Mechanical thrombectomy in acute in-stent thromboembolism.

Following the implantation of a carotid artery stent (CAS), the aetiology of in-stent occlusion typically shifts from embolic events in the acute phase to intimal hyperplasia in the chronic phase. A man in his 70s with a history of CAS implantation (performed 5 years ago) for left internal carotid artery (ICA) stenosis was admitted to our hospital with a chief complaint of left-sided transient scotoma. MRI revealed an acute occlusion of the left ICA, and an urgent digital subtraction angiography (DSA) was performed. The DSA results suggested the presence of an in-stent thrombus instead of in-stent stenosis. An urgent endovascular thrombectomy was performed, and the thrombus was successfully retrieved from the carotid stent. Full reperfusion was achieved, and no damage occurred to the carotid stent. This case highlights the importance of thorough examination of MRI and DSA findings for accurate differentiation between the causes of vessel occlusion.

Reversed-Image Mechanical Thrombectomy for Acute Ischemic Stroke in a Situs Inversus Totalis Patient.

An 85-year-old female with situs inversus totalis presented with right hemiplegia, right facial nerve palsy, eye deviation to the left, and aphasia. Magnetic resonance imaging revealed acute ischemic lesions in the left insular cortex and the frontal lobe. Magnetic resonance angiography revealed an occlusion of the left internal carotid artery. Reversed-image mechanical thrombectomy achieved complete reperfusion in three passes within 54 minutes. Six months post-intervention, the patient could walk indoors independently. Our technique, which replicates the normal arterial anatomy by inversion and angulation, was adapted to situs inversus totalis.

Simplified Transradial Access for Aneurysms Treatment: A Guiding System Using Solo Distal Access Catheter and Anatomical Considerations.

OBJECTIVE: The recent shift from transfemoral access to transradial access in neurointervention has led to gaps in guiding systems. We propose a useful guiding system, the solo distal access catheter system without a conventional guiding catheter or a sheath in transradial access for aneurysms treatment. We also assessed the anatomical features required for suitable patient selection. METHODS: We retrospectively collected data from consecutive patients with aneurysms treated with the solo distal access catheter system at our institution between April 2022 and April 2023, and evaluated the anatomical factors that appeared to affect the procedure. RESULTS: Of the 20 patients who underwent transradial access, 11 were treated using the solo distal access catheter system, and 10 (90.9%) completed the procedure. No radial artery occlusion was detected. The entry angle of the target vessel ranged from 37° to 139°, and the mean proximal parent artery diameter was 9.34 ± 1.48 mm. A double subclavian innominate curve was observed in 3 of 5 patients whose target vessels were the right common carotid artery. CONCLUSIONS: Using a solo distal access catheter as a guiding system for treating aneurysm proved effective and feasible with appropriate patient selection. Anatomical assessment of the entry angle of the target vessel, proximal parent artery diameter, and tortuosity may be important factors for the success of this method.

One-Way Valve Method for Achieving Effective Flow Reversal on Carotid Artery Stenting.

Objective: We report a simplified method of manual transfusion with a one-way valve during carotid artery stenting (CAS) with flow reversal. Case Presentation: A 77-year-old man with cervical internal carotid artery stenosis who developed vulnerable plaques was scheduled for CAS using flow reversal. Blood flow reversal was naturally caused by the arteriovenous pressure gradient, and a method with a one-way valve, which enables simplified manual transfusion using a syringe technique, was used for the patient. CAS was completed without distal embolization. Conclusion: Manual transfusion can be simplified using a one-way valve in cases of flow reversal during CAS, which often require complicated procedures.

Clinical and Morphological Characteristics of Ruptured Small (<5 mm) Posterior Communicating Artery Aneurysms.

CONTEXT: Small intracranial aneurysms (IAs) are considered to have a low risk of rupture; however, in clinical practice, we often encounter patients with subarachnoid hemorrhage (SAH) due to rupture of small IAs. AIMS: This study aims to clarify the clinical and morphological characteristics of ruptured small IA, focusing on posterior communicating artery (PCoA) aneurysms as a prone site. SETTINGS AND DESIGN: We retrospectively reviewed 102 consecutive patients with SAH due to ruptured PCoA aneurysm who underwent microsurgical or endovascular aneurysm repair between April 2013 and March 2018. SUBJECTS AND METHODS: All PCoA aneurysms were diagnosed using three-dimensional rotation angiography or three-dimensional computed tomography angiography. Information regarding the following clinical characteristics was collected: age, sex, past medical history, current smoking, antithrombotic therapy, multiplicity, hydrocephalus, intracerebral hemorrhage, intraventricular hemorrhage, and World Federation of Neurosurgical Societies (WFNS) Grade on admission. STATISTICAL ANALYSIS USED: We analyzed factors of ruptured small IA, focusing on PCoA aneurysms using univariate and multivariate regression analyses. RESULTS: Univariate and multivariate analyses revealed that low aspect ratio (AR) (odds ratio [OR] = 0.33, P = 0.01) and nonfetal type of PCoA (OR = 0.31, P = 0.02) might be independent characteristics of ruptured small PCoA aneurysms. However, age, sex, past medical history, WFNS grade, and treatment outcome were not different between the small and nonsmall PCoA aneurysms. The aneurysm size was not associated to the selection of treatment, proportion of complications, and treatment outcome. CONCLUSIONS: In cases of ruptured PCoA aneurysms, low AR and nonfetal type of PCoA might be associated with rupture of small aneurysms.

Long-Term Outcomes of Elderly Patients with Poor-Grade Aneurysmal Subarachnoid Hemorrhage.

OBJECTIVE: Long-term outcomes after surgical treatment and intensive care have not been investigated in elderly patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to analyze 12-month outcomes and prognostic factors of patients with poor-grade aSAH who were at least age 70 years. METHODS: We performed a single-center, retrospective study including poor-grade (World Federation of Neurological Societies [WFNS] grades IV and V) aSAH patients who were at least age 70 years, were admitted to our stroke center, and received aneurysmal treatment between April 2012 and September 2018. The clinical outcomes were evaluated at months 3 and 12. Univariate/multivariate analyses were performed to identify the independent prognostic factors of good neurologic outcomes (modified Rankin Scale score 0-3). These factors included sex, age, WFNS grade, Fisher group, delayed cerebral ischemia, aneurysm treatment, aneurysm size, aneurysm location, and blood examination data in the 14 days post subarachnoid hemorrhage. RESULTS: The proportion of patients with good outcomes (modified Rankin Scale score 0-3) was increased at 12 months compared with that at 3 months. No intracerebral hemorrhage was a significant predictor of good neurologic outcomes at 3 months (P = 0.03). The absence of delayed cerebral ischemia and small fluctuations in the average absolute daily difference from normal sodium levels were significant predictors of good neurologic outcomes at months 3 and 12 (P = 0.04 and P = 0.03, respectively). CONCLUSIONS: The absence of delayed cerebral ischemia and small fluctuations in the average absolute daily difference from the normal sodium levels were independently associated with good neurologic outcomes at 12 months in elderly patients. Intracerebral hemorrhage did not appear to affect long-term outcomes. These findings suggest that elderly patients with severe subarachnoid hemorrhage should not be excluded from receiving surgical treatment on the basis of their age alone.

A case of cerebral infarction due to pleomorphic carcinoma of the lung.

BACKGROUND: With the increase in endovascular treatment, reports of embolism other than thrombus are scattered, but intracranial tumorigenic embolism is rare and difficult to diagnose. Here, we describe a case of a tumorigenic embolism in a patient with lung cancer whose invasion into the vascular system was not detected on preoperative whole-body imaging. CASE DESCRIPTION: A 66-year-old man who was hospitalized to undergo radiotherapy for pulmonary carcinoma suddenly developed left hemiplegia. He exhibited atrial fibrillation, and emergent radiographic examination revealed a right middle cerebral artery occlusion. Urgent mechanical embolectomy was performed, with successful revascularization. The excised embolus had a unique morphology and was pathologically diagnosed as a cerebral embolism caused by pleomorphic pulmonary carcinoma. CONCLUSION: Tumor-derived cerebral embolism is extremely rare, but it is necessary to consider it as a potential source of embolism during differential diagnosis in patients with malignant tumors.

Uterine rupture at 10 weeks of gestation after laparoscopic myomectomy.

The patient had a previous history of laparoscopic myomectomy. At 10 weeks of gestation, she visited our emergency center due to sudden abdominal pain. An ultrasound examination and MRI showed complete rupture of the uterine myometrium in the fundal wall and a floating gestation sac in Douglas' fossa with fluid. Emergency abdominal laparotomy was immediately performed due to the diagnosis of uterine rupture. During surgery, a small defect of the myometrium was found in the posterior fundal wall of the uterus. Two-layer suturing was performed at the perforation hole. The occasional occurrence of uterine rupture after surgery of the uterus even in the first trimester should be considered.

A practical prediction model for early hematoma expansion in spontaneous deep ganglionic intracerebral hemorrhage.

OBJECTIVE: Early hematoma expansion is a known cause of morbidity and mortality in patients with intracerebral hemorrhage (ICH). The goal of this study was to identify clinical predictors of ICH growth in the acute stage. MATERIALS AND METHODS: We studied 201 patients with acute (<6 h) deep ganglionic ICH. Patients underwent CT scan at baseline and hematoma expansion (>33% or >12.5 ml increase) was determined on the second scan performed within 24 h. Fourteen clinical and neuroimaging variables (age, gender, GCS at admission, hypertension, diabetes mellitus, kidney disease, stroke, hemorrhagic, antiplatelet use, anticoagulant use, hematoma density heterogeneity, hematoma shape irregularity, hematoma volume and presence of IVH) were registered. Additionally, blood pressure was registered at initial systolic BP (i-SBP) and systolic BP 1.5 h after admission (1.5 h-SBP). The discriminant value of the hematoma volume and 1.5 h-SBP for hematoma expansion were determined by the receiver operating characteristic (ROC) curves. Factors associated with hematoma expansion were analyzed with multiple logistic regression. RESULTS: Early hematoma expansion occurred in 15 patients (7.0%). The cut-off value of hematoma volume and 1.5 h-SBP were determined to be 16 ml and 160 mmHg, respectively. Hematoma volume above 16 ml (HV>16) ([OR]=5.05, 95% CI 1.32-21.36, p=0.018), hematoma heterogeneity (HH) ([OR]=7.81, 95% CI 1.91-40.23, p=0.004) and 1.5 h-SBP above 160 mmHg (1.5 h-SBP>160) ([OR]=8.77, 95% CI 2.33-44.56, p=0.001) independently predicted ICH expansion. If those three factors were present, the probability was estimated to be 59%. CONCLUSIONS: The presented model (HV>16, HH, 1.5 h-SBP>160) can be a practical tool for prediction of ICH growth in the acute stage. Further prospective studies are warranted to validate the ability of this model to predict clinical outcome.

Characteristics and prognostic value of acute catecholamine surge in patients with aneurysmal subarachnoid hemorrhage.

OBJECTIVES: The characteristics of serum catecholamine concentration at the hyper-acute phase of aneurysmal subarachnoid hemorrhage (SAH) and its relationship between patient outcome and delayed vasospasm were investigated. METHODS: Patients with aneurysmal SAH (170) were prospectively studied between August 2008 and June 2011. Baseline demographic data and physiological parameters, including plasma concentrations of adrenaline (AD), noradrenaline (NA), and dopamine (DP) were evaluated for all patients. RESULTS: On admission, plasma AD, NA, and DP levels were significantly higher in patients with a poor clinical grade on admission (Hunt and Kosnik grade: IV-V), compared to those with a good clinical grade on admission (Hunt and Kosnik grade: I-III). AD showed a markedly high concentration immediately after the onset of SAH and then rapidly decreased. NA levels peaked within 6 hours after onset, then significantly decreased. The increase of DP with time was not significant, but showed a similar trend to that of NA. The level of each catecholamine showed significant mutual correlation. Our multivariate model demonstrated that age, poor clinical grade at admission, plasma AD and NA levels were good predictors of poor patient outcome [receiver operating characteristic (ROC) area: 0.83]. And that poor clinical grade at admission, Fisher scale, blood sugar level and plasma AD level were good predictors of the development of delayed vasospasm (ROC area: 0.81) (1.3). CONCLUSIONS: The present findings suggest that sympathetic activation in patients in the acute phase of SAH reflects the severity of SAH, and is closely related to the development of delayed vasospasm, leading to the subsequent immune response and inflammatory reactions. Strategies for suppressing catecholamine at the hyper-acute phase may contribute to vasospasm prevention and improve patient outcome.