Anticoagulation Protocol for Secondary Prevention of Acute Ischemic Stroke Associated with Nonvalvular Atrial Fibrillation.

OBJECTIVES: There is no clear evidence regarding when to initiate oral anticoagulants (OACs) for secondary prevention of recurrent stroke in patients with atrial fibrillation (AF). Therefore, this study aimed to evaluate the safety and efficacy of a novel OAC initiation protocol for secondary prevention of acute ischemic stroke associated with AF. MATERIALS AND METHODS: In this multicenter prospective study 597 consecutive Japanese patients with acute ischemic stroke associated with nonvalvular AF received post-stroke OACs according to a protocol based on severity (clinical (NIHSS) and radiological (ASPECTS + W)), rt-PA use, reperfusion, and hemorrhagic transformation (HT). Primary outcomes of safety and efficacy, including symptomatic hemorrhage, cerebral stroke, and disability were evaluated at 14 and 90 days. RESULTS: Mean OAC initiation time was 2.60±2.14 days from onset. The shortest and longest mean initiation times were 0.47±0.50 and 6.16±0.72 days, respectively. Following OAC administration, no ICH was observed within 90 days. A significantly higher incidence of acute recurrent ischemic events occurred 14 days prior to OAC (4.7%) compared with chronic recurrence within 90 days (0.8%) (P = 0.00013, McNemar's test) . Recurrence prior to OAC use was significantly correlated with days to treatment (P = 0.00224), severity (NIHSS, ASPECTS+W: P = 0.0223, P = 0.0393, respectively), and HAS-BLED (P = 0.0395) and there were no correlations with CHADS2 (P = 0.277) or CHA2DS2-VASc (P = 0.246) (Wilcoxon rank sum-test). CONCLUSIONS: This comprehensive OAC initiation protocol was relatively safe and effective for secondary prevention of stroke in patients with AF. Risk of acute recurrence was high, indicating that OACs should be started as early as possible. (clinical trial registration number: 15B 128).

Occipital artery-to-posterior inferior cerebellar artery anastomosis with multiple-layer dissection of suboccipital muscles under a reverse C-shaped skin incision.

Although occipital artery (OA)-to-posterior inferior cerebellar artery (PICA) anastomosis is the most familiar reconstruction for posterior cerebral circulation, the procedure is considered difficult because of the anatomical complex course of OA and the depth of the operative field at the anastomosis site. Therefore, we attempted a safe and reliable method for OA-to-PICA anastomosis under multiple-layer dissection of suboccipital muscles and a reverse C-shaped skin incision. We reviewed the clinical records of patients who underwent OA-to-PICA anastomosis in our institute, and report the outcome with special emphasis on graft patency and surgical complications. Nine patients are described. In one patient the bypass was accomplished at the cortical segment of the PICA and in all others at the caudal loop. The average time for de-clamping the PICA was 29 min and 29 s. Although the overall graft patency rate was 100%, one patient showed a new medulla infarction at the time of post-operatory three-dimensional computed tomography angiography. Besides a secure OA-to-PICA anastomosis, this technique allows safe harvest of the OA and the creation of a shallow and wide anastomosis field.

The graft kinking of high-flow bypass for internal carotid artery aneurysm due to elongated styloid process: a case report.

Elongated styloid process is an often-caused symptom due to the compression of neighboring structures. We present a case of a graft kink of high-flow bypass due to an elongated styloid process and describe the technical pitfalls encountered when creating a graft route from the standpoint of the anatomical site.

Esophageal and Ileal Ulcers Caused by Hydroxycarbamide: A Case Report and Literature Review.

Hydroxycarbamide, an antimetabolic agent used to treat myeloproliferative disorders, causes side effects, including myelosuppression, skin ulcers, and oral mucositis. Gastrointestinal ulcers are uncommon, and esophageal ulcers have not been previously reported. We present the case of a 74-year-old woman who developed esophageal and ileal ulcers after hydroxycarbamide treatment. Our case and previous reports suggest that hydroxycarbamide can cause ulcers throughout the gastrointestinal tract, which can improve rapidly after discontinuing medication. When new signs and symptoms occur, drug-induced etiologies should be considered as a potential cause. Timely diagnostic treatment with discontinuation of medication is crucial in such cases.

Reconstruction of intracranial vertebral artery with radial artery and occipital artery grafts for fusiform intracranial vertebral aneurysm not amenable to endovascular treatment: technical note.

BACKGROUND: Symptomatic fusiform intracranial vertebral artery aneurysms pose a formidable treatment challenge when not amenable to endovascular treatment. In this paper, we illustrate the microsurgical management of such an aneurysm. METHODS: To prevent neurological deterioration, anatomical reconstruction preserving all vessels including posterior inferior cerebellar artery and perforators is essential. In this case illustration, the occipital artery was used as a donor to a perforator originating from the aneurysmal segment. This bypass was performed in an end-to-side fashion. Subsequently, the aneurysmal component of the vertebral artery was resected and an end-to-side (V4 to V3) bypass was performed using a radial artery graft. RESULTS: The patient achieved complete resection of the aneurysm preserving normal anatomy of the posterior circulation without any ischemic complications. CONCLUSIONS: Complex cerebral artery bypass techniques are essential in the armamentarium of cerebrovascular for the treatment of complex lesions not amenable to endovascular therapy.

[The limits and countermeasures of the anterior temporal approach for unruptured upper basilar artery aneurysms].

BACKGROUND AND PURPOSE: In general, upper basilar artery aneurysms are treated following the transsylvian or subtemporal approach. These approaches have both advantages and disadvantages. Therefore, we followed the anterior temporal approach that provides a wider surgical field in the retro-carotid space. METHODS: We reviewed the clinical records of 37 patients with an upper basilar artery aneurysm operated on following the anterior temporal approach between 2002 and 2012 in our institute, and evaluated the usefulness of this approach. RESULTS: In 23 cases, several additional techniques were performed. In all these cases a wide operation field was obtained in the retro-carotid space and the aneurysm was completely obliterated. The post operative adverse events were temporary oculomotor palsy in 6 cases, permanent oculomotor palsy in 3 and temporary epilepsy, aphasia due to venous infarction and asymptomatic cerebral infarction in 1 case each. CONCLUSIONS: The anterior temporal approach allows the additional use of several techniques and provides a wide surgical field. Therefore, we consider this approach is useful to reach and treat upper basilar artery aneurysms.

[Carotid endarterectomy for high cervical internal carotid artery stenosis: study of 22 consecutive patients].

In general, carotid endarterectomy(CEA)for high cervical internal carotid artery(ICA)stenosis is considered a difficult technique. Among 132 patients who underwent CEA between May, 1996 and December, 2012 in our institute, 22 showed high cervical ICA stenosis. A wide operation field was obtained by wide range dissection of shallow anatomical structures without special techniques and the first cervical vertebra was palpable in all patients. All patients underwent CEA and adverse events occurred in 4 patients. We describe the technique and pitfalls of CEA for high cervical ICA stenosis from the anatomical viewpoint.

Efficacy and Safety of Transcutaneous Electrical Nerve Stimulation in Patients Undergoing Inguinal Hernia Repair: A Systematic Review and Meta-analysis.

Background: Postoperative pain is a major cause of delayed recovery following inguinal hernia repair. Transcutaneous electrical nerve stimulation (TENS) is a simple, low-cost method of noninvasive analgesia. This study aimed to assess the efficacy and safety of TENS for pain management following inguinal hernia repair. Methods: We searched nine electronic databases and trial registries to identify randomized controlled trials (RCTs). The primary outcomes were postoperative pain and the use of rescue analgesics. The Risk of Bias 2 tool was used to evaluate the risk of bias in the included trials. The certainty of the evidence was assessed using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). Subgroup analyses were conducted based on the anesthesia type or TENS dose and frequency. This study is registered with PROSPERO (CRD42022353932). Results: Eleven RCTs, with a total of 559 patients, were included. The overall risk of bias was concerning due to the lack of information about concealment or published protocols. TENS may reduce pain on postoperative day (POD) 0 (standardized mean difference [SMD], -2.14; 95% confidence interval [CI], -3.54 to -0.73; moderate certainty of the evidence), POD 1 (SMD, -1.22; 95% CI, -1.92 to -0.52; moderate certainty of the evidence), and POD 2 (SMD, -0.97; 95% CI, -2.04 to 0.10; low certainty of the evidence). According to the subgroup analyses, postoperative pain was reduced, particularly with local anesthesia or repetitive and frequent TENS (P < 0.05). TENS may result in little-to-no difference in rescue analgesic use (risk ratio, 0.75; 95% CI, 0.47-1.18; low certainty of the evidence). No serious adverse events occurred (moderate certainty of the evidence). Conclusions: TENS may reduce pain in patients who have undergone inguinal hernia repair. Further trials are warranted to confirm our findings.

Preoperative Predictive Factors of Short-Term Outcome in Idiopathic Normal Pressure Hydrocephalus.

BACKGROUND: Surgical treatment of idiopathic normal pressure hydrocephalus (iNPH) by ventriculoperitoneal (VP) or lumboperitoneal (LP) shunting can achieve long-term recovery of activities of daily living; however, in a subset of patients, maintenance of independence lasted for <6 months. This study examined positive preoperative predictive factors of short-term outcome for shunted iNPH patients. METHODS: Over a 9-year period, consecutive patients from multiple centers diagnosed with probable iNPH underwent either VP or LP shunt surgery. Preoperative variables of age, symptom duration, iNPH severity, tap test response, and magnetic resonance imaging findings of disproportionately enlarged subarachnoid space hydrocephalus (DESH) or incomplete DESH were retrospectively evaluated in relation to 1-year postoperative outcome. RESULTS: Outcome for 154 shunt patients (12 VP, 142 LP) as measured by postoperative disability modified Rankin Scale (mRS) and iNPH-gait disturbance (GD) was the same regardless of age. Symptom duration was inversely correlated with both iNPH severity (P < 0.0001) and postoperative improvement at 1 year (P = 0.0015). Severity also correlated inversely with postoperative improvement at 1 year (P < 0.0001). Age was not significantly correlated with the degree of postoperative improvement (mRS: P = 0.487; iNPH grading scale [GD]: P = 0.725). Outcome at 1 year (mRS, gait domain, and activities of daily living significantly improved in patients with a good response to the tap test (P < 0.0001) Preoperative DESH correlated with improvement in mRS and GD (P < 0.0001). CONCLUSIONS: Mild preoperative iNPH severity, shorter preoperative symptom duration, good tap test response, and complete DESH were associated with good short-term postoperative outcome at 1 year. These positive factors may be useful for prediction of short-term surgical outcome in iNPH patients.

[Case of invasive sino-orbital aspergillosis developing orbital apex syndrome].

Sino-orbital invasive aspergillosis has been regarded as a lethal disease. The authors report a case with a successful treatment result. A 65 year-old woman, with mild diabetes mellitus, presented progressive right visual disturbance, diplopia, ptosis, and severe periorbital pain over a period of 2 weeks. MR images with gadolinium contrast showed a heterogeneously enhanced mass extending from the right orbital apex to the cavernous sinus. Despite steroid pulse therapy, her symptoms progressed. An open biopsy revealed invasive sino-orbital aspergillosis. Intravenous and oral antifungal agents were administered, but the aspergilloma gradually expanded. Her general status deteriorated due to intractable periorbital pain that was resistant to narcotic analgesics. By a craniotomy, the aspergilloma involving the orbit and cavernous sinus was radically removed leaving the internal carotid artery intact and simultaneously rhizotomy of the trigeminal nerve was carried out. The postoperative course was uneventful and the pain was remarkably ameliorated. Three years after the surgery, she has been well, receiving voriconazole and experiencing no relapse of the disease.

Ultra-Early Combination Antiplatelet Therapy with Cilostazol for the Prevention of Branch Atheromatous Disease: A Multicenter Prospective Study.

BACKGROUND AND PURPOSE: The optimal use of antiplatelet therapy for intracranial branch atheromatous disease (BAD) is not known. METHODS: We conducted a prospective multicenter, single-group trial of 144 consecutive patients diagnosed with probable BAD. All patients were treated within 12 h of symptom onset to prevent clinical progression using dual antiplatelet therapy with cilostazol plus one oral antiplatelet drug (aspirin or clopidogrel). Endpoints of progressive BAD in the dual therapy group at 2 weeks were compared with a matched historical control group of 142 patients treated with single oral antiplatelet therapy using either cilostazol, aspirin, or clopidogrel. RESULTS: Progressive motor paresis occurred in 14 patients (9.7%) in the aggressive antiplatelet group, compared with 48 (33.8%) in the matched single antiplatelet group. Multivariate logistic regression analysis revealed the following variables to be associated with a better prognosis for BAD: baseline modified Rankin Scale score, dual oral antiplatelet therapy with cilostazol, and dyslipidemia (odds ratios of 0.616, 0.445, and 0.297, respectively). Hypertension was associated with a worse prognosis for BAD (odds ratio of 1.955). CONCLUSIONS: Our trial showed that clinical progression of BAD was significantly reduced with the administration of ultra-early aggressive combination therapy using cilostazol compared to treatment with antiplatelet monotherapy.

A modified anterior temporal approach for low-position aneurysms of the upper basilar complex.

BACKGROUND: Although surgery for aneurysms of the upper basilar complex is generally accomplished by a pterional or subtemporal approach, both techniques have disadvantages. Therefore, attempts have been made to combine both the approaches, such as an anterior temporal approach, which exposes the anterior aspect of the temporal lobe during standard fronto-temporal craniotomy. However, in all these techniques, the temporal vein is sacrificed to allow posterior retraction of the temporal lobe, which may cause venous infarction in the temporal lobe. METHODS: Our institutional review board approved this prospective study. We modified the anterior temporal approach for low-position aneurysms of the upper basilar complex by performing posterior clinoidectomy as necessary, thereby preventing the sacrifice of all vessels. RESULTS: From 2007 to 2014, seven patients were operated on using this modified approach, and four patients underwent additional posterior clinoidectomy. Complete clip ligation was performed for all aneurysms without sacrificing any vessels, and there were no permanent complications attributable to manipulation for clipping or posterior clinoidectomy. CONCLUSIONS: The modified anterior temporal approach allows a wider operating field within the retro-carotid space, without sacrificing any vessels, and permits safer posterior clinoidectomy and aneurysm clipping in patients with low-position aneurysms of the basilar complex.

The preparation of anastomosis site at the insular segment of middle cerebral artery.

BACKGROUND: An anastomosis at the insular segment of the middle cerebral artery (M2) is often required in cerebral reconstruction with high- or low-flow bypass. It is necessary to create a shallow, wide, fixed, and bloodless anastomosis field to achieve a safe and quick anastomosis for low surgical morbidity. We describe a method to perform a safe and quick anastomosis. METHODS: From 2009 to 2013, the technique was used in 20 procedures to create an extracranial M2 high-flow bypass. The Sylvian fissure was dissected wide open to expose the M2. A silicon sheet was laid under M2 and the absorbable gelatin-compressed sponges were inserted between M2 and the insula cortex to lift up the M2 and fix it. The rolling surgical sheets were placed at each edge of the dissected Sylvian fissure, instead of brain spatulas. Finally, a small suction tube was placed at the Sylvian fissure and cerebrospinal fluid was continuously sucked. The postoperative patency of the bypass was evaluated by three-dimensional computed tomographic angiography (3D-CTA) in the acute and chronic stages. RESULTS: In all cases, the operation field acquired for the anastomosis was adequate. The average time required for the procedure was 19 min 27 s. Good patency of all high-flow grafts was confirmed by postoperative three-dimensional computed tomography angiography (3D-CTA). CONCLUSION: In our series, there were no technical complications related to the anastomosis at M2 performed according to our method.

Surgical embolectomy for middle cerebral artery occlusion after thrombolytic therapy: A report of two cases.

BACKGROUND: Occlusion of the intracranial main trunk results in a poor functional outcome and a high mortality rate. Accordingly, some revascularization procedures such as intravenous administration of recombinant tissue plasminogen activator (rt-PA), endovascular surgery, or surgical embolectomy in the very acute stage have been attempted. CASE DESCRIPTION: We describe two patients with middle cerebral artery occlusion due to cardiogenic embolism. One patient was subjected to surgical embolectomy shortly after intravenous rt-PA and the other was subjected to same after intra-arterial urokinase. Complete recanalization without new cerebral infarction territory was achieved in both patients. CONCLUSION: Based on our experience, we think that surgical embolectomy is an effective and safe procedure and should be attempted when no response to early thrombolytic therapy is obtained.

Discrepancy between preoperative imaging and postoperative pathological finding of ruptured intracranial dissecting aneurysm, and its surgical treatment: case report.

The choice of therapeutic strategy for intracranial dissecting aneurysm is often based on radiographic features, including characteristic geometry (e.g., irregular stenosis, segmental stenosis, aneurysm formation [pearl-and-string sign]), irregular fusiform or aneurysmal dilation, double lumen, and tapering occlusion. However, there is often a discrepancy between preoperative radiographic data and actual dissecting length. The present report describes three cases in which there was a discrepancy between preoperative radiographic data and actual dissecting length in patients undergoing direct trapping with or without revascularization. All three cases experienced good outcomes, but these cases underscore the fact that open surgery is a good option for management of ruptured intracranial dissecting aneurysms for determination of the rupture point, dissecting length, and the relationship between dissecting area and small arteries arising from the associated vessel.

Vertebral artery-to-vertebral artery bypass with interposed radial artery or occipital artery grafts: surgical technique and report of three cases.

BACKGROUND: The treatment of unclippable vertebral artery (VA) aneurysms incorporating the posterior inferior cerebellar artery with parent artery preservation is among one of the most formidable challenges for cerebrovascular microsurgery and endovascular surgery. We propose that intracranial VA reconstruction using an extracranial VA-to-intracranial VA (VA-VA) bypass with a radial artery graft or an occipital artery graft may be an additional technique in the armamentarium to treat these formidable lesions. The rationale, surgical technique, and complications are discussed. METHODS: Three illustrative cases are described, in which the lesions were a VA dissecting aneurysm with ischemic lesions, bilateral asymptomatic unruptured VA aneurysms, and a VA giant aneurysm with subarachnoid hemorrhage. RESULTS: The partial extreme lateral infrajugular transcondylar approach was used. Computed tomographic angiography was useful for preoperative evaluation of the depth of the distal aneurysmal neck. A VA-VA bypass was performed in two patients. Because there was another ipsilateral aneurysm at the V2 segment in one patient, an external carotid artery-VA bypass was performed. Although two patients were discharged with good clinical results, one patient with subarachnoid hemorrhage died because of brainstem infarction. CONCLUSIONS: The VA-VA bypass using a radial artery graft or an occipital artery graft is an option that can be considered in the strategy for treating VA aneurysms to preserve the normal anatomic vascular configuration in the posterior circulation.

Universal extracranial-intracranial graft bypass for large or giant internal carotid aneurysms: techniques and results in 38 consecutive patients.

OBJECTIVE: To present indications, surgical techniques, and outcomes of extracranial-intracranial (EC-IC) graft bypass. METHODS: Between January 1996 and June 2011, 38 patients with large or giant internal carotid artery (ICA) aneurysms were treated using graft bypass, employing the radial artery (RA) or the saphenous vein (SV) as a graft. Preoperative balloon test occlusions were not performed in any of the cases. In 17 patients, the external carotid artery (ECA)-RA-M2 segment of the middle cerebral artery bypass was used for treatment, and ECA-SV-M2 bypass was used in 21 patients. RESULTS: All aneurysms were completely trapped, and there were no subarachnoid hemorrhages or recanalizations of aneurysms during the follow-up period (8-170 months). Of the 38 bypasses, 36 (94.7%) remained patent, and there were no permanent neurologic deficits. Hyperperfusion syndrome was not experienced in this series. There were 2 temporary neurologic deficits. In 1 case using the RA, graft vasospasm occurred, and kinking occurred in 1 case using the SV. Another patient with a SV graft had to undergo an emergent revision of the graft 8 hours after the initial operation. One patient with a SV graft underwent a second operation to control an epidural abscess. CONCLUSIONS: Universal EC-IC graft bypass is a safe and effective method for treating large or giant ICA aneurysms.

Subarachnoid hemorrhage caused by ruptured posterior inferior cerebellar artery aneurysm arising from the extracranial portion of an anomalous vertebral artery.

A 42-year-old woman presented with subarachnoid hemorrhage caused by a ruptured posterior inferior cerebellar artery aneurysm arising from the extracranial portion of an anomalous vertebral artery. We speculated that the aneurysm formed by dissection of the media because of its shape and location. Therefore, the aneurysm was isolated by trapping and excised, with occipital artery to posterior inferior cerebellar artery bypass. Histological examination showed a typical true aneurysm without evidence of dissection. This case suggests that an aneurysm of an anomalous artery is caused by hemodynamic stress and is a true aneurysm, not a dissection.

Choroid plexus papilloma originating in the sella turcica--case report.

A 51-year-old female presented with a rare case of choroid plexus papilloma originating in the sella turcica manifesting as headaches that was not readily distinguishable preoperatively from pituitary adenoma. Head magnetic resonance imaging revealed a tumor extending from the sella turcica to the suprasellar cistern. The tumor was removed via an endonasal transsphenoidal approach. Histological examination indicated a papillary structure covered with a layer of columnar epithelial cells that resembled normal choroid plexus. These findings, together with immunohistochemistry, led to a diagnosis of choroid plexus papilloma.

Surgical removal of chondroma of the petrous apex resulting in hearing improvement--case report.

An 18-year-old male presented with a chondroma in the petrous apex manifesting as major complaints of headaches and sensorineural hearing disturbance on the right. Head computed tomography and magnetic resonance imaging revealed a neoplastic lesion in the right petrous apex, which had bulged to compress the internal auditory meatus. Surgical removal improved his hearing with normalization of the postoperative air conduction threshold by reduction of the pressure of the internal auditory meatus, suggesting that the function of the cochlea was retained and the tumor was compressing the cochleal nerve at the level of the internal auditory meatus. Histological examination showed the tumor consisted of hyaline cartilage tissue without cellular atypia and the diagnosis was chondroma.