[A Case of Unruptured Cerebral Aneurysm Arising from Duplicate Origin of the Middle Cerebral Artery].

We experienced a case of an unruptured cerebral aneurysm arising from a duplicate origin of the middle cerebral artery(MCA). Initially, we diagnosed the condition as an unruptured aneurysm arising from the internal carotid artery on three-dimensional computed tomography;neck clipping was attempted. However, an unidentified vessel was found around the aneurysmal neck, which could not be easily separated from the aneurysm, making neck clipping difficult. Thus, we only completed coating of the aneurysm without neck clipping. Postoperatively, cerebral angiography showed that the unidentified vessel originated from the internal carotid artery and fused with the MCA horizontal segment. We recognized that the identified vessel was a duplicate origin of the MCA. Few reports on the treatment of an aneurysm arising from a duplicate origin of the MCA are available;there has been no discussion on whether this vessel can be occluded. We assumed that occlusion of the proximal end of the duplicate origin of the MCA together with the aneurysm was unlikely to cause ischemia as the duplicate origin of the MCA fuse with MCA. Coil embolization was performed for the aneurysm, and the duplicate origin was unexpectedly preserved immediately after coil embolization. However, it was not enhanced on cerebral angiography performed after several months, and no cerebral infarction was noted on magnetic resonance imaging. If preservation of the duplicate origin of the MCA is difficult, occlusion of the aneurysm together with the proximal end of the duplicate origin of the MCA can be considered as a surgical strategy.

Prehospital triage for endovascular clot removal in acute stroke patients.

Aim: To establish prehospital triage in accordance with the new guidelines for endovascular therapy, we retrospectively analyzed the monitoring data of the city-wide transportation system using the Maria Prehospital Stroke Scale (MPSS), a novel prehospital stroke scale for emergency medical technicians (EMTs) to predict the likelihood of thrombolytic therapy after transportation. Methods: Kawasaki City, Japan, has six comprehensive stroke centers (CSCs) and six primary stroke centers (PSCs). In CSCs, endovascular therapy can be carried out 24 h a day, 7 days a week, but not in PSCs. There is no "drip and ship" protocol for further endovascular therapy from PSCs to CSCs. We determined the predictive value of MPSS scoring by the EMTs for the performance of endovascular therapy after transportation. Results: There were 2031 patients (mean age, 71.1 ± 13.3 years) registered from April 2012 to March 2015. Multivariate logistic regression analysis indicated that the MPSS score and type of stroke center were independent predictors for performance of endovascular therapy. In particular, the odds ratio (OR) for endovascular therapy was significant for MPSS score 3 (OR, 2.914; 95% confidence interval (CI), 1.152-7.372; P = 0.024), MPSS score 4 (OR, 5.474; 95%CI, 2.300-13.029; P = 0.000), and MPSS score 5 (OR, 11.459; 95%CI, 4.334-30.296; P = 0.000) when MPSS score 1 was set as a reference. The diagnostic accuracy of the MPSS score evaluated by EMTs was 0.689 (95%CI, 0.627-0.751). Conclusions: Prehospital triage using MPSS scores evaluated by EMTs can predict the likelihood of performance of endovascular therapy after transportation, and may become a tool offering a flexible solution for designing a new transportation protocol.