Coaxial Method of PTA Balloon and Aspiration catheter using the delivery wire of a stent retriever for tandem occlusion: CoMBAt tandem occlusion.

PURPOSE: Tandem occlusion, in which the intracranial artery is obstructed along with proximal carotid occlusive or stenotic lesions, occurs in 10-15% of patients with large vessel occlusion. Our study introduces a novel technique for tandem occlusion treatment that involves the simultaneous coaxial deployment of a percutaneous transluminal angioplasty balloon and aspiration catheters with the delivery wire of a stent retriever. After percutaneous transluminal angioplasty of the carotid lesion with a thin balloon catheter, the aspiration catheter was advanced over the balloon to eliminate the ledge between the catheter tip and delivery wire. After balloon removal, intracranial thrombectomy was performed using an aspiration catheter and stent retriever. This study aimed to evaluate the safety and efficacy of this approach. MATERIALS AND METHODS: Medical records of patients with acute stroke due to tandem occlusion treated using our technique were analyzed for its effectiveness and safety. The puncture-to-recanalization time, modified thrombolysis in cerebral infarction (mTICI) grade, functional prognosis and incidence of hyperperfusion were assessed. RESULTS: Seven patients were included in this study. In all patients, mTICI 2b-3 recanalization was achieved after smooth delivery of the aspiration catheter from the carotid lesion to the intracranial thrombus. The median puncture-to-recanalization time was 52 min. Ninety days post-stroke onset, six of seven patients had a modified Rankin Scale score of 0-2, and none of the patients had perioperative hyperperfusion syndrome. CONCLUSION: Our technique allows simultaneous treatment of carotid and intracranial lesions, leading to faster recanalization. Furthermore, percutaneous transluminal angioplasty with a thin balloon may reduce the risk of hyperperfusion.

Prolonged platelet hyperactivity after COVID-19 infection.

Platelet hyperactivity often occurs in patients with coronavirus disease 2019 (COVID-19). However, it remains unclear how long platelet hyperactivity lasts after the acute phase, owing to a lack of follow-up studies. To elucidate the course of platelet hyperactivity, we serially measured platelet activity in patients with COVID-19 up to 40 days after hospital admission using an easily assessable haematology analyser that semi-quantitates platelet clumps on a scattergram. Our results showed that platelet hyperactivity persisted for at least 40 days even after acute inflammation subsided in most patients with COVID-19, regardless of disease severity. Persistent platelet hyperactivity may contribute to thromboembolic complications in post-COVID-19 patients.

Reduced likelihood of the Poggendorff illusion in cerebellar strokes: a clinical and neuroimaging study.

This study aimed to test our hypothesis that the cerebellum plays an important role in the generation of the optical-geometric illusion known as the Poggendorff illusion, the mechanism of which has been explained by accumulated experience with natural scene geometry. A total of 79 participants, comprising 28 patients with isolated cerebellar stroke, 27 patients with isolated cerebral stroke and 24 healthy controls, performed Poggendorff illusion tasks and 2 different control tasks. We also investigated core brain regions underpinning changes in the experience of the illusion effect using multivariate lesion-symptom mapping. Our results indicate that patients with isolated cerebellar stroke were significantly less likely to experience the Poggendorff illusion effect than patients with isolated cerebral stroke or healthy controls (74.6, 90.5 and 89.8%, respectively; F(2,76) = 6.675, P = 0.002). However, there were no inter-group differences in the control tasks. Lesion-symptom mapping analysis revealed that the brain lesions associated with the reduced frequency of the Poggendorff illusion effect were mainly centred on the right posteromedial cerebellar region, including the right lobules VI, VII, VIII, IX and Crus II. Our findings demonstrated, for the first time, that patients with cerebellar damage were significantly less likely to experience the Poggendorff illusion effect and that right posteromedial cerebellar lesions played an important role in this effect. These results provide new insight into alterations of a geometric illusion effect in patients with cerebellar disorders and pave the way for future clinical use of the illusion task to detect cerebellar abnormalities.

Cerebral foreign body granulomas after mechanical thrombectomy: Two case reports and a review of the literature.

OBJECTIVES: A foreign body granuloma after an endovascular intervention is a rare complication. Some cases of foreign body granulomas, especially after coil embolization, have been reported. However, only four cases of foreign body granulomas after mechanical thrombectomy (MT) have previously been reported. The current study reports two cases of post-MT foreign body granulomas, including a biopsy-proven case. MATERIAL AND METHODS: Case 1: A 73-year-old woman presented with complete occlusion of the right middle cerebral artery. Cerebral angiography and MT were successfully performed with improvement in clinical symptoms. Left hemiparesis and a disturbance in attention appeared after discharge and progressed slowly. She was re-admitted to our hospital 120 days after cerebral infarction owing to foreign body granulomas diagnosed on biopsy. Case 2: A 78-year-old man presented with occlusion of the left cervical internal carotid artery and the left middle cerebral artery. Cerebral angiography, percutaneous transluminal angioplasty, and MT were successfully performed. On the 34th day, he experienced progressive consciousness disorder because of foreign body granulomas. Both cases were successfully treated with steroid therapy. RESULTS: MRI after steroid treatment showed the disappearance of most nodular lesions and improvement of the encephalopathy. CONCLUSIONS: The cause of the granuloma may be an allergic reaction to the hydrophilic polymers that peel from endovascular devices. Steroid therapy is an effective treatment; therefore, neurologists should consider this complication when neurological symptoms or signs on image appears or worsens. A reliable diagnosis is important for prompt treatment.

Visual suppression of vestibulo-ocular reflex in patients treated with carotid artery revascularization: A potential biomarker for cerebral perfusion.

BACKGROUND: Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are common treatments for ischemic stroke prevention in patients with carotid artery stenosis. However, the beneficial effects of CEA/CAS for cerebral hypoperfusion due to carotid artery stenosis have yet to be fully established. As dizziness is a common symptom in patients with carotid artery stenosis, we aimed to evaluate the effects of CEA/CAS on cerebral function in patients with carotid artery stenosis, using equilibrium function tests. METHODS: This prospective observational cohort study included 50 patients who had carotid artery stenosis and were scheduled to undergo CEA or CAS. Before CEA/CAS, we quantitatively evaluated the vestibulo-ocular reflex (VOR) and vestibular evoked myogenic potential (VEMP), as indicators of brainstem/inner ear functions related to balance, and visual suppression of VOR, as an indicator of cerebral control over the brainstem reflex related to balance. These were then compared with supratentorial cerebral blood flow (CBF). Changes in VOR, VEMP, visual suppression of VOR, CBF, and dizziness after CEA/CAS were also evaluated. RESULTS: The visual suppression rates of VOR correlated with supratentorial CBFs before CEA/CAS (correlation coefficient = 0.47, p = 0.003). The visual suppression rates of VOR (p < 0.001) and supratentorial CBFs (p = 0.003) were improved by CEA/CAS, while VOR and VEMP did not change. Symptoms of dizziness improved after CEA/CAS. CONCLUSIONS: Our results suggest that visual suppression of the VOR may be a novel and practical marker for the beneficial effects of CEA/CAS on supratentorial cerebral function.

Cerebral perfusion changes in chronic dizziness: A single-photon emission computed tomography study.

BACKGROUND AND PURPOSE: Dizziness may persist even after the causative vestibular imbalance subsides. Although the precise mechanism of chronic dizziness is unknown, various cerebral activity changes associated with it have been reported. To understand its mechanism in the absence of the causative vestibular imbalance, we compared cerebral changes in chronic dizziness with and without persistent vestibular imbalance. METHODS: Between September 2014 and March 2020, we examined regional cerebral blood flow (rCBF) in 12 patients having chronic post-lateral medullary infarction dizziness with persistent brainstem vestibular imbalance and 23 patients having chronic dizziness without currently active vestibular imbalance using single-photon emission computed tomography (SPECT) with 99m Technetium-ethyl cysteinate dimer. Further, we analyzed the SPECT images using a voxel-based group comparison. RESULTS: We observed a decreased rCBF in the occipital lobe and increased rCBF in the medial and inferior parts of the temporal lobe in patients having chronic dizziness with and without active vestibular imbalance compared to healthy controls. However, only patients having chronic dizziness without active vestibular imbalance exhibited increased rCBF in the frontal lobe, including the orbitofrontal cortex. CONCLUSION: This is the first study to highlight the difference in rCBF changes between patients having chronic dizziness with and without active vestibular imbalance. Decreased occipital lobe activity and increased medial and inferior temporal lobe activity may be related to keeping dizziness perception triggered regardless of the presence or absence of active vestibular imbalance, whereas increased frontal lobe activity may explain the dizziness background to persist after the disappearance of vestibular imbalance.

[Vertigo and dizziness].

Pathophysiology of vertigo/dizziness can be understood by eye deviation (nystagmus). In benign paroxysmal positional vertigo, eye deviation of causative semicircular canal stimulation is directly observed. In other peripheral vestibular disorders, eye deviation results from the sum of unilateral all semicircular canal disorders. The central vestibular pathway is controlled by the cerebellum. Thus, in vertigo/dizziness of central origin, not only eye deviation due to impairment of the central vestibular pathway but also deviation due to disinhibition of the pathway from the cerebellum is observed. The cerebellar control on the central vestibular pathway also plays an important role in vestibular compensation. When treating vertigo/dizziness, it is necessary to understand the pathophysiology of the vertigo/dizziness, to set the treatment target based on the pathophysiology, and to intervene for the target.

Bedside video-oculographic evaluation of eye movements in acute supratentorial stroke patients: A potential biomarker for hemispatial neglect.

BACKGROUND AND PURPOSE: The presence of hemispatial neglect adversely affects functional outcomes in stroke patients; consequently, it warrants early targeted rehabilitative intervention. Nevertheless, hemispatial neglect in the acute phase of stroke has often been underdiagnosed. In this study, we aimed to detect hemispatial neglect at the bedside in acute stroke patients by measuring eye movements using video-oculography (VOG). METHODS: Forty-seven patients with acute unilateral supratentorial stroke were enrolled. We quantitatively measured horizontal saccade (latency, velocity, and amplitude) and smooth pursuit (gain) at the bedside using VOG and compared these variables with scores on the Behavioral Inattention Test (BIT), a screening battery to assess hemispatial neglect. RESULTS: Contralesional saccade latency, velocity, and amplitude, and ipsilesional smooth pursuit gain were suppressed compared with those in the opposite directions (p = 0.08, 0.02, 0.04, and 0.02, respectively). These directional ocular hypokinesia values correlated with the total BIT score (correlation coefficients -0.53, 0.48, 0.51, and 0.39, respectively). The association was significant even after adjusting for age and stroke severity. CONCLUSIONS: Eye movement measurements performed using VOG significantly correlated with the tendency for hemispatial neglect in acute supratentorial stroke patients. Bedside VOG measurement may be a simple biomarker for detecting hemispatial neglect even in patients in the supine position during the acute phase of stroke.

[Hypoglycemia].

Hypoglycemia may lead to acute hemiplegia. The most common diffusion-weighted MRI finding in patients with hypoglycemic hemiplegia is a hyperintense internal capsule lesion, which mimics acute ischemic stroke. In addition to the internal capsule lesion, various MRI findings have been reported in patients with hypoglycemia(including hyperintense lesions in the cerebral cortex, basal ganglia, subcortical white matter, and splenium of the corpus callosum). It has recently been reported that hypoglycemic brain damage starts in the large white matter tracts, such as the internal capsule, and spreads to the entire brain, including the gray matter. However, the mechanism underlying the development of focal signs, such as hemiplegia in metabolic disorders, which affects the entire brain, remains unclear.

Antiplatelet Loading Effects Prior to Endovascular Treatment: Carotid Artery Stenosis versus Unruptured Cerebral Aneurysms.

Objective: Carotid artery stenosis and cerebral aneurism may have different platelet functions and antiplatelet responses because these diseases have different etiologies. In this study, we compared the antiplatelet loading effects prior to endovascular treatment between carotid artery stenosis and unruptured cerebral aneurysm (UCA) patients. Methods: Nine patients with asymptomatic carotid artery stenosis (ACS), 14 with symptomatic carotid artery stenosis (SCS), and 20 with unruptured cerebral aneurysms were enrolled in this study. Antiplatelet (aspirin + clopidogrel) loading effects prior to endovascular treatment were evaluated using light transmission aggregometry and platelet aggregate detection methods. Results: Although there are differences in the prevalence of atherosclerosis risk factors, maximum aggregation rates in light transmission aggregometry and platelet aggregation-prone properties were not different in the three disease groups. Conclusion: Preoperative dual antiplatelet therapy with aspirin and clopidogrel may be appropriate for both carotid artery stenosis and cerebral aneurism patients even though their conditions and background factors differ.

Effects of uncomfortable care and histamine H2-antagonists on delirium in acute stroke: A propensity score analysis.

BACKGROUND AND PURPOSE: Uncomfortable care and histamine H2 antagonist (H2A) are implicated in precipitating delirium. In acute stroke, however, the need for them depends on stroke severity, an established risk factor for delirium. So, it is unclear whether care or H2A itself is responsible for delirium. We aimed to evaluate their causal effects on delirium in acute stroke patients. METHODS: This is a prospective cohort study on acute stroke patients admitted to a stroke care unit. Patients without stupor, coma, sedation, or delirium upon admission were enrolled. The treatment was H2A and five care modalities given during the first 24 h: restraint use, prohibited self-transfer, no oral feeding, indwelling catheters, and frequent nighttime care. The outcome was delirium within 5 days defined as Intensive Care Delirium Screening Checklist ≥4 points. We estimated the relative risk (RR) for delirium with regression models weighted by overlap weights using propensity scores estimated through logistic models incorporating known and potential confounders, including stroke severity. RESULTS: Of the 387 participants, 188 were given at least one care modality and 130 were given H2A. A total of 42 developed delirium. Delirium was significantly associated with prohibited self-transfer (RR 1.7, 95% CI 1.0-3.0), frequent nighttime care (RR 2.1, 95% CI 1.2-3.7), and multiple care modalities (RR 2.4, 95% CI 1.3-4.4), while other care modalities and H2A were not. CONCLUSIONS: This study showed possible causal effects of uncomfortable care on delirium and suggests that minimizing it could prevent delirium in acute stroke.

Development of a clinical score, PANDA, to predict delirium in stroke care unit.

BACKGROUND AND PURPOSE: Delirium frequently complicates acute stroke and worsens outcomes. Because delirium is potentially preventable, predicting its occurrence is essential. Although several prediction scores have been proposed, nurses need to quickly predict delirium in stroke care units (SCUs). We aimed to develop a simple tool for this purpose by examining a comprehensive set of potential predictors. METHODS: This is a prospective cohort study on acute stroke patients admitted to an SCU. Patients without stupor, coma, or delirium upon admission were eligible. Participants were followed for 5 days from admission. Delirium was defined as Intensive Care Delirium Screening Checklist ≥4 points. We examined 27 potential predictors, of which 13 predictors were used to developed a least absolute shrinkage and selection operator-penalized logistic regression model. Five variables with the largest coefficients were assigned one point each in the prediction score. The internal validation was performed by bootstrapping. RESULTS: Delirium occurred in 42 of the 387 participants. The score consisted of prior delirium, alcohol, NIHSS ≥5, dementia, and auditory/visual impairment (PANDA). The apparent AUC was 0.84 (95% confidence interval [CI], 0.78-0.89), and the optimism-corrected AUC was 0.81 (95% CI, 0.73-0.88). With a cutoff of ≥2 points, sensitivity was 0.78 (95% CI, 0.65-0.90), and specificity was 0.74 (95% CI, 0.70-0.79). CONCLUSIONS: PANDA score is simple and predicts delirium in an SCU satisfactorily.