rebleeding during the follow-up period. However, recanalization of the VA was observed in four cases and additional coil embolization was performed. All patients were discharged with a good outcome (modified Rankin Scale [mRS] 0; seven patients, mRS 2; one patient). Conclusion: Target embolization preserving the PICA in PICA-involved type RVADA was considered to be an effective treatment method for cases whose rupture point was located in the VA distal to PICA orifice.

Small Unruptured Aneurysm Verification-prevention Effect against Growth of Cerebral Aneurysm Study Using Statin.

Several basic experimental studies have demonstrated that statins have beneficial effects for intracranial aneurysm (IA). Clinical studies on unruptured IAs, however, remain limited to four retrospective studies that have reached different conclusions. This study was the first open-label, multicenter, randomized controlled trial to assess the preventive effects of atorvastatin. Patients with unruptured small saccular IAs were randomly assigned to statin and control groups. The primary endpoint was a composite of aneurysm growth of ≥0.5 mm, new bleb formation confirmed from magnetic resonance (MR) angiography, and rupture. Enrollment was prematurely terminated due to unexpectedly slow enrollment. Of 231 patients (275 target IAs), 110 patients (128 IAs) were randomly assigned to the statin group and 121 patients (147 IAs) to the control group. After excluding 22 dropout patients, 107 IAs in the 93 statin group patients and 140 IAs in the 116 control group patients were finally analyzed. No significant differences of basic characteristics were evident between groups, except for significantly higher systolic pressure in the statin group (P = 0.03). The primary endpoint occurred in 28 IAs (20.0%) in the control group and in 17 IAs (15.9%) in the statin group. No aneurysm rupture was confirmed in either group. Significant beneficial effects of statin for IAs were not demonstrated for the primary endpoint (log-rank P = 0.359). This randomized trial did not establish any preventive effects of atorvastatin for unruptured small IAs. Further studies of larger cohorts are required to clarify the efficacy of statins for patients with unruptured IAs. Clinical trial registration: UMIN000005135.