Urgent Carotid Artery Stenting with Intracranial and Carotid Stent for Symptomatic Bilateral Consecutive Internal Carotid Artery Dissection: A Case Report.

Spontaneous internal carotid artery dissection (CAD) is a relatively rare disease, with patients, including those with bilateral CAD, often recovering after conservative therapy. However, patients with symptomatic and progressive disease require urgent carotid artery stenting (CAS). If CAD extends to the petrous portion of the internal carotid artery (ICA), it is difficult to treat with a carotid stent alone. This report describes a rare case of consecutive spontaneous bilateral CAD that required an intracranial stent with an interval of 4 years between the first and second CAS. A 58-year-old man with a history of dyslipidemia was admitted for transient ischemic attacks. He underwent CAS with carotid and intracranial stents on the third day for the left CAD due to exacerbation of symptoms under antithrombotic therapy and new stroke on magnetic resonance imaging (MRI). He recovered well. However, 4 years after the initial treatment, the patient was admitted again because of a sudden headache, photophobia, and transient weakness of the left lower limb. He was diagnosed with CAD on the contralateral side. He underwent CAS with carotid and intracranial stents due to progressive neurological deterioration under antithrombotic therapy. After treatment, he was clinically stable without any new infarctions on a follow-up MRI. He was discharged without neurological deficit. Our case of bilateral internal CAD treatment demonstrated that early revascularization with immediate stenting with carotid and intracranial stents in CAD contributes to the prevention of extensive neurological damage, thereby providing a favorable outcome in some cases.

Aspect Ratio Is Associated with Recanalization after Coiling of Unruptured Intracranial Aneurysms.

The rate of recanalization after coil embolization for unruptured intracranial aneurysms (UIAs) is reported to occur around 11.3%-49%. This study aims to investigate the factors that influence the recanalization after coil embolization for UIAs in our institution. We retrospectively investigated 307 UIAs in 296 patients treated at our institution between April 2004 and December 2016. The stent-used cases were excluded. Cerebral angiography and 3D time-of-flight magnetic resonance angiography (TOF MRA) were used for evaluation of the postoperative occlusion status. Volume embolization ratio (VER), aneurysmal size, neck width, and aspect ratio (AR) were compared between the recanalized and non-recanalized groups. The mean follow-up period ranged from 6 to 172 months (mean: 79.0 ± 39.8 months). Recanalization was noted in 78 (25.4%) aneurysms, and 19 (6.2%) aneurysms required retreatment. There was no aneurysmal rupture during the follow-up period. Univariate analysis showed that the aneurysm size (p < 0.001), neck width (p < 0.001), AR (p = 0.003), and VER (p = 0.012) were associated with recanalization. Multivariate logistic regression analysis showed that the AR (p =0.004) and VER (p =0.015) were significant predictors of recanalization. To summarize, a higher AR and a lower VER could lead to recanalization after coil embolization of UIAs. Careful follow-up is required for coiled aneurysms with these features.

Impact on Clinical Outcomes of Changes in the Practice of Mechanical Thrombectomy due to the COVID-19 Pandemic.

Objective: To evaluate whether changes in the practice of mechanical thrombectomy could affect the clinical outcomes during the coronavirus disease (COVID-19) pandemic. Methods: Patients who underwent mechanical thrombectomy from April 2019 to March 2021 for anterior circulation proximal large artery occlusion in our institute were divided into two groups of pre- and post-COVID-19, with April 2020 assumed to be the start of the COVID-19 era with the first declaration of a state of emergency. We compared patient characteristics, proportions of patient selection depending on rapid processing of perfusion and diffusion (RAPID) CT perfusion, outcomes including treatment variables such as time and reperfusion status, and patient independence at 3 months. Results: Data for 112 patients (median age, 79 years; 44 females) were included in the analysis. A total of 50 patients were assigned to the pre-COVID-19 group (45%). More patients were selected with RAPID CT perfusion in the post-COVID-19 compared with the pre-COVID-19 (69% vs. 16%; P <0.001). Treatment details and clinical outcomes did not differ between the groups, including the door-to-puncture time (median [interquartile range], 66 [54-90] min vs. 74 [61-89] min; P = 0.15), proportions of significant reperfusion (82% vs. 87%; P = 0.60), and modified Rankin scale score of ≤2 at 3 months (46% vs. 45%; P >0.99). Multivariate logistic regression analysis for the clinical outcome of modified Rankin scale score of ≤2 at 3 months was performed and included the following factors: age, sex, the onset-to-door time, significant reperfusion, and pre- and post-COVID-19. The treatment period did not influence the outcomes (post-COVID-19 group, odds ratio, 0.79; 95% confidence interval, 0.34-1.85, P = 0.59). Conclusion: In the setting of a limited access to emergency MRI during the COVID-19 pandemic, RAPID CT perfusion was performed significantly more often. Changes in the practice of mechanical thrombectomy with the protected code stroke did not bring the different level of treatment and clinical outcomes as before.

Magnetic Resonance-Guided Focused Ultrasound Thalamotomy for Focal Hand Dystonia: A Pilot Study.

BACKGROUND: The efficacy of magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy for the treatment of focal hand dystonia (FHD) is not well known. OBJECTIVE: We aimed to prospectively investigate the efficacy of MRgFUS thalamotomy for the treatment of FHD. METHODS: We performed MRgFUS thalamotomy of the ventro-oral (Vo) nucleus in 10 patients with FHD. We evaluated the scores of the Writer's Cramp Rating Scale (WCRS, 0-30; higher scores indicating greater severity), Tubiana Musician's Dystonia Scale (TMDS, 0-5; lower scores indicating greater severity), and Arm Dystonia Disability Scale (ADDS, 0%-100%; lower scores indicating greater disability) at baseline and 3 and 12 months post-treatment. RESULTS: WCRS, TMDS, and ADDS scores significantly improved from 6.3 ± 2.7, 1.4 ± 0.5, and 58.7% ± 14.3% at baseline to 1.6 ± 3.1 (P = 0.011), 5.0 ± 0 (P = 0.0001), and 81.6% ± 22.9% (P = 0.0229) at 12 months, respectively. There was one prolonged case of dysarthria at 12 months. CONCLUSION: We show that MRgFUS Vo-thalamotomy significantly improved FHD. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Clinical Outcome of Elderly Patients with Subarachnoid Hemorrhage: Validation of Modality Assignment Based on Aneurysmal Morphology and Location.

BACKGROUND: The number of elderly patients with subarachnoid hemorrhage is increasing. Elderly patients have been postulated to benefit more from endovascular coiling, compared with neurosurgical clipping. However, we based our therapeutic modality on the morphology and location of the aneurysms, rather than patients' age or their World Federation of Neurological Surgeons grade. The aim of this study was to investigate the validity of our therapeutic modality over earlier approaches by assessing their clinical outcomes. METHODS: The study sample included 539 patients who underwent surgical procedures between January 2010 and May 2019. Baseline characteristics, aneurysmal morphology and location, surgical and clinical complications, and clinical outcomes were compared between elderly (defined as aged 75 years or older) and young patients. RESULTS: There were 124 elderly patients (23.0%) in the sample. Eighty-five elderly patients (68.5%) received neurosurgical clipping, whereas 67.0% of the young patients (P = 0.827) received neurosurgical clipping. Of the elderly patients who had a poor World Federation of Neurological Surgeons grade, 49.4% and 48.7% underwent neurosurgical clipping and endovascular coiling, respectively (P = 1.000). Elderly patients had fewer favorable outcomes (21.8%) relative to young patients (61.8%; P < 0.001). There were no significant differences in the rate of favorable outcomes between patients undergoing neurosurgical clipping relative to endovascular coiling (21.2% vs. 23.1%; P = 0.818). CONCLUSIONS: Neurosurgical clipping and endovascular coiling yield comparable clinical outcomes in elderly and young patients with subarachnoid hemorrhage. These findings indicate that using a therapeutic modality based on aneurysmal morphology and location may be an effective treatment approach.

Magnetic resonance-guided focused ultrasound for mesial temporal lobe epilepsy: a case report.

BACKGROUND: We report the first case of transcranial magnetic resonance-guided focused ultrasound (MRgFUS) for mesial temporal lobe epilepsy (MTLE). CASE PRESENTATION: The target was located 20 mm lateral from the midline and 15 mm above the skull base (left hippocampus). Despite the application of maximal energy, the ablation temperature did not exceed 50 °C, probably because of the low number of effective transducer elements with incident angles below 25 degrees. The skull density ratio was 0.56. Post-operative magnetic resonance imaging did not reveal any lesion and the patient remained almost seizure-free for up to 12 months. CONCLUSIONS: This preliminary case report suggests that MRgFUS may be effective for treating cases of MTLE. Therefore, the safety and feasibility of MRgFUS should be evaluated in future studies with larger numbers of participants and longer follow-up duration.

A single case of MRI-guided focused ultrasound ventro-oral thalamotomy for musician's dystonia.

Musician's dystonia (MD) is a type of focal hand dystonia that develops only while playing musical instruments and interferes with skilled and fine movements. Lesioning of the ventro-oral (Vo) nucleus of the thalamus (Vo-thalamotomy) using radiofrequency can cause dramatic improvement in MD symptoms. Focused ultrasound (FUS) can make intracranial focal lesions without an incision. The authors used MRI-guided FUS (MRgFUS) to create a lesion on the Vo nucleus to treat a patient with MD. Tubiana's MD scale (TMDS) was used to evaluate the condition of musical play ranging from 1 to 5 (1: worst, 5: best). The patient was a 35-year-old right-handed man with involuntary flexion of the right second, third, and fourth fingers, which occurred while playing a classical guitar. Immediately after therapeutic sonications of FUS Vo-thalamotomy, there was dramatic improvement in the MD symptoms. The TMDS scores before; at 0 and 1 week after; and at 1, 3, 6, and 12 months after MRgFUS Vo-thalamotomy were 1, 4, 4, 5, 5, 5, and 5, respectively. No complications were observed. Focused ultrasound Vo-thalamotomy can be an effective treatment for MD.

Treatment of Large or Giant Cavernous Aneurysm Associated with Persistent Trigeminal Artery: Case Report and Review of Literature.

BACKGROUND: Primitive trigeminal artery (PTA) is the most common anomaly of primitive carotid-basilar anastomosis and is associated with cerebrovascular anomalies, such as aneurysm. Large or giant cavernous aneurysm associated with PTA is rare, and the treatment strategies differ in comparison with large or giant aneurysm without PTA. In this article, we report an unusual case of a giant cavernous aneurysm associated with PTA and review treatment strategies for large or giant cavernous aneurysm associated with PTA. CASE DESCRIPTION: A 38-year-old woman suffered from double vision. Magnetic resonance imaging revealed a mass lesion in the left cavernous sinus, and magnetic resonance angiography showed a giant aneurysm at the cavernous portion of the left internal carotid artery, associated with PTA. Coil embolization, distal to the PTA, was scheduled after high-flow bypass on the same day. Computed tomography scan showed no definite infarction after treatment. A 3-dimensional computed tomography showed disappearance of the aneurysm and good patency of bypass and PTA. The patient experienced improvements in symptoms and was discharged without neurologic deficits (modified Rankin Scale 0). CONCLUSIONS: The treatment strategy for large or giant cavernous aneurysm associated with PTA is different from strategies used for large or giant cavernous aneurysm without PTA. Simple ligation of internal carotid artery is inadequate because the aneurysm is supplied through the PTA, from the vertebrobasilar system. Furthermore, the treatment strategy has to be revised according to whether the PTA can be occluded. Keeping in mind PTA preservation, an appropriate strategy should be selected.

[A case of intraventricular meningioma manifesting akinetic mutism after complicated management of hydrocephalus].

A 26-year-old male with large intraventricular meningioma developed acute hydrocephalus postoperatively, which was difficult to manage. After a repeated course of dilated and slit-like ventricle, he gradually presented a disturbance of consciousness, which was recovered by the use of bromocriptine, suggesting akinetic mutism. At the chronic stage, he suffered from symptoms of hydrocephalus again. Time-slip MRI revealed the stasis of CSF flow around the third ventricle. Neuroendoscopy disclosed that the foramen of Monro was occluded with membrane. After endoscopic third ventriculostomy as well as penetration of the foramen, the symptoms disappeared and hydrocephalus was resolved. This is a rare case of akinetic mutism after complicated management of hydrocephalus associated with intraventricular meningioma.