Impact of atherosclerotic etiology on technical and clinical outcomes of mechanical thrombectomy with a stent retriever: subanalysis of the Japan Trevo Registry.

BACKGROUND: The safety and effectiveness of stent retriever use for patients with acute large vessel occlusion (LVO) due to intracranial atherosclerotic disease (ICAD) is not well established. We investigated the differences in clinical outcomes in patients with and without ICAD. METHODS: We analyzed the Japan Trevo Registry, a nationwide registry which enrolled patients with acute LVO who underwent endovascular therapy (EVT) using the Trevo retriever alone or in combination with an aspiration catheter. We compared the technical and clinical outcomes of EVT between the ICAD and No-ICAD groups. The primary outcome was effective reperfusion and the secondary outcome was modified Rankin scale (mRS) score 0-2 at 90 days. Safety outcomes were worsening of neurologic symptoms within 24 hours, any intracranial hemorrhage within 24 hours, vessel dissection/vessel perforation related to using the Trevo retriever and mortality at 90 days. RESULTS: A total of 835 patients (45 in the ICAD group and 790 in the No-ICAD group) were analyzed. In the ICAD group, more men (68.9% vs 50.8%, P=0.02) and a lower median National Institutes of Health Stroke Scale score at admission (11 vs 18, P<0.0001) were observed. The primary outcome was significantly more common in the No-ICAD group (92.5%) than in the ICAD group (80.0%) (adjusted odds ratio (aOR) 0.21, 95% CI 0.09 to 0.50). The proportion of patients with mRS score 0-2 at 90 days was significantly lower in the ICAD group (44.4% vs 42.4%, aOR 0.49, 95% CI 0.23 to 1.00, P=0.0496). Other secondary and safety outcomes were not significantly different between the two groups. CONCLUSIONS: Patients with LVO with ICAD had a lower rate of effective reperfusion than those with No-ICAD.

Perioperative Antiplatelet Management in the Flow-Diverter Treatment for Unruptured Cerebral Aneurysms: A Single-Center, Retrospective Analysis.

BACKGROUND: Although periprocedural antiplatelet therapy for the treatment of unruptured intracranial aneurysms (UIAs) using flow-diverter stents (FDSs) is necessary to avoid thromboembolic complications, a definite antiplatelet therapy has not been established. We aimed to evaluate the safety and efficacy of periprocedural antiplatelet management in UIA treatment with FDS. METHODS: A single-center retrospective analysis of consecutive patients with UIAs treated with FDSs between September 2013 and January 2022 was conducted. Patients received dual antiplatelet therapy (DAPT) (aspirin and clopidogrel) for 14-day before and 3-6 months after FDS placement. Platelet aggregation was evaluated prior to treatment using light transmission aggregometry, which was classified into 3 grades; 1-3: promoted, 4-6: appropriate, and 7-9: non-responder, for adenosine diphosphate (ADP) and collagen. By this classification, the antiplatelet regimen was modified. Outcome included hemorrhagic and ischemic events. RESULTS: 193 patients with 200 UIAs underwent 213 FDSs placement. The median platelet aggregability grade before treatment was 5 for ADP and 4 for collagen. Antiplatelet therapy modification was performed in 62 patients (32.1%). The median postoperative DAPT duration was 94 days. Antiplatelet medicine-related hemorrhagic events occurred in 4 patients (2.1%) and ischemic events occurred in 6 patients (3.1%). These patients had no morbido-mortality. CONCLUSIONS: Periprocedural antiplatelet management based on the value of platelet aggregability was relatively safe and effective for treating UIA with FDS.

Intravenous alteplase before endovascular therapy for acute large vessel occlusion with large ischemic core: subanalysis of a randomized clinical trial.

BACKGROUND: The efficacy of endovascular therapy (EVT) in patients with large ischemic core has been reported, but it remains unclear whether IV alteplase (IVT) has beneficial effects in addition to EVT in such patients. We evaluated the efficacy and safety of EVT with or without IVT. METHODS: The RESCUE-Japan LIMIT was an open-label, prospective, multicenter, randomized clinical trial to evaluate the efficacy and safety of EVT in stroke patients with large ischemic core, defined as Alberta Stroke Program Early CT Score (ASPECTS) 3-5. This subanalysis evaluated the differences in the effects of EVT with medical care (EVT group) compared with medical care alone (No-EVT group) between those who received IVT (IVT stratum) and those who did not (No-IVT stratum) before EVT. RESULTS: Among 202 enrolled patients, 147 (73%) did not receive IVT. In the No-IVT stratum, the modified Rankin Scale (mRS) score of 0-3 at 90 days was significantly higher in the EVT group than in the No-EVT group (31.1% vs 12.3%, OR 3.21 (95% CI 1.37 to 7.53)). In the IVT stratum, the mRS score of 0-3 was 30.8% in the EVT group and 13.8% in the No-EVT group (OR 2.78 (95% CI 0.72 to 10.7)) (interaction p=0.77). The incidence of symptomatic intracranial hemorrhage was not different between the two groups in the No-IVT stratum (OR 1.20 (95% CI 0.35 to 4.12)), but it was significantly higher in the EVT group than in the No-EVT group in the IVT stratum (11.5% vs 0%, p=0.03). CONCLUSIONS: There was no difference in efficacy of EVT with or without IVT, while IVT before EVT might increase symptomatic intracranial hemorrhage in patients with large ischemic core. TRIAL REGISTRATION INFORMATION: NCT03702413.

Endovascular therapy for acute intracranial large vessel occlusion due to atherothrombosis: Multicenter historical registry.

BACKGROUND: Atherothrombotic stroke-related large vessel occlusion (AT-LVO) is caused by two etiologies, the intracranial artery occlusion due to in situ occlusion (intracranial group) or due to embolism from cervical carotid occlusion or stenosis (tandem group). The prognosis and reocclusion rate of each etiology after endovascular therapy (EVT) is unclear. METHODS: We conducted a historical multicenter registry study at 51 Japanese centers to compare the prognoses of AT-LVO between two etiologies. The primary outcome was the incidence of recurrent ischemic stroke or reocclusion of the treated vessels within 90 days after EVT. Each of the primary outcome means the incidence of recurrent ischemic stroke and reocclusion of the treated vessels within 90 days after EVT. RESULTS: We analyzed 582 patients (338 in the intracranial group and 244 in the tandem group). Patients in the intracranial group were younger (mean 71.9 vs 74.5, p=0.003), more of them were female and fewer of them were current smokers than those in the tandem group. In the tandem group, the patients' National Institutes of Health Stroke Scale score on admission was higher (13 vs 15, p=0.006), onset to puncture time was shorter (299 [145-631] vs 232 [144-459] minutes, p=0.03) and Alberta Stroke Program Early CT Score (ASPECTS) was lower (8 [7-9] vs 8 [6-9], p=0.0002). The primary outcome was higher in the intracranial group (22.5% vs 8.2%, p<0.0001). However, any ICH and death were not significantly different in the two groups. CONCLUSIONS: The incidence of recurrent ischemic stroke or reocclusion after EVT for AT-LVO was higher in the intracranial group.

Effect of current smoking on ischemic events in patients with atrial fibrillation taking vitamin K antagonist.

Purpose: We investigated the association between current smoking and clinical outcomes in patients with atrial fibrillation (AF) prescribed vitamin K antagonist (VKA). Methods: We conducted a retrospective study at 71 centers in Japan. The inclusion criterion was taking a VKA for AF. Exclusion criteria were mechanical heart valves or history of pulmonary thrombosis or deep vein thrombosis. Consecutive patients were registered in February 2013 and followed until February 2017. The primary outcomes included ischemic events and major bleedings. The secondary outcomes were ischemic stroke, hemorrhagic stroke, and all-cause mortality. Results: A total of 7826 patients were included, with a mean age of 73 years; 5274 (67%) were men. The adjusted hazard ratios (HRs; 95% confidence intervals [CIs]) of current smokers relative to non-current smokers for ischemic events and major bleedings were 1.64 (1.05-2.57) and 1.09 (0.72-1.65), respectively. The adjusted HRs (95% CIs) of current smokers relative to non-current smokers for ischemic stroke, hemorrhagic stroke, and all-cause mortality were 1.65 (1.03-2.64), 0.52 (0.12-2.15), and 1.26 (0.83-1.92), respectively. Conclusions: There were significant associations between current smoking and ischemic events or ischemic stroke in patients with AF on VKA.

[Important Points for Patient Positioning and Head Fixation in Cerebral Aneurysm Surgery].

Patient positioning and head fixation are two of the most important aspects of cerebral aneurysm surgery. These procedures require an accurate understanding of the anatomy of the scalp and skull and of the process for approaching aneurysms. We describe the basics of this procedure in frontotemporal craniotomy, which is most frequently used in cerebral aneurysm surgery, with a focus on head fixation using the MAYFIELD three-pin skull clamp(Integra LifeSciences). The insertion sites of the head pins should be avoided in areas with thin bone, such as the frontal sinus and temporal squama, and just above the arteries of the scalp and venous sinuses. The position of the head should be determined based on three factors: rotation, vertex up or down, and tilt. The head should be elevated to reduce intracranial pressure, and cervical hyperflexion should be avoided to prevent increased venous pressure.

Posterior Inferior Cerebellar Artery Thrombosed Aneurysm Associated with Persistent Primitive Hypoglossal Artery Successfully Treated with Condylar Fossa Approach.

A 68-year-old woman presented with generalized seizure due to the left internal carotid artery (ICA) aneurysmal compression of the ipsilateral medial temporal lobe. Computed tomography angiography (CTA) revealed multiple aneurysms of the right persistent primitive hypoglossal artery (PPHA), the right ICA, and the right anterior cerebral artery (ACA). The right PPHA originated from the ICA at the level of the C1 and C2 vertebral bodies and passed through the hypoglossal canal (HC). The PPHA aneurysm was large and thrombosed, which was located at the bifurcation of the right PPHA and the right posterior inferior cerebellar artery (PICA), projecting medially to compress the medulla oblongata. Since this patient had no neurological deficits, sequential imaging studies were performed to follow this lesion, which showed gradual growth of the PPHA aneurysm with further compression of the brain stem. Although the patient remained neurologically intact, considering the growing tendency clipping of the aneurysm was performed. Drilling of the condylar fossa was necessary to expose the proximal portion of the PPHA inside the HC. The key of this surgery was the preoperative imaging studies to fully understand the anatomical structures. The PPHA was fully exposed from the dura to the corner its turning inferiorly without damaging the occipital condylar facet. Utilizing this technique, the neck ligation of the aneurysm was safely achieved without any surgical complications.

Impacts of pressure bonding fixation on a bone flap depression and resorption in patients with craniotomy.

Fixation of bone flaps after craniotomy is a routine part of every neurosurgical procedure. Common problems encountered are bone flap depression and resorption. Authors performed the pressure-bonding bone flap fixation (PBFF) using absorbable craniofix (AC) and hydroxyapatite wedge (HW). The aim of the present study is to evaluate the efficacy of PBFF to prevent a bone flap depression and resorption in patients treated with craniotomy. Four-hundred fifty-four patients underwent craniotomies. Authors collected the following data: age, sex, type of craniotomy, what kind of surgery, whether bypass surgery was performed, whether surgery was the initial, whether AC and the HW were used, bone flap depression and resorption at 6-month after the craniotomy. PBFF was defined as a bone flap fixation using both AC and HW to impress a bone flap to forehead. The mean age was 62±13years and 404 (89%) patients were women. PBFF was performed in 71 patients (16%), either AC or HW was used in 141 (31%), only AC was used in 116 (25%), and only HW was used in 25 (5.5%). At 6-month after the surgery, a bone flap depression was seen in 38 patients (8.4%), and a bone flap resorption was seen in 66 (15%). Multivariate analysis showed that only a PBBF showed a negative correlation with bone flap depression (p=0.044) and resorption (p=0.011). The results of the present study showed that PBFF reduced a bone flap depression and resorption and provided excellent postoperative cosmetic results.

A Contralateral Transcondylar Fossa Approach with Bilateral V3 Segment Exposure for Repairing Complex Vertebral Artery Aneurysms.

BACKGROUND AND IMPORTANCE: Microsurgical treatment for vertebral artery aneurysms can be approached through the lateral aspect of the brainstem and cerebellum. A contralateral approach may be selected in complex aneurysms with tortuous running and the intracranial vertebral artery distal to the aneurysm located in the contralateral cerebellopontine angle. When repairing the aneurysm, exposing the V3 segment before craniotomy is advantageous. We describe the detailed surgical procedures of the contralateral transcondylar fossa approach with bilateral V3 segment exposure for the repair of a complex vertebral artery aneurysm. CLINICAL PRESENTATION: A 48-year-old woman presented with a 23-mm unruptured thrombosed fusiform aneurysm in the right vertebral artery. The aneurysm and the V4 segment distal to it deviated to the left, and the aneurysm was compressing the left anterior aspect of the medulla oblongata. We treated the patient with trapping and thrombectomy, using a contralateral transcondylar fossa approach with bilateral V3 exposure. During the procedure, proximal vascular control was achieved by occluding the contralateral V3 segment and distal control was achieved by occluding the V4 segment. The aneurysm was successfully trapped and decompressed. The patient's postoperative course was good and she was discharged with a modified Rankin Scale score of 0. CONCLUSIONS: The contralateral transcondylar fossa approach with bilateral V3 exposure is feasible for the repair of complex vertebral artery aneurysms showing a deviated and difficult to access V4 segment proximal to the aneurysm. Bilateral V3 exposure may also facilitate aneurysm bypass procedures such as those using a V3-V4 anastomosis.

Radical resection of a craniopharyngioma via the extradural anterior temporal approach with zygomatic arch osteotomy.

BACKGROUND: Though the extradural anterior temporal approach (EDATA) with zygomatic osteotomy is useful, there are only few reports of this approach being used for craniopharyngioma resection. Herein, we report our surgical case series and the technical importance of EDATA for the radical removal of a craniopharyngioma. METHODS: We report 7 cases of craniopharyngiomas treated surgically between April 1999 and October 2015. The surgical approaches, clinical presentation, pre and postoperative radiographic examination results, surgical outcomes, and morbidity were analyzed. RESULTS: The mean follow-up period was 89.1 months. The surgical approach was EDATA with zygomatic osteotomy in 4, combined interhemispheric translamina terminalis approach (IHTLA) and trans-sylvian anterior temporal approach (ATA) in 2, and IHTLA in 1 patient. Complete tumor resection was achieved in all cases, without any recurrence during the follow-up period. Transient morbidities were oculomotor nerve palsy in 2, and meningitis and hydrocephalus in 1 patient. There was 1 case of permanent morbidity due to hydrocephalus that needed a ventriculoperitoneal shunt, and 1 case of blindness on the operative side. Visual acuity and visual field improved in 4 cases, showed no change in 2 cases, and deteriorated in 1 case. Though the pituitary stalk was preserved in 2 cases, all 7 cases needed total hormone replacement therapy. CONCLUSION: EDATA with zygomatic osteotomy ensures sufficient mobility of the internal carotid artery, and provides a good lateral and look up operative view. Hence, it can be used effectively for radical resection of craniopharyngiomas through the opticocarotid space and retrocarotid space.

"Reverse" bypass using a naturally formed "bonnet" superficial temporal artery in symptomatic common carotid artery occlusion: a case report.

We herein describe a patient with symptomatic common carotid artery occlusion who underwent a reverse superficial temporal artery (STA)-middle cerebral artery (MCA) single bypass using a naturally formed "bonnet" STA. The surgical procedure was performed without difficulty, and no further neurological deterioration was observed after surgery. In practice, this case highlights that the reverse STA-MCA bypass can be achieved safely and less invasively using a naturally formed "bonnet" STA.

Anterior cerebral artery dissecting aneurysm associated with untreated craniopharyngioma.

Coexistence of cerebral aneurysm and untreated craniopharyngioma is extremely rare. We present an extremely rare case of anterior cerebral artery dissecting aneurysm associated with untreated craniopharyngioma, and discuss the relationship between these two lesions.

Vestibular schwannoma with repeated intratumoral hemorrhage.

Repeated hemorrhage from a vestibular schwannoma is very rare. We report a 15-year-old male, to our knowledge the fourth known patient with repeated hemorrhage of vestibular schwannoma, who presented with rapidly progressive right-sided hearing loss and tinnitus. MRI showed a mass lesion in the right cerebellopontine angle. T1-weighted and T2-weighted MRI revealed a hyperintense intratumoral area, indicating subacute hemorrhage within the tumor. Nine weeks after the initial onset, the patient again presented with a sudden onset headache, nausea, and ataxia. A CT scan showed recurrence of an intratumoral hemorrhage. A subtotal resection was achieved. A histopathological examination of the resected specimen showed typical features of schwannoma. We review the pertinent literature and discuss the features of repeated hemorrhage from a vestibular schwannoma.