Safety of Apixaban Monotherapy for Non-Valvular Atrial Fibrillation-Related Acute Stroke with Intra-/Extracranial Artery Stenosis.

INTRODUCTION: We investigated whether apixaban is safe for the prevention of further adverse events in non-valvular atrial fibrillation (NVAF) patients with intra-/extracranial artery stenosis (Stenosis group) compared with acute large vessel occlusion without intra-/extracranial artery stenosis (No stenosis group). We also examined whether combination therapy using apixaban and antiplatelet is safe. METHODS: ALVO (Apixaban on clinical outcome of patients with Large Vessel Occlusion [LVO] or stenosis) was a historical and prospective multicenter registry at 38 centers in Japan. Patients with NVAF and acute LVO or stenosis who received apixaban within 14 days after onset were included. We conducted the post hoc analysis using the ALVO dataset. We compared patients with stenosis versus those without stenosis in terms of the primary outcome, which was defined as a composite of all-cause death, major bleeding events, and ischemic events 365 days after onset. RESULTS: Of the 662 patients, 54 (8.2%) patients were classified into the Stenosis group, and 104 patients of the total (16%) reached the primary outcome. The cumulative incidence of primary outcome was not significantly different between the No stenosis and the Stenosis groups (hazard ratio [HR] 1.2, 95% confidence interval [CI]: 0.64-2.4; p = 0.52). Even after adjustment for predictive clinical variates, no significant difference in the primary endpoint between the No stenosis and the Stenosis groups was shown (adjusted HR 1.2, 95% CI: 0.59-2.5; p = 0.60). Fifty patients (7.6%) used an antiplatelet with apixaban. Among the Stenosis group patients, the cumulative incidence of the primary outcome was significantly higher among patients treated with an antiplatelet and apixaban (HR 3.5, 95% CI: 1.0-12; p = 0.048). CONCLUSION: Apixaban monotherapy appears safe for the prevention of further adverse events in the Stenosis group patients similar to the No stenosis group patients. Concomitant use of an antiplatelet might not be favorable in patients with stenosis.

Prediction of Functional Outcome in Patients with Acute Stroke by Measuring tRNA Derivatives.

BACKGROUND AND PURPOSE: Transfer RNA (tRNA) is a noncoding RNA that delivers amino acids to ribosomes for protein synthesis. tRNA is also involved in cell stress response programs. Oxidative stress induces direct conformational change in tRNA structure that promotes subsequent tRNA fragmentation. Using an antibody against tRNA-specific modified nucleoside 1-methyladenosine (m1A), we can detect tRNA derivatives such as conformationally changed tRNA, tRNA-derived fragments, and mononucleotide-free m1A. Based on these findings, tRNA derivatives may have potential as an early tissue damage marker. The purpose of this study was to investigate the plasma tRNA derivatives in stroke patients to clarify whether tRNA derivatives in the acute phase can detect early brain damage and then predict the functional outcome. METHODS: Patients (75 patients with ischemic and 66 with hemorrhagic stroke) and 22 healthy volunteers were prospectively enrolled for this study between November 2016 and February 2019. Plasma samples were collected within 24 h and at 1 day, 7 days, and 30 days from the onset. Plasma tRNA derivative concentrations were measured by ELISA kit using the anti-m1A antibody. RESULTS: The plasma tRNA derivative level on admission was significantly increased in both ischemic (mean ± standard error, 232.2 ± 33.1 ng/mL) and hemorrhagic stroke patients (212 ± 23.4 ng/mL) compared to the healthy volunteers (86.0 ± 7.9 ng/mL) (p = 0.00042 and p = 0.00018, respectively). The infarction size (r = 0.445, p = 0.00018) and hematoma volumes (r = 0.33, p = 0.0072) were also significantly correlated with tRNA derivatives. The concentrations of tRNA derivatives were associated with poor functional outcome (Modified Rankin Scale score 3-6 at 30 days from the onset) in patients with ischemic stroke at 7 days after onset (p = 0.020). CONCLUSIONS: Stress-induced tRNA derivatives can detect brain tissue damage, predicting functional outcome in patients with ischemic stroke.

Lectin-Like Oxidized Low-Density Lipoprotein Receptor-1 Levels as a Biomarker of Acute Intracerebral Hemorrhage.

BACKGROUND: Correct diagnosis of cerebral stroke type, hemorrhagic or ischemic, is essential in the early stage to establish the optimum treatment. The diagnosis is mainly determined based on imaging studies. Other more available diagnostic methods are desirable, such as blood sample examination. Lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1) is very important in vascular dysfunction induced by oxidized low-density lipoprotein, including cell apoptosis. The present study evaluated LOX-1 as a biomarker for cerebral stroke. SUBJECTS AND METHODS: Patients with newly diagnosed stroke were prospectively enrolled between February and July 2014. LOX-1 serum values were measured twice, within 24 hours and 2 months after the onset. RESULTS: A total of 16 patients were enrolled; 7 patients with intracerebral hemorrhage (ICH) and 9 patients with cerebral infarction. Median LOX-1 values of patients with ICH and infarction in the acute phase were 1825.8 and 593.9 pg/mL, respectively, significantly higher in patients with ICH than in patients with infarction (P < .0001). CONCLUSION: LOX-1 serum level has potential as a biomarker of ICH.

Clinical features of subarachnoid hemorrhage in patients with positive cancer history.

Advances in cancer treatment have dramatically increased long-term survivors. Prolonged survival increases comorbidity risk, but there is a paucity of studies on how cancer history alters clinical outcomes from subsequent diseases. This study aims to investigate whether positive cancer history influences clinical outcome following subarachnoid hemorrhage (SAH). We retrospectively reviewed consecutive SAH patients admitted between January 2008 and March 2014. Medical histories, known SAH risk factors, and outcome were compared between SAH patients with and without cancer history. Out of the 498 SAH patients, 55 cases had cancer history, 438 cases had no cancer history and 5 cases had an unknown cancer history. Compared with SAH patients without cancer history, those with cancer history had poorer Hunt & Hess grade at SAH presentation (P = 0.021), and poorer modified Rankin Scale (mRS) score at discharge (P < 0.001). After adjustment for age, sex, modified Fisher, previous SAH, history of hypertension, current smoking status, and current alcohol consumption, positive cancer history remained an independent risk factor for poorer mRS0-6 [odds ratio (OR) = 2.25, 95 % confidence interval (CI) 1.28-3.94] and mRS6 (OR = 2.74, 95 % CI 1.40-5.37). Furthermore, stratified analysis by Hunt & Hess grade adjusted by age, sex, and modified Fisher scale, OR of poorer mRS0-6 was 2.12 (95 % CI 0.89-5.05) and OR of mRS6 was 3.68 (95 % CI 1.35-10.04). After adjustment of patients for demographic factors, classical risk factors for SAH and Hunt & Hess grade, previous cancer history is a risk factor for the poor functional outcome of SAH.

Nonaneurysmal Subarachnoid Hemorrhage Due to Unfused or Twiglike Middle Cerebral Artery Rupture: Two Case Reports.

BACKGROUND: An unfused or twiglike middle cerebral artery (MCA) is a congenital anomaly related to the abnormal development of the MCA. An unfused or twiglike MCA can cause both ischemic and hemorrhagic strokes. Previous reports have shown that an unfused or twiglike MCA with coexisting aneurysms can cause subarachnoid hemorrhage (SAH). CASES: Two patients presented with nonaneurysmal SAH due to an unfused or twiglike MCA. Both patients had stenosis of the proximal M1 segment of the left MCA and abnormal vascular nets distal to the stenotic lesion. Vasculature distal to the abnormal vascular nets remained grossly normal. These findings were not evident in computed tomography or magnetic resonance angiography. CONCLUSION: An unfused or twiglike MCA can cause nonaneurysmal SAH. Digital subtraction angiography is necessary for accurate diagnosis.

Recurrent extracranial internal carotid artery vasospasm diagnosed by serial magnetic resonance angiography and superselective transarterial injection of a calcium channel blocker.

Recurrent vasospasm of the extracranial internal carotid artery (ICA) is extremely rare, and optimal management is unclear. A 25-year-old woman developed transient dysarthria and left-sided hemiparesis. Initial magnetic resonance (MR) imaging showed spotty acute infarction in the right temporal lobe, and MR angiography revealed right ICA occlusion. ICA occlusion was spontaneously resolved within 6 days of its onset, whereas transient left ICA narrowing was evident at 12 days. Because recurrent occlusion of the right ICA occurred at 14 days when the contralateral ICA was still narrowed, we attempted a local intra-arterial injection of a calcium channel blocker based on the diagnosis of recurrent extracranial ICA vasospasm. The local injection of 1 mg of nicardipine partially dilated the affected ICA, which confirmed the diagnosis of vasospasm. After the introduction of oral medication with benidipine hydrochloride, bilateral ICA vasospasm was completely resolved 23 days after its onset, as shown by MR angiography. In conclusion, we recommend intensive radiologic follow-up at the acute stage and therapeutic catheter angiography when the bilateral lesion is evident because bilateral occlusion of the ICA could lead to a catastrophic condition.

A ruptured aneurysm arising at the leptomeningeal collateral circulation from the extracranial vertebral artery to the posterior inferior cerebellar artery associated with bilateral vertebral artery occlusion.

We report an extremely rare case of a small ruptured aneurysm of the leptomeningeal collateral circulation from the vertebral artery (VA) to the posterior inferior cerebellar artery (PICA); this aneurysm was associated with bilateral VA occlusion. A 72-year-old woman with sudden headache, nausea, and subarachnoid hemorrhage (SAH) was admitted to our hospital. On admission, no evidence of cerebral signs or cranial nerve palsy was found. Computed tomography imaging showed SAH predominantly in the posterior fossa, and digital subtraction angiography revealed bilateral VA occlusion and the left VA aneurysm located proximal to the VA union. In addition, a small aneurysm was observed at the leptomeningeal collateral circulation located between the extracranial left VA and the left PICA. The patient underwent radical surgery on the day of the onset of the symptoms associated with SAH. However, the VA aneurysm was unruptured and surgically trapped. The small aneurysm arising at the leptomeningeal collateral circulation was ruptured during the surgery and was electrocoagulated; the collateral circulation was preserved, and no neurologic deficits were observed. The postoperative course was uneventful. SAH with the occlusion of major vessels should be diagnosed with utmost caution to allow preoperative neurologic and radiological assessments.

Prospective registry of carotid artery stenting in Japan--investigation on device and antiplatelet for carotid artery stenting.

BACKGROUND: Carotid artery stenting (CAS) is minimally invasive but may cause perioperative cerebral infarction associated with distal embolization. We conducted a multicenter prospective observational study on the onset of vascular events after CAS to find out the efficacy and safety of CAS in Japan and to investigate the effects of antiplatelet drugs administered before and after CAS on efficacy and safety of CAS. METHODS: A total of 949 patients with cervical carotid artery stenosis were enrolled at 43 institutions in Japan; 934 who had undergone CAS with antiplatelet drugs and followed for 1 year were analyzed. Primary end point was the incidence of the first event of death, ischemic stroke, hemorrhagic stroke, transient ischemic attack, myocardial infarction, or serious hemorrhage within 1 year after enrollment. Comparison of the incidences of events according to antiplatelet drugs was also conducted. RESULTS: The primary end point was observed in 69 patients (7.4%) within 30 days of enrollment and in 40 patients (4.3%) between 31 days and 1 year after enrollment. The incidence of the first event for aspirin+cilostazol was significantly lower than that for aspirin+clopidogrel (P=.01), aspirin+clopidogrel+cilostazol (P=.01), and antiplatelet monotherapy (P<.01). Patient age (P=.01), presence of ischemic cerebrovascular disease (P=.02), presence of antidiabetic drugs (P<.01), femoral artery puncture (P=.02), guiding catheter used (P=.02), and Angioguard XP used (P=.01) were also correlated with the primary end point. CONCLUSION: Incidences of the primary end point within 30 days and 1 year of enrollment were comparable with previous reports, suggesting that CAS is a useful alternative for carotid endarterectomy in carotid stenosis patients with high risk for carotid endarterectomy. Further randomized controlled studies are needed to determine whether differences in mechanism of action of antiplatelet drugs might have contributed to the results of the present study.

Paradoxical worsening of ocular symptoms after transvenous embolization of cavernous sinus dural arteriovenous fistula due to coil-induced perifocal inflammation: A case report.

Ocular symptoms usually completely resolve after successful transvenous embolization of cavernous sinus dural arteriovenous fistulas (CS-dAVFs). Herein, we report a case of CS-dAVF in which sinus packing of the superior ophthalmic vein (SOV) caused coil-induced inflammation in orbital tissue, leading to deteriorating ocular symptoms. A 73-year-old woman presented with right-eye exophthalmos and chemosis. Cerebral angiography demonstrated right CS-dAVF, which retrogradely drained into the right SOV. We conducted sinus packing with coils via the right inferior petrosal sinus, resulting in obliteration of the shunts. One day after sinus packing, right exophthalmos and chemosis progressed, suggesting dAVF recurrence. However, no residual angiographic shunts were observed. Orbital magnetic resonance imaging (MRI) revealed edema in intraorbital tissue and gadolinium contrast enhancement of SOV wall. We presumed that the coils in SOV induced perifocal inflammation at the venous wall and surrounding orbital tissue, leading to aggravation of ocular symptoms. Following steroid therapy for 2 months, ocular symptoms and contrast enhancement on orbital MRI significantly improved without anticoagulant treatment. Posttreatment paradoxical worsening of ocular symptoms could be caused by coil-induced inflammation of the SOV wall near the orbital tissue. Steroid therapy could be effective in reducing orbital inflammatory reactions.

Andexanet Alfa for the Reversal of Factor Xa Inhibitor Activity: Prespecified Subgroup Analysis of the ANNEXA-4 Study in Japan.

AIMS: Andexanet alfa, a specific antidote to factor Xa (FXa) inhibitors, has been approved for clinical use in several countries, including Japan, based on the results from the phase 3 trial ANNEXA-4. We aimed to assess the efficacy and safety of andexanet alfa treatment in FXa inhibitor-related acute major bleeding in patients enrolled for ANNEXA-4 in Japan. METHODS: This prespecified analysis included patients enrolled at Japanese sites in the prospective, open-label, single-arm ANNEXA-4 trial. Eligible patients had major bleeding within 18 hours of oral FXa inhibitor administration. The coprimary efficacy endpoints were percent change in anti-FXa activity and proportion of patients achieving excellent or good hemostatic efficacy 12 hours post-treatment. RESULTS: A total of 19 patients were enrolled, all of whom had intracranial hemorrhage; 16 patients were evaluable for efficacy. Median percent reduction in anti-FXa activity from baseline to nadir was 95.4% in patients taking apixaban, 96.1% in patients taking rivaroxaban, and 82.2% in patients taking edoxaban. Overall, 14/16 patients (88%) achieved excellent or good hemostasis (apixaban, 5/5; rivaroxaban, 6/7; edoxaban, 3/4). Within 30 days, treatment-related adverse events (AEs) and serious AEs occurred in 2 and 5 patients, respectively. One patient died during follow-up, and 2 patients experienced thrombotic events. CONCLUSION: Treatment with andexanet alfa rapidly reduced anti-FXa activity with favorable hemostatic efficacy in Japanese patients with acute major bleeding. Serious AEs of thrombotic events during rapid reversal of anti-FXa activity arose as particular safety concerns in this population as with previous studies.

Trends and Progress in Neuroendovascular Treatment in Japan: Japanese Registry of Neuroendovascular Therapy (JR-NET) 4. Main Report.

We reported the main results of the Japanese Registry of Neuroendovascular Therapy (JR-NET) 4, a nationwide surveillance of therapy (NET) in Japan from January 2015 to December 2019. JR-NET 4 registered consecutive patients who underwent NETs by Japan Society of Neuroendovascular Therapy (JSNET) -certified specialists. The primary endpoint was functional independence (mRS score of 0-2) at 30 days post-NET, with secondary endpoints focusing on technical success and major adverse events within 30 days.A total of 63,230 patients and 60,354 NET procedures from 166 participating centers were analyzed. During the study period, NET cases have consistently increased, with an increase in the proportion of elderly patients. A significant trend shift was observed in the distribution of NET procedures, with endovascular treatment for acute ischemic stroke that showed a dramatic increase in 5 years. This trend aligns with key randomized clinical trials from 2015 that presented the efficacy of this treatment. Clinical outcomes at 30 days posttreatment revealed that endovascular treatment for acute ischemic stroke and other NETs maintained safety and effectiveness despite varying prevalence of functional independence between target diseases. The study also observed a steady increase in emergency treatment cases, reflecting the increase in acute ischemic stroke, a time-sensitive medical condition.This comprehensive surveillance highlights the trend of NET practices in Japan, driven by clinical evidence and advancements in treatment devices. Although these findings were specific to Japan, they offer valuable insights into the broader trends in NETs and acute stroke care.

P2Y12 Reaction Units and Clinical Outcomes in Acute Large Artery Atherosclerotic Stroke: A Multicenter Prospective Study.

AIMS: We aimed to determine the association between acute platelet reactivity and clinical outcome in acute ischemic stroke (AIS) or transient ischemic attack (TIA) with large-artery atherosclerosis (LAA). METHODS: In this prospective, 16-multicenter study, we enrolled AIS/TIA patients with LAA receiving clopidogrel. We assessed the association of P2Y12 reaction units (PRU) 24 hours after initiation of antiplatelets with the CYP2C19 genotype and recurrent ischemic stroke within 90 days, and the difference between acute (≤ 7 days) and subacute (8-90 days) phases. RESULTS: Among the 230 AIS/TIA patients enrolled, 225 with complete outcome data and 194 with genetic results were analyzed. A higher PRU was significantly associated with recurrent ischemic stroke within 90 days (frequency, 16%), and within 7 days (10%). Twenty-nine patients (15%) belonged to a CYP2C19 poor metabolizer group (CYP2C19＊2/＊2, ＊2/＊3, or ＊3/＊3). Multivariable receiver-operating characteristic analysis showed a greater area-under-the-curve (AUC) in predicting recurrence within 7 days, compared to 8-90 days (AUC, 0.79 versus 0.64; p=0.07), with a cut-off PRU of 254. Multivariable analysis showed high PRU (≥ 254), which had a comparable predictive performance for recurrent ischemic stroke within 7 days (odds ratio, 6.82; 95% CI, 2.23-20.9; p＜0.001) to the CYP2C19 poor metabolizer genotype. The net reclassification improvement, calculated by adding high PRU (≥ 254) to a model including the CYP2C19 poor metabolizer genotype in the prediction of recurrence within 7 days, was 0.83 (p＜0.001). CONCLUSIONS: Acute PRU evaluation possesses predictive value for recurrent ischemic stroke, especially within 7 days in AIS/TIA with LAA.

[A case of moyamoya disease presenting with progressive stroke during the late perinatal period successfully managed by bilateral revascularization surgeries].

We report a case of moyamoya disease presenting with progressive stroke during the late perinatal period, which was successfully managed by emergency caesarean section and subsequent bilateral revascularization surgeries. A 27-year-old woman at 33 weeks of pregnancy suffered from progressive monoparesis on her left hand. Magnetic resonance (MR) imaging/angiography revealed definitive moyamoya disease presenting with acute spotty cerebral infarctions on the right cerebral hemisphere. At 34 weeks of pregnancy, she was transferred to our hospital, where both neurosurgeons and obstetricians were involved in her management. She underwent emergency caesarean section on the day of admission without deterioration of her neurological status, while MRI demonstrated newly-formed spotty infarction on the left hemisphere. Then she was managed by antithrombotic therapy for 4 weeks, and then underwent right superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis, followed by left STA-MCA anastomosis one month later without complications. Postoperative course was uneventful, and MRI after surgeries showed no expansion of ischemic lesion. The MRA showed apparently patent STA-MCA bypasses bilaterally. She was discharged without complication, and her symptom significantly improved two weeks after the left revascularization surgery.

[Childhood transverse sinus dural arteriovenous fistula treated with endovascular and direct surgery: a case report].

Infantile dural arteriovenous fistula is a rare cerebrovascular malformation carrying a poor prognosis with an anatomic cure of only 9%. Endovascular embolization is mainly selected to treat this entity, aiming to obtain normal development of the patients. We present a case of a 20-month-old girl with epilepsy. Digital subtraction angiography revealed a dural arteriovenous fistula involving the right transverse sinus. The arteriovenous fistula was fed by multiple dural branches from the middle meningeal, occipital, meningohypophyseal, and anteroinferior cerebellar arteries. The right transverse sinus was transvenously embolized with platinum coils. Although the shunt flow remained, the patient was liberated from epilepsy. Nine months later, the patient suffered from a recurrence of epilepsy. Digital subtraction angiography demonstrated some increase in shunt flow. Right middle meningeal, occipital, posterior deep temporal, and tentorial arteries were transarterially embolized using N-butyl cyanoacrylate, followed by complete surgical resection of the right transverse sinus. The shunt flow disappeared after surgery, and her epilepsy improved significantly. Our experience suggests that the combination of endovascular and surgical treatment is effective for recurrent infantile dural arteriovenous fistula.

Stent-Assisted Embolization for Acutely Ruptured Aneurysm.

Objective: The purpose of this study was to report the results of stent-assisted embolization performed at our hospital for acutely ruptured aneurysms. Methods: This study consisted of 19 patients (4 men and 15 women) with acutely ruptured wide neck aneurysm who underwent stent-assisted coil embolization in acute stage between December 2016 and October 2020. Stent-assisted embolization in the acute stage was performed for very wide neck ruptured aneurysm only when balloon-assisted embolization was failed or was thought to be impossible. Factors related to poor clinical outcome were examined. Results: There were nine internal carotid artery (ICA) aneurysms, four anterior communicating artery (AcomA) aneurysms, three basilar artery (BA) aneurysms, two vertebral artery (VA) aneurysms and one anterior cerebral artery (ACA) aneurysm. The stents used were one Neuroform EZ and 18 Neuroform Atlas (Stryker). The contrast of the bleb disappeared in all cases with obvious bleb. Complete obliteration was achieved in two cases, neck remnant was in ten, and body filling was in seven. Both of the complete obliteration cases developed thrombotic complications. Modified Rankin score of 0-2 was observed in eight patients (good clinical outcome), whereas that of 4-6 was observed in 11 patients (poor clinical outcome). Several factors possibly affected to poor clinical outcome were examined and only age over 80 years was statically different. Complications related to procedure occurred in five patients; two cases of in-stent thrombosis, one case each of MCA perforation, stent occlusion, and coil fracture. Conclusion: Stent-assisted coil embolization using Neuroform EZ and Neuroform Atlas could be considered as an emergency treatment for acutely ruptured cerebral aneurysms with very wide neck. It is rarely indicated in patients with age over 80 years.

Direct carotid puncture for endovascular surgery of intracranial aneurysms: Technical note for avoiding complications.

BACKGROUND: While the most intracranial aneurysms are approachable by femoral or brachial artery puncture during endovascular surgery, in some cases, the lesion is difficult to reach due to complications such as the presence of winding pathways. Direct carotid puncture (DCP) is an alternative access approach, despite the potential risk of fatal neck hematoma. Herein, we describe the DCP technique in a series of five patients with intracranial aneurysms, together with its technical considerations. METHODS: Patients with intracranial aneurysms who underwent endovascular surgery using DCP were reviewed retrospectively. We selected the 3F to 6F systems for DCP depending on the necessity of adjunctive techniques. To prevent DCP-associated complications, we (1) conducted a micropuncture before introducing the short sheaths,(2) selected the smallest possible size for the system, (3) reversed heparin postoperatively, and (4) performed perioperative intubation/sedation management. RESULTS: Five out of 535 patients underwent DCP in our hospital between 2015 and 2019; successful vascular access was achieved in all cases. Although a minor neck hematoma occurred in one case, the patient did not require additional treatment. According to a literature review, severe neck hematoma requiring rescue therapy occurs in 5 out of 95 cases (5.3%). CONCLUSION: Although the potential risk of neck hematoma is not negligible, the DCP technique appears to be a safe and effective approach in treating intracranial aneurysms with challenging access routes in cases where perioperative counter measurements are appropriately performed.

Potential hemorrhagic risk of endovascular revascularization therapy due to recanalization of the dissected perforator in intracranial internal carotid artery dissection: A case report.

BACKGROUND: Intracranial internal carotid artery (ICA) dissection manifesting as ischemic stroke is rare. Although endovascular revascularization therapy is effective in preventing the progression of stroke, little is known about the potential risk of this therapeutic approach. CASE DESCRIPTION: We report a case of a 38-year-old woman who presented with acute ischemic infarcts in the territory of the left anterior choroidal artery (AChA) due to intracranial ICA dissection. She underwent balloon angioplasty, resulting in the complete resolution of the stenosis. The AChA, which was nearly occluded preoperatively, was unexpectedly recanalized after the procedure. Four hours later, she developed a parenchymal hemorrhage in the left basal ganglia without subarachnoid hemorrhage. The AChA, suspected as the hemorrhagic source during surgical hematoma removal, was revealed to have a disrupted internal elastic lamina on pathological examination, suggesting that the dissection of the ICA extended to the AChA. CONCLUSION: To the best of our knowledge, this is the first case report demonstrating that the intracranial ICA dissection extends to the associated perforator. Considering the potential risk of subsequent hemorrhagic complications by recanalization of the dissected perforator, prudent postoperative management, including strict blood pressure control, is advisable following endovascular revascularization therapy against intracranial artery dissection involving perforators.

Flow diverter therapy for immunosuppressant-resistant vertebral artery fusiform aneurysm due to eosinophilic granulomatosis with polyangiitis: illustrative case.

BACKGROUND: Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic small-vessel vasculitis characterized by the presence of asthma and eosinophilia. Because cerebral aneurysm formation induced by EGPA is a rare occurrence, there is no established treatment strategy for this condition. OBSERVATIONS: A 67-year-old female who was diagnosed with idiopathic eosinophilia 3 months ago developed de novo fusiform aneurysms in the left vertebral, left internal carotid, and bilateral superficial temporal arteries, as noted during a regular follow-up examination of a convexity meningioma. Pathological examination of the resected superficial temporal artery revealed eosinophilic granulomas, which led to the diagnosis of EGPA, as well as EGPA-induced aneurysm formation. As the partially thrombosed vertebral artery fusiform aneurysm enlarged, the compression of the medulla oblongata occurred despite intensive immunosuppressive therapy for 1 year. The patient underwent flow diversion therapy administered using the pipeline embolization device, resulting in complete disappearance of the aneurysm. LESSONS: Considering that the entire circumference of the aneurysmal wall is affected by necrotizing vasculitis, flow diverter therapy would be a reasonable and efficient approach for the treatment of EGPA-related aneurysms in cases in which the patient is nonresponsive to immunosuppressants.

Rupture of an adjacent cerebral aneurysm following the deployment of a Pipeline embolization device: illustrative case.

BACKGROUND: Although the Pipeline embolization device (PED) is effective for intracranial aneurysm treatment, its impact on the surrounding vascular structure is unknown. OBSERVATIONS: A 71-year-old woman was incidentally found to have a simultaneous large posterior communicating artery aneurysm and an ipsilateral small anterior choroidal artery aneurysm. She underwent flow diversion therapy for both aneurysms with a PED, but the distal shortening of the PED after deployment led to the exposure of the anterior choroidal artery aneurysm. Follow-up angiography revealed complete obliteration of the posterior communicating artery aneurysm, but the anterior choroidal artery aneurysm remained. Three years after the endovascular surgery, the patient experienced a subarachnoid hemorrhage due to the rupture of the anterior choroidal artery aneurysm. Retrospective analysis of angiographic images revealed a change in the vascular geometry surrounding the ruptured aneurysm after PED deployment; this was further accompanied by an increase in the flow velocity inside the aneurysm. LESSONS: Because PED use might induce the adverse effects on the adjacent uncovered aneurysm by changing the vascular geometry and hemodynamic stress, a cautious therapeutic strategy, such as proper placement of the stent and using a longer and appropriate-sized PED, should be chosen when deploying the PED.

Rescue of distally placed stents in the setting of internal carotid artery dissection: A report of 2 cases with mechanistic insights.

Potential procedural complications of endovascular therapy for carotid artery dissection have not been clarified. Herein, we present the cases of a 46-year-old woman and a 59-year-old man who underwent carotid artery stenting for left cervical internal carotid artery dissection. During the procedure, intramural hematoma was squeezed out by stent placement, causing further extension of the pseudolumen and a prominent stenosis proximal to the stent. Additional stent deployment was subsequently performed to fully cover the newly arising stenosis, resulting in good recanalization. In cases with a long-affected lesion, we should consider the potential risk of dissection advancement following stent deployment. Using longer stents or additional rescue stenting would be efficient in counteracting this rare complication.