Factors Influencing Discontinuation of Clazosentan Therapy in Elderly Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study from a Japanese Single Center.

BACKGROUND Clazosentan is an endothelin receptor antagonist approved in Japan for preventing cerebral vasospasm and vasospasm-associated cerebral ischemia and infarction. This study included elderly patients aged ≥75 years with aneurysmal subarachnoid hemorrhage (SAH) and aimed to evaluate the factors associated with discontinuing anti-vasospasm therapy with clazosentan. MATERIAL AND METHODS In this single-center retrospective observational study, we extracted diagnostic and therapeutic work-up data of consecutive 40 patients with SAH treated with clazosentan infusion (10 mg/h) as first-line anti-vasospasm therapy between May 2022 and August 2023. Patient data were compared between the discontinued and completed groups, and related factors for the discontinuation were further analyzed. RESULTS Clazosentan was discontinued in 22% (n=9) of patients due to intolerable dyspnea accompanied by hypoxemia at 5±3 days after therapy initiation, in which 44% (n=4) were elderly (≥75 years). Patients who discontinued clazosentan therapy showed significantly lower urine volumes compared with those who completed the therapy (P<0.05). Multivariate regression analysis revealed that day-to-day urine volume variance and older age were independent risk factors for drug cessation (P<0.05). The cut-off value for predicting clazosentan discontinuation was -0.7 mL/kg/h with sensitivity of 86% and specificity of 75% (area under the curve: 0.76±0.10; 95% confidence interval: 0.56-0.96; P=0.035). CONCLUSIONS Our results suggest that approximately 20% of SAH patients suffered from intolerable respiratory symptoms attributable to hypoxemia. We found that both reduced day-to-day urine volume variation and older age are independent risk factors for drug discontinuation.

Cardiopulmonary Events of the Elderly (≥75 Years) during Clazosentan Therapy after Subarachnoid Hemorrhage: A Retrospective Study from a Tertiary Stroke Center in Japan.

Clazosentan has been shown to prevent vasospasm and reduce mortality in patients after aneurysmal subarachnoid hemorrhage (SAH) and has been approved for clinical use in Japan; however, its systemic events in the elderly (aged ≥ 75 years) have not been well-documented. Here, we report serious/intolerable cardiopulmonary complications requiring discontinuation of drug therapy in elderly SAH patients. In this single-center case series study, medical records of consecutive SAH patients treated postoperatively with clazosentan (10 mg/h) between June 2022 and May 2023 were reviewed retrospectively. Thirty-three patients received clazosentan therapy, of whom six were elderly with a mean age of 80.3 ± 5.2 (range 75-89) years. Among them, despite no obvious medical history of systemic abnormalities, clazosentan was discontinued in three (50%) patients due to pleural effusion and hypoxemia with or without hypotension at 5 ± 3 days after therapy initiation, which was higher than the incidence for younger patients (15%). The elderly patients had significantly lower urine output (1935 ± 265 vs. 1123 ± 371 mL/day, p = 0.03) and greater weight gain (2.1 ± 1.1 vs. 4.2 ± 1.9 kg from baseline, p = 0.04) than patients who completed the therapy. One 89-year-old female developed congestive heart failure and hydrostatic pulmonary edema associated with increased intravascular and lung volumes even after therapy was discontinued, while the remaining two cases recovered within 2 days after drug cessation. These results suggest that elderly patients are more vulnerable to fluid retention and have a higher risk of cardiopulmonary complications during clazosentan therapy than younger patients. Careful monitoring of urine volume and weight gain and caution regarding age- and therapy-related hemodynamic insufficiencies are required.

Secular Trends in the Background of Intracerebral Hemorrhage from 2010 to 2015.

OBJECTIVE: Direct oral anticoagulants (DOACs) were recently introduced for the clinical use in stroke prevention, and they are reported to show a lower risk of intracerebral hemorrhage (ICH) compared to warfarin. We were interested to know whether there is any change in clinical backgrounds of ICH patients to date. METHODS: From 2010 to 2015, ICH patients admitted to our hospital were consecutively screened (n = 658). Hematoma size was assessed by brain computed tomography images on admission. Outcome was measured by the modified Rankin Scale, and favorable outcome was defined as modified Rankin Scale 0-2. Biennial trends were compared in 3 periods, P1: 2010-2011, P2: 2012-2013, and P3: 2014-2015. RESULTS: The percentage of ICH patients taking antithrombotics had been slightly decreasing (P = .245: [P1] 33.0%, [P2] 27.4%, and [P3] 26.2%). The frequency of patients taking antiplatelets had significantly decreased (P = .001: [P1] 50.7%, [P2] 44.3%, and [P3] 22.8%), and those taking DOACs had significantly increased (P = .001: [P1] 1.4%, [P2] 4.9%, and [P3] 19.3%). Frequency of favorable outcomes in patients taking antithrombotics was slightly increased in P3 compared to P1 and P2 (23.3%, 21.1%, and 21.3%, respectively). There was no significant difference in hematoma size between patients taking warfarin and DOACs. CONCLUSIONS: Number of ICH patients taking antithrombotics has been slightly decreasing and the percentage taking DOACs among ICH has been increasing for 6 years.

Outcome of Secondary Stroke Prevention in Patients Taking Non-Vitamin K Antagonist Oral Anticoagulants.

BACKGROUND: Since non-vitamin K antagonist oral anticoagulants (NOACs) were released for clinical use, many studies have investigated its effectiveness in stroke prevention. In this study, to determine whether or not there is a difference in outcome in secondary stroke prevention between warfarin and NOACs, patients with embolic stroke with newly prescribed anticoagulants were prospectively analyzed. METHODS: Patients with acute ischemic stroke, who newly started anticoagulant therapy, were consecutively asked to participate in this study. Enrolled patients (76.3 ± 11.0 years old) were classified into warfarin (n = 48), dabigatran (n = 73), rivaroxaban (n = 49), and apixaban (n = 65). The outcome in 1 year was prospectively investigated at outpatient clinic or telephone interview. Recurrence of stroke and death was considered as the critical incidence. RESULTS: The prevalence of risk factors was not different among all medicines. Patients with dabigatran showed significantly younger onset age (P < .001: 72.2 years old) and milder neurologic deficits than patients on other medicines (P < .001). Cumulative incident rates were 7.1%, 15.3%, 19.0%, and 29.7% for dabigatran, apixaban, rivaroxaban, and warfarin, respectively. Dabigatran showed relatively better outcome compared with warfarin (P = .069) and rivaroxaban (P = .055). All patients on NOACs presented lower cumulative stroke recurrence compared with warfarin. CONCLUSION: Even in the situation of secondary stroke prevention, noninferiority of NOACs to warfarin might be demonstrated.

[Ruptured aneurysm at the anomalous arterial wall of the distal anterior inferior cerebellar artery: a case report].

Distal anterior inferior cerebellar artery(AICA)aneurysms are rare, so its pathogenesis and treatment remain controversial. Here, we report the unique pathogenesis of a ruptured aneurysm in this area that was based on anomalous components as well as partial dissection of the arterial wall. A 61-year-old woman presented to our hospital with sudden headache and nausea. On admission, neurological examination revealed slight consciousness disturbance. Computed tomography(CT)of the head showed a clotted subarachnoid hemorrhage(SAH)that was dominant in the right cerebellopontine and prepontine cistern. Three-dimensional CT angiography detected an irregular fusiform aneurysm 4.5×3.2mm in size in the distal portion of the AICA. The patient underwent trapping without distal vascular reconstruction by the lateral suboccipital approach. After surgery, she experienced right hearing disturbance and ipsilateral facial palsy that were considered to be caused by vasogenic edema at the cerebellar peduncle that resulted from the initial SAH damage. Pathology revealed an aneurysmal wall with anomalous components and arterial dissection in the arterial wall. To our knowledge, only one article has reported the histological findings of a distal AICA aneurysm. Based on the pathology of this case, these findings may suggest a useful treatment strategy for this rare aneurysm.

[Contribution of increasing age to carotid plaque morphology and symptoms].

OBJECTIVE: Aging is considered to cause atherosclerotic changes in the carotid artery, but few studies have evaluated this relationship. In this study, we used carotid plaques removed from patients with carotid artery stenosis and investigated how aging contributes to carotid plaque morphology and symptoms. MATERIALS AND METHODS: A total of 60 patients(55 men, 5 women; mean age, 70.5 years; range, 53-85 years) treated at our hospital between January 2009 and April 2012 were enrolled in this study. All patients underwent carotid endarterectomy; their carotid plaques were stained with hematoxylin-eosin and/or Elastica-Masson stain and examined by a pathologist. Using these data, the carotid systolic velocity and plaque morphology were analyzed considering the age by decade as well as the symptomatology. RESULTS: Of the 60 patients, 29 were symptomatic(transient ischemic attack (TIA) in 8 patients; infarction in 20;and amaurosis in 1). Symptoms were less common as patient age increased. The incidence of TIA also tended to decrease with an increase in age, although the opposite trend was seen with infarction. In plaque morphology, the presence of active plaque, macrophage, inflammatory infiltration, and capillary angiogenesis decreased as age increased, while the presence of degenerative plaques, decrease in smooth muscle cell number, and calcification inversely increased. Active, degenerative, and combined (active/degenerative) lesions are statistically unrelated to symptoms as well as systolic velocity (cm/sec) at the carotid stenosis. The rates of hemorrhagic lesions were similar among decades, but the lesion statistically contributed to increasing symptoms (p=0.0045) and increasing systolic velocity (p=0.031). CONCLUSION: Increasing age contributes to morphological changes in carotid plaques and symptoms. When hemorrhagic lesions are suspected in carotid plaques, patients will be symptomatic and may require surgery.

Diffusion MRI Fiber Tractography and Benzodiazepine SPECT Imaging for Assessing Neural Damage to the Language Centers in an Elderly Patient after Successful Reperfusion Therapy.

BACKGROUND: Intravenous thrombolysis and mechanical thrombectomy are the first-line reperfusion therapies for acute ischemic stroke. Here, we describe the utility of diffusion magnetic resonance imaging (MRI) fiber tractography and 123I-iomazenil benzodiazepine receptor single-photon emission computed tomography to estimate the prognosis of post-stroke aphasia after successful reperfusion therapy. CASE REPORT: An 81-year-old man was admitted to the hospital approximately 3.5 h after the onset of symptoms, including decreased consciousness, right hemiparesis, and aphasia. An MRI revealed acute cerebral infarction due to M1 segment occlusion. Intravenous alteplase thrombolysis followed by endovascular thrombectomy resulted in recanalization of the left middle cerebral artery territory. A subsequent MRI showed no new ischemic or hemorrhagic lesions. Although the patient's motor hemiparesis gradually recovered, motor aphasia persisted. Diffusion MRI fiber tractography performed 2 weeks after admission revealed partial injury to the left arcuate fasciculus, indicated by lower fractional anisotropy values than on the contralateral side. A decreased benzodiazepine receptor density was also detected in the left perisylvian and temporoparietal cortices. The patient showed no clear signs of further improvement in the chronic stage post-stroke and was discharged to a nursing home after 3 months. CONCLUSIONS: The application of functional neuroimaging techniques to assess neuronal damage to the primary brain regions 2 weeks after reperfusion therapy for large-vessel occlusion may allow for an accurate prognosis of post-stroke aphasia. This may have a direct clinical implication for navigating subacute-to-chronic phases of rehabilitative care.

Clinical Impact of a Local Triage System Using the Emergent Large Vessel Occlusion Screen with a Rotation System of Thrombectomy-Capable Hospitals.

Objective: Early intervention with mechanical thrombectomy (MT) is expected to improve the functional outcome in patients with large vessel occlusion (LVO); however, a method for the effective detection of these patients in a prehospital setting and early transport to MT-capable hospitals has not been established. This study aimed to analyze the clinical impact and diagnostic performance of the emergent large vessel occlusion (ELVO) screen and its influence on the transportation time. Methods: The emergency medical services (EMS) in one of the secondary medical areas in Akita, Japan, introduced a prehospital triage system employing an ELVO screen and a rotation system of three MT-capable hospitals on December 1, 2021. Patients who were transferred to each of the three hospitals involved in the rotation system according to a predefined priority list from December 2021 to November 2022 were included in the triage group. Patients who underwent MT in the three hospitals before the introduction of the triage system were assigned to the pre-triage group. We compared the transportation time parameters between the two groups and analyzed the performance of the ELVO screen for the diagnosis of LVOs. This study was approved by the institutional review boards of all three hospitals. Results: Time parameters were compared between the 37 and 42 patients who underwent MT and had detailed data in the triage (n = 351) and pre-triage (n = 43) groups, respectively. The time from door to puncture tended to decrease in the triage group in all hospitals, with one hospital showing a statistically significant shortening of 14 min (p = 0.018). In the triage group, 209 ELVO screen-positive patients were present, with 60 (28.7%) of these having LVO. The sensitivity, specificity, positive and negative predictive values, and area under the curve of the ELVO screen to detect LVO under the present triage system were 87.0%, 47.2%, 28.7%, 93.7%, and 0.671, respectively. Conclusion: The present study demonstrated that the introduction of a triage system may have shortened the time required for MT. ELVO screen may be considered a useful marker for screening LVO in prehospital settings in terms of the sensitivity and negative predictive value; however, further improvement may be necessary to reduce the rate of false positive results.

[Ruptured fusiform aneurysm of the supreme anterior communicating artery: a case report].

The supreme anterior communicating artery (SAcom) is a very rare anomaly that appears as a communicating artery between the anterior cerebral arteries (ACAs). This anomaly was first reported by Laitinen and Snellman in 1960. They described the SAcom as a connection between both pericallosal bifurcations. They also suggest that the SAcom may be an embryological remnant and a cause of aneurysm formation. A distal ACA aneurysm can be associated with the SAcom. In this case report, we describe a ruptured fusiform aneurysm originating from the SAcom. We treated the patient by trapping the SAcom along with the aneurysm. This is the first case report regarding a ruptured fusiform aneurysm originating from the SAcom itself.

[Remote cerebellar hemorrhage after single burr hole drainage of chronic subdural hematoma of the elderly].

Remote cerebellar hemorrhage is a usual complication after supratentorial craniotomy. Especially, only several cases have been reported regarding the occurrence of remote cerebellar hemorrhage after burr hole drainage for the treatment of chronic subdural hematoma (CSDH). In this paper, we present an elder patient with this rare postoperative complication. A 73-year-old man presented with dysarthria and right hemiparesis. Computed tomography (CT) demonstrated a left chronic subdural hematoma. Hematoma drainage through a single burr hole was perfomed. About 3 hours after the surgery, the patient became restless and presented nausea and dizziness with a relatively large amount of drainage of hematoma. CT revealed resolution of the subdural hematoma and bilateral cerebellar hemorrhage appearing as "zebra sign". Magnetic resonance angiography and 3D-CT angiography showed the normal structure of posterior circulation in both the arterial and venous phases. The remote cerebellar hemorrhage was suspected to have happened as a result of overdrainage of hematoma. Finally, he was discharged without any neurological deficits. Although remote cerebellar hemorrhage after drainage through a burr hole for the treatment of chronic subdural hematoma is a rare complication, it is necessary to be aware of the possibility of such a complication after supratentorial surgery.

[CSF leakage and anosmia in aneurysm clipping of anterior communicating artery by basal interhemispheric approach].

We studied the incidence of postoperative infection related to CSF leakage and anosmia in basal interhemispheric approach (BIH). Between April, 1990 to March, 2009, 142 cases of anterior communicating (Acom) aneurysm including both unruptured and ruptured have been treated by clipping surgery using BIH. We retrospectively obtained clinical informations from medical records and video records about infectious complications, CSF leakage of cerebrospinal fluid (CSF), olfactory dysfunction and intraoperative findings of damage to the olfactory nerve. In most cases (139 patients, 97%), frontal sinus were opened at craniotomy. Of all, CSF rinorrhea occurred in 4 cases (2.8%), and meningitis in 6 cases. There was only one patient who sufferd from meningitis due to CSF rinorrhea. All that patients recovered completely without deficit. Anosmia occurred in 6 cases (4.2%), and intraoperative injuries in 4 cases (2.8%). There was only one patient in whom anosmia was consistent with nerve injury. In conclusion, BIH is an appropriate procedure for infection risk control in Acom aneurysm surgery. It is difficult to avoid olfactory dysfunction completely, even if olfactory nerves are preserved in form.

Role of magnetic resonance vessel wall imaging in detecting and managing ruptured aneurysms among multiple intracranial aneurysms.

BACKGROUND: Wall enhancement of intracranial saccular aneurysms in high-resolution magnetic resonance vessel wall imaging (MR-VWI) might indicate a ruptured aneurysm. Therefore, this study aimed to determine the diagnostic ability of wall enhancement to detect the ruptured aneurysms among multiple aneurysms. METHODS: Patients with subarachnoid hemorrhage (SAH) and multiple intracranial aneurysms who underwent MR-VWI before craniotomy and clipping were included in the study. Three-dimensional T1-weighted fast spin-echo sequences were obtained before and after gadolinium injection. Aneurysm rupture was estimated based on the subarachnoid clot distribution, aneurysmal contours, and MR-VWI findings. We selectively performed surgical clipping and confirmed the rupture site intraoperatively. RESULTS: Thirteen patients with SAH with 13 ruptured and 17 unruptured aneurysms were treated at out facility. The accuracy rate of rupture site diagnosis using MR-VWI was 69.2% (9/13 cases). Each unruptured aneurysm was equally or more strongly enhanced in the other four cases than the ruptured aneurysms. In three of the four unruptured aneurysms with positive MR-VWI findings, atherosclerosis of the aneurysmal wall was observed during simultaneous or elective clipping surgery. Further, clipping surgery was performed without intraoperative rupture in two cases with the help of MR-VWI findings. CONCLUSION: Correct diagnosis of the rupture site using MR-VWI alone was unreliable due to false positives caused by the wall enhancement of unruptured aneurysms with atherosclerosis. Therefore, ruptured aneurysms should be detected using more information in addition to MR-VWI images. MR-VWI may be advantageous to determine surgical strategies when managing patients with SAH and multiple aneurysms.

Risk of Rupture After Intracranial Aneurysm Growth.

Importance: Unruptured intracranial aneurysms not undergoing preventive endovascular or neurosurgical treatment are often monitored radiologically to detect aneurysm growth, which is associated with an increase in risk of rupture. However, the absolute risk of aneurysm rupture after detection of growth remains unclear. Objective: To determine the absolute risk of rupture of an aneurysm after detection of growth during follow-up and to develop a prediction model for rupture. Design, Setting, and Participants: Individual patient data were obtained from 15 international cohorts. Patients 18 years and older who had follow-up imaging for at least 1 untreated unruptured intracranial aneurysm with growth detected at follow-up imaging and with 1 day or longer of follow-up after growth were included. Fusiform or arteriovenous malformation-related aneurysms were excluded. Of the 5166 eligible patients who had follow-up imaging for intracranial aneurysms, 4827 were excluded because no aneurysm growth was detected, and 27 were excluded because they had less than 1 day follow-up after detection of growth. Exposures: All included aneurysms had growth, defined as 1 mm or greater increase in 1 direction at follow-up imaging. Main Outcomes and Measures: The primary outcome was aneurysm rupture. The absolute risk of rupture was measured with the Kaplan-Meier estimate at 3 time points (6 months, 1 year, and 2 years) after initial growth. Cox proportional hazards regression was used to identify predictors of rupture after growth detection. Results: A total of 312 patients were included (223 [71%] were women; mean [SD] age, 61 [12] years) with 329 aneurysms with growth. During 864 aneurysm-years of follow-up, 25 (7.6%) of these aneurysms ruptured. The absolute risk of rupture after growth was 2.9% (95% CI, 0.9-4.9) at 6 months, 4.3% (95% CI, 1.9-6.7) at 1 year, and 6.0% (95% CI, 2.9-9.1) at 2 years. In multivariable analyses, predictors of rupture were size (7 mm or larger hazard ratio, 3.1; 95% CI, 1.4-7.2), shape (irregular hazard ratio, 2.9; 95% CI, 1.3-6.5), and site (middle cerebral artery hazard ratio, 3.6; 95% CI, 0.8-16.3; anterior cerebral artery, posterior communicating artery, or posterior circulation hazard ratio, 2.8; 95% CI, 0.6-13.0). In the triple-S (size, site, shape) prediction model, the 1-year risk of rupture ranged from 2.1% to 10.6%. Conclusion and Relevance: Within 1 year after growth detection, rupture occurred in approximately 1 of 25 aneurysms. The triple-S risk prediction model can be used to estimate absolute risk of rupture for the initial period after detection of growth.

[Cerebral complications induced by neurotoxity of nonionic contrast medium after embolization of unruptured cerebral aneurysms: report of 2 cases].

We successfully performed endovascular coil embolization for 2 patients with unruptured saccular aneurysms. However, transient cortical blindness and generalized seizure associated with CNS neurotoxity of contrast medium were noted for each patient after the procedure. In the first case of a 62-year-old woman with a right BA-SCA aneurysm, she complained of blindness with restlessness one day after the intervention but no evidence of embolism on MRA. Abnormal EEG with slow, large amplitudes and 99mTc-HMPAO SPECT-evidenced hyperperfusion were observed in the occipital area. Accompanied by resolution of the edematous changes on MRI in conjunction with normalization of EEG and rCBF by anticonvulsant administration, her visual acuity completely recovered 8 days after the onset. According to these findings, we considered this case as transient cortical blindness. In the second case of a 68-year-old man with a left MCA aneurysm, he exhibited generalized seizure 8 hours after the procedure. CT scan revealed retention of the contrast medium over the left hemisphere. Postictal EEG one day after the seizure showed left frontal slowing but had no evidence of contrast medium retention or hyperperfusion. He recovered well with corticosteroid, anticonvulsant, and intravenous hydration. His follow-up DSA 2 years after the coiling was performed without trouble by reducing the amount/concentration of the contrast medium and by prophylactic steroid and hydration. Non-ionic contrast medium-related neurotoxity as represented by transient cortical blindness or generalized seizure should be recognized as a possible complication of endovascular surgery where patients' brain areas are locally vulnerable to contrast medium exposure.

Dissection of the Superficial Temporal Artery: Significance and Performance with Bipolar Forceps.

BACKGROUND: Adequate bypass harvesting of the superficial temporal artery (STA) is a standard procedure for every neurosurgeon, so mastery of techniques for its management and care is mandatory. METHODS: Here, we report the effectiveness of using the bipolar forceps as a novel procedure. RESULTS: This procedure improves safety, efficiency, and bleeding compared to the usual dissection. CONCLUSIONS: In cases requiring an STA donor, this technique may be as useful as the traditional method and could become part of the neurosurgeon's armamentarium.

Analysis of cerebral perfusion and metabolism assessed with positron emission tomography before and after carotid artery stenting. Clinical article.

OBJECT: The authors analyzed cerebral perfusion and metabolism in patients with internal carotid artery stenosis before and after carotid artery stenting (CAS). METHODS: Sixteen patients with internal carotid artery stenosis (>70%) underwent PET scanning before CAS, 1-7 days after CAS, and 3-4 months after CAS to assess a variety of parameters related to cerebral perfusion and metabolism. RESULTS: Cerebral blood flow at rest (CBFrest) significantly increased in the immediate postoperative stage before returning to normal levels over the long term; this trend was also recognized on the contralateral side. In contrast, there was gradual improvement in the rate of CBF variation on acetazolamide administration (% CBFaz). Cerebral perfusion pressure (CBF/cerebral blood volume) increased rapidly during the acute stage and decreased in the long term, and the oxygen extraction fraction decreased slightly during the acute stage before normalizing over the long term. The cerebral metabolic rate of oxygen (CMRO2) increased slightly after stenting over both the short and long term. The ratios of ipsilateral to contralateral values (asymmetry index) for CBFrest, % CBFaz, cerebral blood volume, oxygen extraction fraction, and CMRO2 tended to approach 1.0 over time. CONCLUSIONS: Repeated PET scanning revealed improvements in CBF, perfusion pressure, and oxygen metabolism after CAS. In particular, the vascular reserve tended to improve gradually, while CBF, cerebral perfusion pressure, and CMRO2 increased rapidly and peaked soon after CAS. These results suggest that a large discrepancy between rapidly increased CBF, perfusion pressure, and a small increase in vascular reserve in the acute stage after CAS could cause hyperperfusion syndrome.

OCCUPATIONAL RADIATION EXPOSURE OF THE EYE IN NEUROVASCULAR INTERVENTIONAL PHYSICIAN.

Neurovascular interventional radiology (neuro-IR) procedures tend to require an extended fluoroscopic exposure time and repeated digital subtraction angiography. To evaluate the actual measurement of eye lens dose using a direct eye dosemeter in neuro-IR physicians is important. Direct dosimetry using the DOSIRIS™ (IRSN, France) [3 mm dose equivalent, Hp(3)] was performed on 86 cases. Additionally, a neck personal dosemeter (glass badge) [0.07 mm dose equivalent, Hp(0.07)] was worn outside the protective apron to the left of the neck. The average doses per case of neuro-IR physicians were 0.04 mSv/case and 0.02 mSv/case, outside and inside the radiation protection glasses, respectively. The protective effect of radiation protection glasses was approximately 60%. The physician eye lens dose tended to be overestimated by the neck glass badge measurements. A correct evaluation of the lens dose [Hp(3)] using an eye dosemeter such as DOSIRIS™ is needed for neuro-IR physicians.

[Elderly patient with cerebellar malignant astrocytoma].

Malignant cerebellar astrocytoma is very rare and the prognosis is extremely poor. We report herein the case of an elderly patient with malignant cerebellar astrocytoma. This 80-year-old man initially presented with dizziness and ataxia of the right hand. Metastatic cerebellar tumor was diagnosed on first admission, based on a past history of colon cancer treated by surgery and magnetic resonance imaging (MRI) findings supporting the diagnosis of metastasis. The patient underwent gamma knife surgery (20 Gy) and was discharged. Follow-up after discharge was insufficient. Two years after gamma knife surgery, he returned to our hospital complaining of dizziness, headache, and right limb ataxia. MRI revealed a cystic mass in the right cerebellar hemisphere, and the lesion was removed by right suboccipital craniotomy. The tumor represented malignant astrocytoma. Optimal management of patients harboring sush difficult. to-treat tumors, including the role of gamma-knife radiosurgery, is discussed.

Anti-inflammatory and antiplatelet effects of non-vitamin K antagonist oral anticoagulants in acute phase of ischemic stroke patients.

BACKGROUND: Recently, non-vitamin K antagonist oral anticoagulants such as direct thrombin and direct factor Xa inhibitors have been prescribed for prevention of embolic stroke. While in Japan, argatroban, also a direct thrombin inhibitor, is available for the treatment of atherothrombotic stroke patients. This study aimed to explore whether there is any differences between direct thrombin and direct factor Xa inhibitors regarding the inhibiting effect against thrombogenesis in the clinical setting of acute ischemic stroke. METHODS: Acute ischemic stroke patients newly prescribed anti-thrombotic agents were consecutively screened, and 44 patients with single medicine were enrolled (median 72.0 years-old). Blood samples were obtained at 1 and 2 weeks after the medication started. The extent of anticoagulation activity, inflammatory markers and platelet aggregation were assessed. Patients with antiplatelets were used as control. RESULTS: Prescribed antithrombotics were dabigatran (group D: n = 12), apixaban (group A: n = 14) and antiplatelet agents (group P: n = 18). Prevalence of stroke risks and anticoagulation activity were not different between groups D and A. The alteration of inflammatory markers in a week in the group A showed similar trend to those in the group P. The group D presented relatively lower amount of high-sensitive C-reactive protein and higher amount of pentraxin-3 compared with groups A and P. While 88.9% of group P patients showed decreased platelet aggregation activity with adenosine diphosphate, 55.6% of group D and 40.0% of group A presented the inhibition of platelet aggregation activity. CONCLUSIONS: Even in acute ischemic stroke patients, both apixaban and dabigatran equally showed the anticoagulation activity. The reduction of inflammatory response might be prominent in apixaban, whereas the inhibition of platelet aggregation activity might be evident in dabigatran.