Intra-arterial infusion of fasudil hydrochloride to treat post-traumatic cerebral vasospasm.

BACKGROUND: The effect of intra-arterial infusion of fasudil hydrochloride in patients with post-traumatic cerebral vasospasm remains unclear. Here we report a case of intra-arterial infusion of fasudil hydrochloride for post-traumatic cerebral vasospasm. CASE PRESENTATION: A 47-year-old man was transferred to our hospital with a fractured skull and traumatic subarachnoid hemorrhage. As rhinorrhea of cerebrospinal fluid had not improved, repair surgery was carried out on day 4. Aphasia appeared on day 13. Magnetic resonance imaging and angiography showed an ischemic region in the left temporal lobe and vasospasm of the left middle cerebral artery. We immediately carried out angiography and diagnosed severe vasospasm of the M1 region of the left middle cerebral artery. After placing a microcatheter into the proximal middle cerebral artery, we injected fasudil hydrochloride intra-arterially. Vasospasm improved and aphasia resolved. CONCLUSION: In this case, intra-arterial infusion of fasudil hydrochloride was effective against post-traumatic cerebral vasospasm.

Carotid artery stenting for patients with occipital-vertebral anastomosis.

BACKGROUND AND PURPOSE: We report the outcomes of carotid artery stenting for patients with angiographically visible occipital artery-vertebral artery anastomosis. METHODS: Among 47 consecutive patients who underwent carotid artery stenting from January 2007 to December 2010, seven patients for whom cerebral angiograms clearly showed occipital artery-vertebral artery anastomosis were selected. Four different protection methods were used: distal internal carotid artery protection; carotid flow reversal; seatbelt and airbag technique; and double protection method of protecting both the external and internal carotid artery. RESULTS: One patient with distal internal carotid artery protection showed a high-intensity lesion at the border of the upper thalamus, internal capsule and lateral ventricle wall after carotid artery stenting. The other patient with the double protection method did not show any high-intensity lesions on postoperative diffusion-weighted imaging in the vertebrobasilar territory. All seven patients with visible occipital artery-vertebral artery anastomosis showed ipsilateral vertebral artery severe stenosis or occlusion. CONCLUSION: Large occipital artery-vertebral artery anastomosis may be a pathway for embolic materials during carotid artery stenting. External carotid artery protection is recommended for carotid artery stenting in such patients.

Life-Threatening Hemorrhagic Moyamoya Disease: Report of Rare Case of Atraumatic Acute Subdural Hematoma Due to Ruptured Transdural Anastomosis.

BACKGROUND: Atraumatic acute subdural hematoma (ASDH) associated with moyamoya disease (MMD) is rare, and only a few studies have reported the bleeding origin. We present a case of atraumatic ASDH attributable to a transdural anastomosis that developed owing to the compensatory mechanisms involved in the pathogenesis of advanced MMD. This is the first case of life-threatening atraumatic ASDH associated with MMD in which the rupture point was clearly visualized using a 3-dimensional rotational reconstructed image. CASE DESCRIPTION: A 37-year-old woman presented with sudden-onset, serious, atraumatic ASDH requiring emergency decompressive craniectomy. The cerebral angiograms revealed that she had advanced MMD with transdural anastomosis that was classified as Suzuki stage V with a 5-mm saccular aneurysm in the middle meningeal artery on the affected side, which was suggested as the bleeding origin. Follow-up angiograms demonstrated that the aneurysm spontaneously disappeared and was inferred to be a pseudoaneurysm. We performed a left extraintracranial bypass to prevent recurrent hemorrhage. With intensive rehabilitation, the patient accordingly achieved stroke-free survival with a modified Rankin Scale score of 3 for 1 year. CONCLUSIONS: Atraumatic ASDH associated with MMD is a rare type of hemorrhagic MMD, and a 3-dimensional-rotational reconstructed image was useful to confirm the origin of the bleeding. The transdural anastomosis development most likely correlates with the occurrence of any type of hemorrhagic MMD. We should consider that the transdural anastomosis collapse can cause a life-threatening atraumatic ASDH and should plan a surgical strategy carefully so as not to destroy collateral supply through the transdural anastomosis in such cases.

Small Hyperintensities in the Area of the Perforating Arteries in Patients with Seizure.

BACKGROUND/AIM: We previously observed spotty hyperintense lesions in the region of the perforating arteries on peri-ictal diffusion-weighted imaging (DWI); however, no report has formally described these findings. The aim of this study was to investigate focal intensities on peri-ictal DWI, and to evaluate the clinical significance of these lesions. METHODS: We conducted a retrospective review of 677 consecutive patients with seizure who completed peri-ictal DWI within 24 h after seizure onset. Patients were grouped according to the presence or absence of diffusion hyperintense lesions (DHLs) in the region of the perforating arteries. We compared clinical and imaging characteristics between these 2 groups. RESULTS: Among 677 patients, 23 patients (3.4%) had DHLs. Analyses of apparent diffusion coefficient values and fluid attenuated inversion recovery images suggested that DHLs were acute or subacute ischemic lesions that had appeared prior to seizure onset. Patients with DHLs were more likely to be older in age, have atrial fibrillation, and coronary artery disease, and have more severe deep white matter hyperintensity or leukoaraiosis compared to patients without DHLs. CONCLUSION: DHLs detected on peri-ictal DWI may represent incidental acute cerebral microinfarcts in the aging brain, especially in patients with small vessel disease.

Decompressive Craniectomy in Conjunction With Evacuation of Intracranial Hemorrhagic Lesions Is Associated With Worse Outcomes in Elderly Patients With Traumatic Brain Injury: A Propensity Score Analysis.

BACKGROUND: When it comes to evacuating intracranial hemorrhagic lesions in patients with traumatic brain injury (TBI), neurosurgeons perform either a craniotomy or a decompressive craniectomy (DC). The aim of the present study was to estimate the impact of DC on outcomes in elderly patients. METHODS: This retrospective cohort study, conducted in a neurosurgical institute in Japan from April 2009 to June 2014, included 91 consecutive patients with TBI (aged 60 years or older) who underwent evacuation of intracranial hemorrhagic lesions. Patients were divided into 2 groups: craniotomy only or DC. We set the primary endpoint as an unfavorable outcome (death or vegetative state), as evaluated on the Glasgow Outcome Scale at 6 months after injury. The secondary endpoints included existence of delayed hemorrhage and occurrence of hydrocephalus requiring shunt placement. The inverse probability of treatment weighting method was used to develop a propensity model to adjust for baseline imbalances between groups. RESULTS: The DC group exhibited greater severity both in clinical and computed tomography findings according to baseline characteristics. After we adjusted for these differences by inverse probability of treatment weighting using the propensity score, DC was significantly associated with unfavorable outcomes (adjusted odds ratio, 8.00; 95% confidential interval, 2.30-27.84; P = 0.002) and delayed hemorrhage (adjusted odds ratio, 13.42; 95% confidential interval, 1.52-118.89; P = 0.022). There was no significant difference in the occurrence of hydrocephalus requiring shunt placement. CONCLUSIONS: DC in conjunction with evacuation of intracranial hemorrhagic lesions was associated with worse functional outcome in elderly patients with TBI.

Endovascular trapping for vertebral artery fusiform aneurysm in a patient with idiopathic thrombocytopenic purpura.

A 56-year-old woman with adult idiopathic thrombocytopenic purpura (ITP) diagnosed 17 years previously presented with a fusiform aneurysm manifesting as chronic headache. She had suffered no major hemorrhagic complications, although her platelet counts were between 3.0 x 10(9)/l and 50.0 x 10(9)/l. Magnetic resonance angiography identified a fusiform aneurysm of the right vertebral artery. Endovascular trapping after high-dose gammaglobulin with steroid therapy was performed. The patient received antiplatelet therapy to prevent thromboembolic events. The parent artery and aneurysm were completely occluded with no hemorrhagic complications. Endovascular treatment is considered safe in patients with ITP, although careful periprocedural management of platelet count is required.