Initial real-world experience of clazosentan for subarachnoid hemorrhage in Japan.

BACKGROUND: Cerebral vasospasm (CVS) is one of the most critical factors associated with clinical outcomes of patients with subarachnoid hemorrhage (SAH). Clazosentan has been investigated worldwide as a prophylactic agent to prevent CVS. We evaluated a new CVS management protocol which included clazosentan. METHODS: Consecutive 138 patients with SAH, hospitalized in our institution between January 2017 and December 2022, were included in this study. Baseline characteristics, clinical findings, and operative records were analyzed retrospectively. From May 2022, 10 mg/h clazosentan was co-administered with fasudil to all patients according to the indication in the Japanese label. Patients admitted before this date received the conventional combined protocol using the fasudil hydrochloride, nicardipine, and ozagrel. RESULTS: Eighteen (13.0%) patients received the new protocol during the CVS period (defined as day 1 up to day 14 after SAH onset). There were 54 (39.1%) elderly patients aged 75 years or older. Seventy-two (52.2%) patients underwent neurosurgical clipping, whereas 55 (39.9%) patients received endovascular coiling. Among the patients with new protocol, only one patient (5.6%) had symptomatic CVS, compared with 18 patients (15.0%) in those with conventional protocol. More patients who received the new protocol had fluid retention compared with control group (38.9% [7/18] vs. 8.3% [10/120]). Other results did not differ between the two groups. CONCLUSIONS: Clinical outcomes of the new protocol were comparable to those of conventional protocol. Clazosentan may simplify anti-vasospasm treatment. Fluid retention was a specific side-effect of clazosentan, which requires attention especially in the first half of the CVS period.

Efficacy, safety, and predictors for functional outcomes of mechanical thrombectomy in patients aged over 90 years with acute ischemic stroke and literature review.

BACKGROUND: No evidence supports the efficacy and safety of mechanical thrombectomy (MT) in patients aged ≥ 90 years with acute ischemic stroke (AIS). This study clarifies the efficacy, safety, and predictors of MTs in patients aged ≥ 90 years by investigating our results and reviewing previous studies. METHODS: We retrospectively investigated data from 80 consecutive patients who underwent MT at our hospital between 2018 and 2021. We analyzed outcomes using the modified Thrombolysis in the Cerebral Infarction (mTICI) scale and modified Rankin Scale (mRS). Functional outcomes were investigated at 90 days or discharge. RESULTS: We obtained functional outcomes mRS ≤ 3 patients in 41.6%. The mortality rate was 16.6%. The rate of successful recanalization was 75%. Comparison mRS ≤ 3 and mRS ≥ 4 at 90 days or discharge showed statistical significance in the National Institute of Health Stroke Scale, the location of occluded vessels, and mTICI ≥ 2b at the first pass. Univariable logistic regression analysis indicated that the Alberta Stroke Program Early Computed Tomography Score was a predictor of mRS ≤ 3. CONCLUSIONS: The efficacy is lower than that of patients aged < 90; however, MT is effective even in patients aged ≥ 90 years. The safety of MT in patients aged ≥ 90 years was similar to that in those aged < 90 years. Neuro-interventionalists should consider predictors and take the best strategies to achieve successful recanalization in patients aged ≥ 90 years with AIS.

Giant saccular aneurysm of the cervical internal carotid artery treated with aneurysmectomy and side-to-end anastomosis.

Background: Cervical aneurysms are rare, accounting for <1% of all arterial aneurysms, including dissecting, traumatic, mycotic, atherosclerotic, and dysplastic aneurysms. Symptoms are usually caused by cerebrovascular insufficiency; local compression or rupture is rare. We present the case of a 77-year-old man with a giant saccular aneurysm of the cervical internal carotid artery (ICA), which was treated with aneurysmectomy and side-to-end anastomosis of the ICA. Case Description: The patient had experienced cervical pulsation and shoulder stiffness for 3 months. The patient had no significant medical history. An otolaryngologist performed the vascular imaging and referred the patient to our hospital for definitive management. Neurological deficits were not observed. Digital subtraction angiography showed a giant cervical aneurysm with a diameter of 25 mm within the ICA, and there was no evidence of thrombosis within the aneurysm. Aneurysmectomy and side-to-end anastomosis of the cervical ICA were performed under general anesthesia. After the procedure, the patient experienced partial hypoglossal nerve palsy but fully recovered with speech therapy. Postoperative computed tomography angiography revealed the complete aneurysm removal and patency of the ICA. The patient was discharged on postoperative day 7. Conclusion: Despite several limitations, surgical aneurysmectomy and reconstruction are recommended to eliminate the mass effect and to avoid postoperative ischemic complications, even in the endovascular era.

Association between population changes and the number of endovascular thrombectomies.

Background: Randomized controlled trials have demonstrated the efficacy of mechanical thrombectomy (MT) for acute ischemic stroke. However, few studies indicate an association between the number of mechanical thrombectomies and population changes. We aimed to clarify the association between population changes and the number of mechanical thrombectomies for proper allocation of limited medical resources. Methods: We retrospectively analyzed data from 162 patients who underwent MT for large vessel occlusion at our hospitals and compared the number of mechanical thrombectomies per 100,000 person/year to population changes in five regions covered by our hospitals within 2015-2016 and 2017-2019. We performed a simple linear regression analysis to determine the association between population changes and the number of mechanical thrombectomies. Results: Overall, the number of mechanical thrombectomies increased from 15.1 to 19. However, a significant decrease was noted in Toya Lake and Sobetsu/Toyoura. Furthermore, there was a significant negative linear correlation between the overall population reduction rate and the number of mechanical thrombectomies and a positive linear correlation between the increased proportion of the population aged >65 years and the number of mechanical thrombectomies. Conclusion: The number of mechanical thrombectomies may decrease in areas where the overall population reduction rate exceeds 8% or the increased rate of the population aged >65 years is <4%. However, it is necessary to continue establishing a system for MT in areas that have yet to reach these levels.

Embolization using endovascular technique in acute and chronic stages of traumatic ophthalmic artery aneurysm - case report - .

A 44-year-old man presented with traumatic aneurysm of the left ophthalmic artery. The first coil embolization intervention achieved relatively tight packing of the aneurysm and the parent artery. After 5 months, a second embolization procedure was required because of recurrence of the aneurysm with transition of the intraaneurysmal coil formation. No recurrence occurred after the second embolization. We thought that the first embolization might have prevented catastrophic rupture, whereas the second embolization resulted in complete obliteration of the aneurysm. No entity of the aneurysmal wall formation of the current traumatic aneurysm in the acute stage may have resulted in the recanalization of the aneurysm followed by the second intervention. The stability of the wall in the chronic stage may correlate with the complete obliteration.

Dural arteriovenous fistula of the anterior cranial fossa with carotid artery stenosis treated by simultaneous transarterial embolization and carotid artery stenting.

A 71-year-old male presented with a rare case of dural arteriovenous fistula (AVF) of the anterior cranial fossa associated with carotid artery stenosis manifesting as a transient visual disorder. The therapeutic strategy was complicated because the collateral network to the ischemic brain from the external carotid artery was associated with the dural AVF. Transarterial embolization of the shunt was performed simultaneously with carotid artery stent placement. The patient showed good recovery despite a tiny skin ulcer around his nose.

[A study of intraarterial pressure changing during cerebral angiography].

BACKGROUND: Elevation of cerebral blood pressure induced by injection of contrast medium has been postulated as a major cause of rerupture of cerebral aneurysms during angiography. The current study was performed to clarify whether intra-arterial pressure elevation occurs during contrast injection. MATERIALS AND METHODS: The study included six patients. To confirm the accuracy of pressure measurement, a pressure wire (SmartWire) was used. The changes in intravascular pressure were measured by the pressure wire and through a microcatheter and a guiding catheter The data from these modalities were then compared. The contrast injection flow rate was 4 ml/s in ICAG (internal carotid angiography), 3 ml/s in VAG (vertebral angiography) and 5 ml/s in CAG (carotid angiography), and all injections were administered without contrast wedging, regurgitation or mechanical spasm in adjacent arteries. RESULTS: The pressure measured through the guiding catheter was the same as that measured with the pressure wire, but the data obtained through the microcatheter was not more than reference data. The changes in pressure were not evident in the distal end of the catheter tip. CONCLUSION: Intra-arterial pressure elevation probably doesn't occur under appropriate injection, resulting in safer cerebral angiography. However, in case a high contrast injection flow rate is required to produce a better image, surgeons should also be aware of the possibility of pressure elevation.

[A case of ruptured internal carotid artery aneurysm mimicking pituitary apoplexy].

A 48-year-old female presented with a sudden onset of headache and visual impairment. Nineteen years before, she had undergone a transsphenoidal surgery for a prolactin producing pituitary adenoma at our hospital without intraoperative arterial bleeding. On arrival, she exhibited dilated pupils and loss of bilateral visual acuity, but improved immediately after all examinations. MRI revealed a pituitary tumor with intratumoral hemorrhage, intraventricular hemorrhage and subdural hemorrhage. Cerebral angiography revealed a left intracavernous carotid artery aneurysm. Her medical history and radiological findings suggested the rupture of a de novo aneurysm causing a hemorrhage into a pituitary adenoma mimicking pituitary apoplexy. Endovascular occlusion of the aneurysm was performed by use of platinum coils. Because of rapid improvement of visual acuity, administration of terguride was chosen for shrinking the pituitary adenoma. If a pituitary adenoma is present, the possibility of a coincidental aneurysm should always be considered. This association should be kept in mind when evaluating any case of pituitary apoplexy.