Efficacy of intraoperative irrigation with artificial cerebrospinal fluid in chronic subdural hematoma surgery: study protocol for a multicenter randomized controlled trial.

BACKGROUND: The surgical techniques for treatment of chronic subdural hematoma (CSDH), a common neurosurgical condition, have been discussed in a lot of clinical literature. However, the recurrence proportion after CSDH surgery remains high, ranging from 10 to 20%. The standard surgical procedure for CSDH involves a craniostomy to evacuate the hematoma, but irrigating the hematoma cavity during the procedure is debatable. The authors hypothesized that the choice of irrigation fluid might be a key factor affecting the outcomes of surgery. This multicenter randomized controlled trial aims to investigate whether intraoperative irrigation using artificial cerebrospinal fluid (ACF) followed by the placement of a subdural drain would yield superior results compared to the placement of a subdural drain alone for CSDH. METHODS: The study will be conducted across 19 neurosurgical departments in Japan. The 1186 eligible patients will be randomly allocated to two groups: irrigation using ACF or not. In either group, a subdural drain is to be placed for at least 12 h postoperatively. Similar to what was done in previous studies, we set the proportion of patients that meet the criteria for ipsilateral reoperation at 7% in the irrigation group and 12% in the non-irrigation group. The primary endpoint is the proportion of patients who meet the criteria for ipsilateral reoperation within 6 months of surgery (clinical worsening of symptoms and increased hematoma on imaging compared with the postoperative state). The secondary endpoints are the proportion of reoperations within 6 months, the proportion being stratified by preoperative hematoma architecture by computed tomography (CT) scan, neurological symptoms, patient condition, mortality at 6 months, complications associated with surgery, length of hospital stay from surgery to discharge, and time of the surgical procedure. DISCUSSION: We present the study protocol for a multicenter randomized controlled trial to investigate our hypothesis that intraoperative irrigation with ACF reduces the recurrence proportion after the removal of chronic subdural hematomas compared with no irrigation. TRIAL REGISTRATION: ClinicalTrials.gov jRCT1041220124. Registered on January 13, 2023.

Real-world data of clazosentan in combination therapy for aneurysmal subarachnoid hemorrhage: a multicenter retrospective cohort study.

Aneurysmal subarachnoid hemorrhage (aSAH) may lead to cerebral vasospasm, significantly associated with morbidity and mortality. In double-blind, placebo-controlled phase 3 studies, clazosentan reduces cerebral vasospasm-related morbidity and all-cause mortality in patients with aSAH. There are no reports about the clinical efficacy of clazosentan combination therapy with some other drugs. Initially, we explored the efficacy of clazosentan combination therapy with cilostazol, statin, and antiepileptic drugs. Subsequently, we assessed the add-on effect of fasudil to clazosentan combination therapy for aSAH patients. This multicenter, retrospective, observational cohort study included Japanese patients with aSAH between June 2022 and March 2023. The primary outcome was the ordinal score on the modified Rankin Scale (mRS; range, 0-6, with elevated scores indicating greater disability) at discharge. Among the 47 cases (women 74.5%; age 64.4 ± 15.0 years) undergoing clazosentan combination therapy, 29 (61.7%) resulted in favorable outcomes. Overall, vasospasm occurred in 16 cases (34.0%), with four cases (8.5%) developing vasospasm-related delayed cerebral ischemia (DCI). Both hypotension and vasospasm-related DCI were related to unfavorable outcome at discharge. Fasudil were added in 18 (38.3%) cases. Despite adding fasudil to clazosentan combination therapy, the incidence of aSAH-related vasospasm did not decrease. Added-on fasudil to combination therapy related to pulmonary edema, vasospasm, and vasospasm-related DCI, and unfavorable outcomes. Clazosentan combination therapy could potentially result in favorable outcomes for aSAH patients to prevent post-aSAH vasospasm-related DCI. The add-on effect of fasudil to combination therapy did not demonstrate a significant impact in reducing aSAH-related vasospasm or improving outcomes at discharge.

Paroxysmal Sympathetic Hyperactivity in Stroke.

OBJECTIVE: Paroxysmal sympathetic hyperactivity (PSH) is a life-threatening neurological emergency associated with severe brain injury. Stroke-related PSH, particularly post-aneurysmal subarachnoid hemorrhage (aSAH) PSH, has been relatively understudied and is often misdiagnosed as an aSAH-related hyperadrenergic crisis. This study aims to clarify the feature of stroke-related PSH. METHODS: This study discusses the case of a patient with post-aSAH PSH and identifies 19 articles (25 cases) on stroke-related PSH by searching the PubMed database from 1980 to 2021. RESULTS: In the total cohort, 15 (60.0%) patients were male and the average age was 40.1 ± 16.6 years. The primary diagnoses included intracranial hemorrhage (13 cases, 52.0%), cerebral infarction (7 cases, 28.0%), subarachnoid hemorrhage (4 cases, 16.0%), and intraventricular hemorrhage (1 case, 4.0%). The sites of stroke damage were predominantly the cerebral lobe (10 cases, 40.0%), basal ganglia (8 cases, 32.0%), and the pons (4 cases, 16.0%). The median time of PSH onset after admission was 5 (1-180) days. Most cases employed combination therapy with sedation drugs, beta-blockers, gabapentin, and clonidine. On the Glasgow Outcome Scale, outcomes included death (4 cases, 21.1%), vegetative state (2 cases, 10.5%), severe disability (7 cases, 36.8%), and in only one case (5.3%) was a good recovery noted. CONCLUSIONS: The clinical features and treatment of post-aSAH PSH differed from those of aSAH-related hyperadrenergic crises. Early diagnosis and treatment can prevent severe complications. PSH should be acknowledged as a potential complication of aSAH. Differential diagnosis can aid in developing individualized treatment plans and improving patient prognosis.

Concurrent cerebral infarction and intracranial tuberculoma induced by the carotid plaque complicated with miliary tuberculosis.

Cerebrovascular complications of central nervous system tuberculosis (TB) are predictors of poor prognosis and adverse outcomes. These complications are mainly intracranial arterial involvement, with occasional venous involvement. Here, we present a 67-year-old woman with concurrent cerebral infarction and intracranial tuberculoma induced by the carotid plaque complicated by miliary tuberculosis. Mycobacterium tuberculosis was observed on the luminal side of the carotid plaques in pathological specimens. Treatment with anti-TB drugs alone would likely not cure the patient, as M. tuberculosis would continue to disseminate. Endarterectomy could directly remove the embolic source, and a complete cure was achieved.

The prognosis and treatment effectiveness of de novo aneurysm formation after radiation therapy for brain tumor.

Radiation therapy is a well-established, minimally invasive method of treating brain tumors. In recent years, the number of post-radiotherapy patients has increased, and delayed side effects are evident. De novo aneurysm formation after radiation often manifests as fatal subarachnoid hemorrhage (SAH), resulting in severe clinical outcomes. Nevertheless, the prognosis and therapeutic efficacy of radiation-induced aneurysms (RIAs) remain unclear. Using the PubMed database from 1980 to 2021, we screened 45 articles (53 individual cases) on RIAs; approximately 70% of RIAs were diagnosed after rupture. Of 38 ruptured RIAs, 12 (31.6%) had modified Rankin scale (mRS) 5-6. On the other hand, all unruptured RIAs (15 cases) recovered without neurological deficits (p = 0.012). Ten of the 39 ruptured RIAs were treated surgically, and 22 were treated endovascularly. There was no significant difference in mRS between treatment modalities (p = 0.393), but conservative therapy was significantly related to unfavorable outcomes (p = 0.025). To improve clinical outcomes, RIAs need to be diagnosed before rupture. Surgeons should be aware of de novo aneurysm formation in patients long after radiation therapy.

Future stroke risk in the chronic phase of post-percutaneous coronary intervention.

A percutaneous coronary intervention (PCI) is widely performed for acute coronary syndromes or chronic coronary syndromes. Periprocedural stroke is a clinically significant complication during PCI. The incidence of cerebrovascular events (CVEs) after PCI in the chronic phase is obscure. This study aimed to investigate the prevalence of CVEs after PCI in the chronic phase and evaluate the usefulness of a simple coronary artery calcification (CAC) evaluation method. This prospective observational study included 179 patients who underwent PCI between January 2016 and December 2018. The incidence of cerebral infarction was examined from one month after PCI to December 2019. In total, 171 individuals (134 men; mean age, 69.8 ± 9.8 years) were recruited. During a median follow-up period of 33 months, the onset of cerebral infarction was observed in 20 individuals (11.7%). More CAC sites (p = 0.009) and post-PCI for the chronic coronary syndrome (p = 0.049) showed a significant association with future CVEs. There was no significant cervical internal carotid artery stenosis for patients who occurred CVEs. The cutoff value for the number of CAC sites for predicting future CVEs was 4.5. The new and easy method accurately reflected future CVEs risk and may be clinically applicable.

Acute Hydrocephalus Requiring External Ventricular Drainage Following Perimesencephalic Nonaneurysmal Subarachnoid Hemorrhage in a Pediatric Patient: Case Report and Review of the Literature.

BACKGROUND: Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSAH) is a well-described subset of subarachnoid hemorrhage with an excellent prognosis in adults. However, its characteristics in the pediatric population have not yet been fully understood. We present a case of acute hydrocephalus requiring external ventricular drainage following pediatric PNSAH. CASE DESCRIPTION: A previously healthy 10-year-old girl was admitted to our neurosurgical department after sudden onset of severe headache with vomiting during exercise. Cerebral non-contrast computed tomography detected subarachnoid hemorrhage filling all perimesencephalic cisterns. However, digital subtraction angiography could not locate the hemorrhage source. Her consciousness deteriorated within 7 hours of onset, and a computed tomography scan revealed acute hydrocephalus. We subjected the patient to external ventricular drainage for 10 days. She was discharged after 38 days of hospitalization, when she was physically and neuropsychologically healthy. Repeated digital subtraction angiography performed at the 6-month follow-up did not show any obvious source of hemorrhage except for a variant drainage pattern of the basal vein of Rosenthal. Based on the observations, we diagnosed the patient with PNSAH of a venous origin. CONCLUSIONS: We propose that acute hydrocephalus be suspected in pediatric patients with nonaneurysmal subarachnoid hemorrhage filling all perimesencephalic cisterns, as in adults. We also propose that one of the possible causes of pediatric PNSAH as of venous origin and related to the abnormal drainage pattern of basal vein of Rosenthal and elevation of venous pressure with exercise. Immediate surgical drainage could obtain a good outcome in a symptomatic case.

Endovascular Intervention in Basilar Artery Entrapment within the Longitudinal Clivus Fracture: A Case Report.

Although vascular complications after head trauma is well recognized, basilar artery entrapment within the longitudinal clivus fracture is rare. A 69-year-old man presented with progressive disturbance of consciousness and right hemiplegia after trauma. Computed tomography scan showed a right-sided acute subdural hematoma and multiple skull fractures, including a longitudinal clivus fracture. Magnetic resonance imaging revealed basilar artery occlusion and a small infarction at the ventral part of the pons. On the assumption of acute arterial occlusion caused by thrombus, endovascular thrombectomy was attempted, but resulted in perforation. After the procedure, basilar artery entrapment within the longitudinal clivus fracture turned out to be the cause of the occlusion. The present case suggests that basilar artery entrapment within the longitudinal clivus fracture is a possible cause of neurological deficits after trauma. In this subset, endovascular intervention without a correct diagnosis of this phenomenon is high risk.

Fenestration of a supraclinoid internal carotid artery associated with dual aneurysms: case report.

BACKGROUND AND IMPORTANCE: We present a rare case of fenestration of the left supraclinoid intracranial internal carotid artery with 2 associated aneurysms arising proximally and distally from the fenestration that were successfully treated with endovascular coil embolization. This is the first report of these types of aneurysms treated with coiling alone. CLINICAL PRESENTATION: A 47-year-old woman underwent a diagnostic workup; magnetic resonance angiography incidentally revealed 2 tandem aneurysms at the supraclinoid and paraclinoid portion of the left internal carotid artery. Angiography revealed fenestration of the left supraclinoid internal carotid artery with 2 aneurysms both proximal and distal to the fenestration. The patient underwent endovascular coil embolization of the aneurysms simultaneously. The smaller trunk was intentionally occluded to achieve complete packing of the proximal aneurysm. Both aneurysms were totally occluded, and no neurological deficits developed in the patient. CONCLUSION: Based on previous reports, fenestration has the potential to form an aneurysm, and there seemed to be a relatively high incidence of rupture if accompanied by aneurysm. Coiling is one good option to treat aneurysms and should be considered when multiple aneurysms exist because all aneurysms can be treated simultaneously. Proximal occlusion of the smaller trunk is acceptable because of a retrograde flow from the distal end, even if one exists.