Transarterial Embolization With N-Butyl-2-Cyanoacrylate for Rapidly Enlarging Distal Anterior Choroidal Artery Aneurysm Associated With Moyamoya Disease: A Case Report.

Peripheral aneurysms associated with moyamoya disease, particularly those originating from the anterior choroidal artery, often have a poor prognosis and are typically managed with endovascular treatments. Comprehensive imaging diagnostics and anatomical expertise are critical in minimizing ischemic complications during treatment. We present a case of a 55-year-old woman with a rapidly enlarging distal anterior choroidal artery aneurysm identified during an intracerebral hemorrhage associated with moyamoya disease. The patient underwent super-selective embolization using N-butyl-2-cyanoacrylate (NBCA) during the chronic phase, resulting in a favorable outcome. Detailed intraoperative imaging was essential in guiding the treatment and mitigating risks.

Association Between Cerebral Angiography and Asymmetrical Cortical and Deep/Medullary Vein Signs on T2 Star Magnetic Resonance Imaging in Patients with Hyperacute Horizontal Segment of the Middle Cerebral Artery Occlusion.

BACKGROUND: When treating acute ischemic stroke patients, evaluation of collateral flow to the ischemic area is essential. Blood-oxygen-level-dependent imaging, including T2 star (T2∗), can identify elevated deoxyhemoglobin levels, reflecting an increase in the oxygen extraction fraction. Prominent veins on T2∗ represent increased deoxyhemoglobin and cerebral blood volume. This study compared asymmetrical vein signs (AVSs) on T2∗ and digital subtraction angiography findings during mechanical thrombectomy (MT) in patients with hyperacute middle cerebral artery occlusion. METHODS: Clinical and imaging data of 41 patients with occlusion of the horizontal segment of the middle cerebral artery who underwent MT were collected. Patients were divided into 2 groups based on angiographic occlusion sites as: proximal and distal to the lenticulostriate artery (LSA). AVSs on T2∗ were divided into asymmetrical cortical vein sign (cortical AVS) and asymmetrical deep/medullary vein sign (deep/medullary AVS), and were compared with the findings of intraoperative digital subtraction angiography. RESULTS: Twenty-seven patients had AVSs. Cortical AVS was the only parameter with a significant association with poor angiographic collateral supply. In terms of occlusion site, deep/medullary AVS was the only parameter with a significant association with occlusion proximal to the LSA. CONCLUSIONS: In patients with occlusion of the horizontal segment of the middle cerebral artery, presence of the cortical AVS on T2∗ suggests a poor angiographic collateral supply, while presence of the deep/medullary AVS suggests impaired blood flow to the basal ganglia through LSAs. Both these signs contribute to poor outcomes in patients undergoing MT.

Clinical features of Barré-Lièou syndrome and efficacy of trazodone for its treatment: A retrospective single center study.

Barré-Lièou syndrome (BLS) is a manifestation of various autonomic and secondary symptoms including muscle stiffness, tinnitus, dizziness, and pain in various body parts. Although considered to be caused by hyperactivation of the autonomic nervous system due to trauma, there is currently no firmly established etiology or evidence on the treatment and clinical features of BLS. We retrospectively examined the clinical features of BLS and evaluated the efficacy of trazodone (TZD) for its treatment. We conducted a retrospective analysis of the data of 20 consecutive cases with suspected BLS who were treated in our hospital between 2016 and 2019. BLS symptoms were rated on a 10-point scale, and two groups were defined, that is, a mild-BLS group (BLS scores, 1-5) and a severe-BLS group (BLS scores, 6-10). Univariate analysis of patient factors was performed. The BLS score was 6.0 ± 1.7, and the maximum TZD dose was 80 ± 34 mg/day; nine patients (45%) were TZD free, and no TZD side effects were observed, while all patients had a good clinical outcome. There were significant differences between the mild-BLS and severe-BLS groups in the period from injury to diagnosis (p = 0.015), chest/back pain (p < 0.001), constipation (p = 0.001), and maximum TZD dose (p = 0.008). BLS involves posttraumatic autonomic symptoms accompanied by depression and insomnia. The sympathetic hypersensitivity theory could explain its etiology. TZD could effectively and safely treat BLS, and early diagnosis and treatment can contribute toward good clinical outcomes. Enhanced recognition and understanding of this disease are warranted.

Intrapartum Subarachnoid Hemorrhage from Suspected Lateral Posterior Choroidal Artery Dissection.

Stroke associated with pregnancy or puerperium is rare, but represents an important problem for women of childbearing age. We herein report a case of subarachnoid hemorrhage (SAH) due to suspected lateral posterior choroidal artery (LPChA) dissection during delivery. A 34-year-old woman developed deterioration of consciousness during delivery at a maternity clinic. Her Glasgow Coma Scale score was E3V3M6. She was sent to our hospital after 12 hr, where CT revealed SAH with intraventricular hematoma. Radiographic examinations showed contrast pooling on the left LPChA. Repeated angiography showed enlargement of the contrast pooling, which indicated pseudoaneurysm. It also showed a relatively clear but stenosed LPChA communicated with the lesion which could not be recognized in the angiography on day 0. This stenosed LPChA indicated arterial dissection. Therefore, endovascular parent artery occlusion was performed on day 11. Determining the exact extent of dissection was difficult because the LPChA was extremely narrow. Occlusion of the posterior cerebral artery was needed to achieve complete hemostasis, which, however, resulted in infarction of the medial temporal and occipital lobes. At the time of final follow-up 3 years later, the patient was alert and completely independent, but showed persistent incomplete homonymous hemianopsia. We reported a rare case of SAH from suspected LPChA dissection during delivery. Repeated angiography provided information about the source of hemorrhage and definite diagnosis, which opened the way to treatment. It is also important to recognize the difficulty in identifying the exact extent of dissection when treating dissections of small arteries.

Characteristics and clinical outcomes in pituitary incidentalomas and non-incidental pituitary tumors treated with endoscopic transsphenoidal surgery.

PURPOSE: In this retrospective study, we investigated the status and validity of endoscopic transsphenoidal surgery (eTSS) for pituitary incidentalomas (PIs) as well as the value of basing the indication for surgery on the PI guidelines. METHODS: Patients who underwent eTSS at Fukuoka University Chikushi Hospital between 2012 and 2018 were divided into the PI group and the non-PI group in accordance with the PI guideline of the Endocrine Society and their clinicopathological characteristics and outcomes were compared and analyzed. RESULTS: A total of 59 patients were enrolled, with 35 patients in the PI group and 24 patients in the non-PI group. The diagnoses in the PI group were of non-functioning pituitary adenoma (NFPA) (n = 12, 34%), gonadotropin-producing pituitary adenoma (n = 8, 23%), Rathke cleft cyst (n = 7, 20%), meningioma (n = 4, 11%), and growth hormone-producing pituitary adenoma (n = 3, 9%); those in the non-PI group were of NFPA (n = 6, 25%), gonadotropin-producing pituitary adenoma (n = 3, 13%), Rathke cleft cyst (n = 3, 13%), growth hormone-producing pituitary adenoma (n = 3, 13%), and prolactin producing pituitary adenoma (n = 3, 13%). Regarding the preoperative factors, 1 patient in the PI group with panhypopituitarism was diagnosed with pituitary apoplexy (pure infarction) of an NFPA. The rates of postoperative anterior pituitary hormonal deficiencies (14% vs 46%, P = .015), residual tumor size (2 ±â€Š5 vs 6 ±â€Š7 mm, P = .008), and reoperation (n = 0, 0% vs n = 5, 21%, P = .005) were significantly different between the PI and non-PI groups. CONCLUSIONS: This study showed that, postoperatively, the incidence of anterior pituitary hormonal deficiencies was lower in the PI than in the non-PI group, although it was comparable between the 2 groups before the operation. The patients in the PI group also had smaller residual tumors and a lower risk of reoperation than those in non-PI group. PIs could have a better postoperative clinical outcome than non-PIs when the indication for eTSS is based on preoperative scrutiny according to the PI guidelines and eTSS is performed by an experienced pituitary surgeon. Hence, more aggressive scrutiny and treatment for PIs might be desirable.

Successful endoscopic biopsy for Primary central nervous system lymphoma of the corpus callosum in the splenium with bilateral visuomotor ataxia.

Primary central nervous system lymphoma (PCNSL) is a rare malignant tumor of the central nervous system. It is associated with poor prognosis. Early diagnosis and subsequent planning of adequate treatment strategy are relevant to improve survival and reduce neurological deficit. Specifically, there are no reports of successful endoscopic biopsy for PCNSL of the corpus callosum in the splenium with bilateral visuomotor ataxia. An 74-year-old woman presented to our hospital with anorexia, depression and ataxia beginning six months earlier. Head computed tomography and magnetic resonance imaging showed malignant tumor suspected in the corpus callosum. Endoscopic biopsy was performed via the low parieatal approach, suspecting GBM or PCNSL. She had no new postoperative neurological deficits and was pathologically diagnosed with diffuse large B-cell lymphoma (DLBCL). She is currently undergoing radiation chemotherapy with a modified Rankin Scale score of 2. Regarding preoperative symptoms, ataxia was considered to be bilateral visuomotor ataxia caused by damage to the corpus callosum in the splenium, and anorexia and depression were considered symptoms of the surrounding limbic system. Delay in the diagnosis of PCNSL can lead to a poor prognosis. Visuomotor ataxia should also consider the potential for the corpus callosum in the splenium lesion, including PCNSL, and appropriate imaging and pathological diagnosis with endoscopic biopsy can contribute to a good clinical outcome.

Efficacy of trazodone for treating paroxysmal sympathetic hyperactivity presenting after left temporal subcortical hemorrhage.

Paroxysmal sympathetic hyperactivity (PSH) is a clinical condition characterized by abnormal paroxysmal surges in sympathetic nervous system activity. PSH is known to occur after severe head injury and hypoxic encephalopathy. Cases of PSH that develop after stroke have been reported worldwide; however, PSH is not commonly reported in the field of stroke research in Japan. Some studies have suggested that gabapentin may improve the symptoms of PSH. To our knowledge, this is the first case report demonstrating the efficacy of trazodone for the treatment of PSH that developed after temporal subcortical hemorrhage. A 49-year-old woman presented to our clinic with mild confusion and sensory aphasia after experiencing left temporal subcortical hemorrhage; a conservative treatment was initiated at our hospital. Immediately upon hospitalization, she developed prolonged consciousness disorder, high fever, tachycardia, malignant hypertension, tachypnea, constipation, and overactive bladder. The patient's symptoms improved after the administration of trazodone. She was diagnosed with PSH after intracranial hemorrhage and was subsequently transferred to a recovery and rehabilitation hospital unit where the oral administration of trazodone continued. Prolonged PSH contributes significantly to the impairment of daily activities in patients with stroke; therefore, early diagnosis and treatment are critical. Here, we report on the efficacy of trazodone as an effective treatment option for improving clinical outcomes and reducing the stay in the stroke care unit.

Successful early diagnosis and treatment of non-convulsive status epilepticus-induced Takotsubo syndrome.

Takotsubo syndrome (TTS) is often preceded by emotional or physical stress. Epileptic seizures have been described in more than 100 TTS cases. Due to the lack of typical symptoms, seizure-induced TTS can be overlooked. Here, we describe a rare case where TTS induced by non-convulsive status epilepticus (NCSE) was diagnosed early and successfully treated. An 82-year-old man presented to our hospital with confusion, anorexia, aphagia, and abnormal behavior beginning a few days earlier. Head computed tomography and magnetic resonance imaging did not show any structural abnormalities. Upon hospitalization, blood sampling revealed elevated levels of myocardial escape enzymes; however, cardiac ultrasonography showed apical asystole, and emergency coronary angiography did not show any significant stenosis or occlusion. The patient's symptoms improved after the administration of antiepileptic drugs consisting of diazepam, fosphenytoin, and levetiracetam. On day 2 of hospitalization, an electroencephalogram showed high amplitude slow waves in the left cerebral hemisphere and NCSE-induced TTS was diagnosed. The patient was discharged after 2 weeks with a modified Rankin Scale score of 0 and continuing oral administration of levetiracetam. Delay in the diagnosis of NCSE-induced TTS can lead to a poor prognosis. Early diagnosis and treatment for NCSE and NCSE-induced TTS may result in favorable outcomes for the patient.

Safety of direct oral anticoagulant - and antiplatelet therapy in patients with atrial fibrillation treated by carotid artery stenting.

BACKGROUND: The periprocedural administration of dual antiplatelet therapy has been recommended in patients treated by carotid artery stenting. However, some patients with concurrent disease have been prescribed anticoagulants. We compared the post-operative incidence of hemorrhagic and thromboembolic events in two patient groups treated by different regimens of multi-antithrombotic agents. METHODS: As our 31 patients had a history of nonvalvular atrial fibrillation, they had received anticoagulants; they were also treated with aspirin and clopidogrel before carotid artery stenting. The prior anticoagulant therapy was continued in 17 patients and they received vitamin K antagonist plus dual antiplatelet therapy after the procedure (group 1). Other 14 patients underwent direct oral anticoagulant plus aspirin or clopidogrel (group 2). Post-procedural hemorrhagic and thromboembolic events were compared between two groups. RESULTS: Carotid artery stenting was angiographically successful in all patients. Complications were encountered in two group 1 patients. Post-operative image revealed a silent subarachnoid hemorrhage in one. The other presented with superior mesenteric artery occlusion 6 months after the procedure. No hemorrhagic or thromboembolic events occurred in group 2. CONCLUSION: We concluded that the administration of a direct oral anticoagulant plus an antiplatelet agent reduced the risk for periprocedural hemorrhagic and embolic events in patients with concurrent nonvalvular atrial fibrillation who underwent carotid artery stenting.

[A Case of Rapidly Progressing High-grade B-cell Lymphoma with c-Myc Translocation and Bcl-2 Protein Expression].

We report a case of rapidly progressing primary high-grade B-cell lymphoma of the central nervous system with c-Myc translocation and Bcl-2 protein expression that resulted in the patient's death 45 days after the onset of convulsions. Further, we provide a literature review. CASE:A 74-year-old man was admitted to our hospital for convulsions. Magnetic resonance imaging on admission showed tumorous lesions at the left temporoparietal junction. An open biopsy was performed promptly. The patient was diagnosed with primary high-grade B-cell lymphoma of the central nervous system with c-Myc translocation and Bcl-2 protein expression(<50%). The tumor showed rapid progression postoperatively. The patient did not respond to steroids and died 45 days after the onset of convulsions. CONCLUSION:The c-Myc translocation, showing a strong c-Myc protein positivity, and co-expression of the Bcl-2 protein were poor prognostic factors for the tumor.

Pituitary incidentaloma diagnosed as acromegaly triggered by trauma: A case report.

Pituitary incidentaloma (PI) is a generic term for pituitary tumors that are identified on images acquired for non-malignant conditions. Acromegaly is an extremely rare form of PI. Occasionally, a functional pituitary adenoma (PA) may be misdiagnosed as PI, which may result in a poor clinical outcome. Here we report the first case, to the best of our knowledge, of PI diagnosed as trauma-triggered acromegaly. A 42-year-old man with a chief complaint of head trauma was referred to our hospital after computed tomography (CT) revealed a pituitary tumor. His appearance was suggestive of acromegaly. Mild hypertrophy of the extremities was also observed. Preoperative blood tests, magnetic resonance imaging (MRI), and endocrine tolerance test findings indicated acromegaly. Accordingly, we suspected a growth hormone (GH)-producing PA, and we performed endoscopic transsphenoidal surgery (eTSS). Histopathology showed a densely granulated GH-producing PA, which was also confirmed via immunohistochemistry. Two months after surgery, blood tests showed decreased levels of GH and insulin-like growth factor-1. In addition, a postoperative endocrine tolerance test revealed no abnormalities. There was no recurrence at 24 months after surgery. The findings from this case suggest that PIs can also present as functional adenomas, which can be diagnosed using initial hormone examinations and endocrine tolerance tests. Therefore, thorough endocrine examination is necessary for early diagnosis and treatment and improved patient outcomes.

Effectiveness of endoscopic transsphenoidal surgery for gonadotroph adenoma mimicking dementia: A case report.

There are few reports of pituitary adenomas (PA) mimicking dementia. Delay in disease diagnosis and treatment may result in poor clinical outcome. We experienced a rare case where endoscopic transsphenoidal surgery (eTSS) effectively treated a gonadotroph adenoma mimicking dementia and report on literature considerations. We report the case of a 72-year-old man with chief complaints of cognitive decline, bradykinesia, anorexia, dressing apraxia, and vigor decline over several months. He was admitted to our hospital for scrutiny in a disoriented state. Blood tests showed hyponatremia and thyroid hormone depression. Magnetic resonance imaging showed a pituitary tumor, and preoperative endocrine stress tests showed reduced reactivities of growth hormone, adrenocorticotropic hormone/cortisol, and luteinizing hormone/follicle-stimulating hormone. Symptomatic pituitary adenoma was suspected, and eTSS was performed. The permanent pathological diagnosis was of gonadotroph adenoma. Postoperatively, the hyponatremia, cognitive decline, movement retardation, loss of appetite, dressing apraxia, and limb edema markedly improved. The patient was discharged under hydrocortisone 15 mg/day administration without complications. The endocrine stress test performed 2 months postoperatively showed secondary hypoadrenocorticism, while the other endocrine functions had normalized. No recurrence had occurred by 30 months postoperatively; the medication of hydrocortisone was gradually discontinued and the patient at the time was still being followed as an outpatient with modified Rankin Scale score 0. Secondary hypothyroidism and secondary hypoadrenocorticism due to the pituitary tumor primarily caused the condition. It is important to consider PA in the differential diagnosis of dementia, and early diagnosis and treatment can contribute to a patient's good clinical outcome.

[A Case of Cerebral Amyloid Angiopathy-related Subarachnoid Hemorrhage with Parkinson Disease Dementia].

We report a case of cerebral amyloid angiopathy(CAA)-related subarachnoid hemorrhage(SAH)with Parkinson's disease dementia(PDD), along with a literature review. CASE: A 67-year-old woman with a history of Parkinson's disease was diagnosed with SAH(World Federation of Neurosurgical Societies grade I). The plain head CT performed on admission, revealed an atypical hematoma distribution. Blood sampling, MRI and cerebral angiography revealed no vascular abnormalities, meningitis, encephalitis, or primary angiitis of the central nervous system. MRI performed on the third day after admission confirmed the presence of bilateral cortical or subcortical hemorrhage in the parietal lobe, with amyloid-related imaging abnormalities. A preliminary diagnosis of CAA was made, based on the Boston criteria. She was also diagnosed with PDD, based on the cognitive decline during hospitalization. CONCLUSION: Stroke related with CAA, as seen in SAH, may contribute to cognitive decline and the progression of lesions in PDD.

Neurovascular compression syndrome of the brain stem with opsoclonus-myoclonus syndrome combined with vestibular paroxysmia and autonomic symptoms.

We describe a rare case of neurovascular compression syndrome (NVCS) of the brain stem and opsoclonus-myoclonus syndrome (OMS) complicated with vestibular paroxysmia (VP) and autonomic symptoms. Moreover, we discuss the case with respect to the available information in medical literature. A 36-year-old man with vertigo and nausea had difficulty standing, and was transported by an ambulance to our hospital. He had VP, opsoclonus, cervical myoclonus, anxiety, and restless legs syndrome. Magnetic resonance imaging at hospitalization showed that the dolichoectatic vertebral artery was in contact with the postero-lateral side of the pontomedullary junction. He was diagnosed with NVCS of the brain stem (most likely of the input to the vestibular nucleus) associated with contact with the dolichoectatic vertebral artery. Combination therapy using multiple antiepileptic drugs, such as low-dose carbamazepine, clonazepam, and lacosamide, improved his clinical symptoms. He was finally able to walk and was discharged on day 42 after admission. He is being routinely followed-up since then. Further research is needed to confirm the validity of the combination therapy.

Focus on diagnosis, treatment, and problems of Barré-Lièou syndrome: Two case reports.

Barré-Lièou syndrome is a manifestation of various autonomic and secondary symptoms, such as muscle stiffness, tinnitus, dizziness, and pain in the head, neck, eyes, throat, ears, chest, and back. While thought to be caused by hyperactivation of the autonomic nervous system due to trauma, there is currently no firmly established etiology. This, and the nonspecific nature of many of its symptoms, presents a challenge both for clinicians, who must provide a correct diagnosis and patients, who are often misdiagnosed or faced with undue scrutiny from insurance companies. Here, we present two cases of Barré-Lièou syndrome, focusing on the processes leading to diagnosis, treatment, and problems encountered. Case 1 involves a 68-year-old woman whose head computed tomography (CT) scan revealed no abnormalities following a car accident. Approximately 10 months after her initial injury, Barré-Lièou syndrome was suspected because of autonomic symptoms that developed over time. She was prescribed an α-blocker, and 9 months later, her symptoms subsided. Case 2 was a 69-year-old woman who presented with bruising to the right chest and right knee after colliding with a car while riding her bicycle. One month later, Barré-Lièou syndrome was suspected because of her autonomic symptoms. She was prescribed an α-blocker, and 17 months later, her symptoms subsided. Because of the characteristic autonomic and secondary symptoms described above and a positive response to α-blockers, Barré-Lièou syndrome was suspected in both cases. We believe reporting cases will aid in the understanding of this disease and help patients obtain positive outcomes.

A case of drug-induced hypersensitivity syndrome induced by salazosulfapyridine combined with SIADH caused by interstitial pneumonia.

We present a case of a patient with drug-induced hypersensitivity syndrome (DIHS) caused by salazosulfapyridine combined with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) caused by interstitial pneumonia (IP). A 67-year-old man with a past history of rheumatism (RA) presented with right hemiparalysis and aphasia as the chief complaints. A diagnosis of left embolic cerebral infarction following trial therapy for RA based on computed tomography findings was made, and external decompression was performed. Salazosulfapyridine was newly started on day 7. Dabigatran was started on day 37. On day 41, the patient developed fever. On day 42, edema and erythema appeared on his face, and erythema and rash appeared on his trunk and extremities, with gradual transition to erythroderma. The drug eruption was initially attributed to the dabigatran. Various symptoms of organ dysfunction (enteritis, myocarditis, interstitial pneumonia, hepatic disorder, stomatitis, and others) then appeared and persisted; hence, a diagnosis of DIHS associated with human herpes virus 6 and cytomegalovirus infection induced by salazosulfapyridine was suggested, and the oral administration of salazosulfapyridine was discontinued on day 53. Hyponatremia was observed in association with exacerbation of IP. Due to low serum osmotic pressure and prompt improvement of the serum sodium level by fluid restriction, the SIADH was attributed to IP. In this case, steroid pulse therapy followed by gradual decrease therapy prevented worsening of the condition.

Efficacy of trazodone for treating paroxysmal sympathetic hyperactivity presenting after thalamic hemorrhage: A case report.

Paroxysmal sympathetic hyperactivity (PSH) is a clinical condition characterized by abnormal paroxysmal surges in sympathetic nervous system activity. PSH is known to occur after severe head injury and hypoxic encephalopathy. Cases of PSH that develop after stroke have been reported worldwide; however, PSH is not commonly reported in the field of stroke research in Japan. Some studies have suggested that gabapentin may improve the symptoms of PSH. To our knowledge, this is the first case report demonstrating the efficacy of trazodone for the treatment of PSH that developed after thalamic hemorrhage. A 45-year-old woman presented to our clinic with headache and paralysis of the left side of her body after experiencing right thalamic hemorrhage; a conservative treatment was initiated at our hospital. Immediately upon hospitalization, she developed high fever, tachycardia, tachypnea, constipation, and overactive bladder and had breathing difficulties. Blood sampling revealed elevated levels of myocardial escape enzymes; however, coronary angiography did not show any significant stenosis or occlusion. The patient's symptoms improved after the administration of trazodone. She was diagnosed with catecholamine cardiomyopathy associated with PSH after intracranial hemorrhage and was subsequently transferred to a recovery and rehabilitation hospital unit where the oral administration of trazodone continued. Prolonged PSH contributes significantly to the impairment of daily activities in patients with stroke; therefore, early diagnosis and treatment are critical. Here, we report on the efficacy of trazodone as an effective treatment option for improving clinical outcomes and reducing the stay in the stroke care unit.

Different Clopidogrel Response Elicited by Lansoprazole or Esomeprazole in Patients Undergoing Neurointervention with Dual Antiplatelet Therapy.

BACKGROUND: Aspirin-clopidogrel dual antiplatelet therapy and a proton-pump inhibitor are used worldwide to prevent thromboembolism and peptic ulceration in patients undergoing neurointervention. We performed VerifyNow assays (Accumetrics, San Diego, CA, USA) to retrospectively examine the relationship between the effectiveness of antiplatelet agents and different proton-pump inhibitor types. METHODS: Sixty-four patients with unruptured intracranial aneurysm scheduled for neurointervention received aspirin-clopidogrel dual antiplatelet therapy plus the proton-pump inhibitor lansoprazole (n = 34) or esomeprazole (n = 30). A low response to aspirin and clopidogrel was defined in terms of aspirin reaction units > 550 and P2Y12 reaction units ≥ 230, respectively, by VerifyNow assay. The characteristics, response to antiplatelet therapy, and clinical outcomes were compared in patients treated with lansoprazole or esomeprazole. RESULTS: The preoperative mean VerifyNow aspirin reaction units and P2Y12 reaction units were 466.0 ± 67.3 and 205.0 ± 67.6, respectively. The mean aspirin reaction unit value was 482.0 ± 64.1 in the lansoprazole group, and 461.5 ± 70.9 in the esomeprazole group (p = 0.77). The mean P2Y12 reaction unit was 220.0 ± 64.4 in the lansoprazole group, and 174.5 ± 65.0 in the esomeprazole group; there was a significant difference in the clopidogrel response of patient treated with lansoprazole or esomeprazole (p = 0.005). CONCLUSIONS: Our VerifyNow assay results suggest that when on lansoprazole fewer patients achieved the therapeutic goal and required extra therapy before neurointervention.

[A Surgical Case of Aseptic Meningitis and Secondary Hypophysitis due to Rupture of a Rathke's Cleft Cyst].

PURPOSE: We describe a surgical case of aseptic meningitis and secondary hypophysitis due to rupture of a Rathke's cleft cyst(RCC)and report on literature considerations. CASE: A 36-year-old woman with a past history of menstrual irregularity who had been taking a low-dose contraceptive for five years visited our hospital. She had discomfort in her right eye four years earlier. A waxy nodule observed on MRI was diagnosed to be an asymptomatic RCC. She experienced periodic headaches and retrobulbar pain without any prior history. MRI showed dural thickening on gadolinium-T1-weighted(GdT1)imaging, disappearance of the waxy nodule on T1/T2-weighted imaging, signal change of the cyst contents, and suspected cerebrospinal fluid in the pre-pontine cistern. Aseptic meningitis or hemorrhagic adenoma due to RCC rupture was suspected, and endoscopic transsphenoidal surgery was performed on day 26. The pathological results indicated that the ruptured RCC had resulted in aseptic meningitis and secondary hypophysitis. CONCLUSION: If the rupture of an RCC is suspected and subsequent secondary hypophysitis and optic neuritis are observed, early diagnosis and surgery with informed consent are essential. This is because of the high risk for panhypopituitarism with vision loss and visual field disturbance.

Revascularization for In-Hospital Acute Ischemic Stroke After Video-Assisted Thoracic Surgery: Report of 2 Cases and Literature Review.

BACKGROUND: Postoperative cerebral embolism after left upper lobectomy caused by a thrombus in the pulmonary vein stump (PVS) is a serious complication. However, it is unclear whether cerebral embolism can develop after other types of lobectomy. We present 2 cases of revascularization for in-hospital acute ischemic stroke after video-assisted thoracic surgery (VATS). CASE DESCRIPTION: Patient 1 is a 71-year-old man with a history of hypertension and dyslipidemia. VATS was performed for lung cancer in the left upper lobe. On day 0 after VATS, he developed an acute ischemic stroke (left M3 occlusion). Revascularization was performed, and TICI 2b was obtained. He was transferred to a recovery rehabilitation hospital with a modified Rankin Scale score of 3. No ischemic or hemorrhagic stroke was observed 12 months postoperatively. Patient 2 is a 76-year-old man who had a history of hypertension. VATS was performed for metastatic lung cancer in the left lower lobe. On day 6 after VATS, he developed an acute ischemic stroke (left M1 occlusion). Revascularization was performed and TICI 3 was obtained. He was transferred to a recovery rehabilitation hospital with a modified Rankin Scale score of 1. No ischemic or hemorrhagic stroke was observed 13 months postoperatively. CONCLUSIONS: Postoperative PVS thrombosis causes embolisms, and dabigatran has been effective in preventing postoperative recurrences. Further study of preventive and perioperative management is necessary.