BACKGROUND: Cerebral vasospasm (CVS) is one of the most critical factors associated with clinical outcomes of patients with subarachnoid hemorrhage (SAH). Clazosentan has been investigated worldwide as a prophylactic agent to prevent CVS. We evaluated a new CVS management protocol which included clazosentan. METHODS: Consecutive 138 patients with SAH, hospitalized in our institution between January 2017 and December 2022, were included in this study. Baseline characteristics, clinical findings, and operative records were analyzed retrospectively. From May 2022, 10 mg/h clazosentan was co-administered with fasudil to all patients according to the indication in the Japanese label. Patients admitted before this date received the conventional combined protocol using the fasudil hydrochloride, nicardipine, and ozagrel. RESULTS: Eighteen (13.0%) patients received the new protocol during the CVS period (defined as day 1 up to day 14 after SAH onset). There were 54 (39.1%) elderly patients aged 75 years or older. Seventy-two (52.2%) patients underwent neurosurgical clipping, whereas 55 (39.9%) patients received endovascular coiling. Among the patients with new protocol, only one patient (5.6%) had symptomatic CVS, compared with 18 patients (15.0%) in those with conventional protocol. More patients who received the new protocol had fluid retention compared with control group (38.9% [7/18] vs. 8.3% [10/120]). Other results did not differ between the two groups. CONCLUSIONS: Clinical outcomes of the new protocol were comparable to those of conventional protocol. Clazosentan may simplify anti-vasospasm treatment. Fluid retention was a specific side-effect of clazosentan, which requires attention especially in the first half of the CVS period.
BACKGROUND: No evidence supports the efficacy and safety of mechanical thrombectomy (MT) in patients aged ≥ 90 years with acute ischemic stroke (AIS). This study clarifies the efficacy, safety, and predictors of MTs in patients aged ≥ 90 years by investigating our results and reviewing previous studies. METHODS: We retrospectively investigated data from 80 consecutive patients who underwent MT at our hospital between 2018 and 2021. We analyzed outcomes using the modified Thrombolysis in the Cerebral Infarction (mTICI) scale and modified Rankin Scale (mRS). Functional outcomes were investigated at 90 days or discharge. RESULTS: We obtained functional outcomes mRS ≤ 3 patients in 41.6%. The mortality rate was 16.6%. The rate of successful recanalization was 75%. Comparison mRS ≤ 3 and mRS ≥ 4 at 90 days or discharge showed statistical significance in the National Institute of Health Stroke Scale, the location of occluded vessels, and mTICI ≥ 2b at the first pass. Univariable logistic regression analysis indicated that the Alberta Stroke Program Early Computed Tomography Score was a predictor of mRS ≤ 3. CONCLUSIONS: The efficacy is lower than that of patients aged < 90; however, MT is effective even in patients aged ≥ 90 years. The safety of MT in patients aged ≥ 90 years was similar to that in those aged < 90 years. Neuro-interventionalists should consider predictors and take the best strategies to achieve successful recanalization in patients aged ≥ 90 years with AIS.
Background: Cervical aneurysms are rare, accounting for <1% of all arterial aneurysms, including dissecting, traumatic, mycotic, atherosclerotic, and dysplastic aneurysms. Symptoms are usually caused by cerebrovascular insufficiency; local compression or rupture is rare. We present the case of a 77-year-old man with a giant saccular aneurysm of the cervical internal carotid artery (ICA), which was treated with aneurysmectomy and side-to-end anastomosis of the ICA. Case Description: The patient had experienced cervical pulsation and shoulder stiffness for 3 months. The patient had no significant medical history. An otolaryngologist performed the vascular imaging and referred the patient to our hospital for definitive management. Neurological deficits were not observed. Digital subtraction angiography showed a giant cervical aneurysm with a diameter of 25 mm within the ICA, and there was no evidence of thrombosis within the aneurysm. Aneurysmectomy and side-to-end anastomosis of the cervical ICA were performed under general anesthesia. After the procedure, the patient experienced partial hypoglossal nerve palsy but fully recovered with speech therapy. Postoperative computed tomography angiography revealed the complete aneurysm removal and patency of the ICA. The patient was discharged on postoperative day 7. Conclusion: Despite several limitations, surgical aneurysmectomy and reconstruction are recommended to eliminate the mass effect and to avoid postoperative ischemic complications, even in the endovascular era.
Background: Randomized controlled trials have demonstrated the efficacy of mechanical thrombectomy (MT) for acute ischemic stroke. However, few studies indicate an association between the number of mechanical thrombectomies and population changes. We aimed to clarify the association between population changes and the number of mechanical thrombectomies for proper allocation of limited medical resources. Methods: We retrospectively analyzed data from 162 patients who underwent MT for large vessel occlusion at our hospitals and compared the number of mechanical thrombectomies per 100,000 person/year to population changes in five regions covered by our hospitals within 2015-2016 and 2017-2019. We performed a simple linear regression analysis to determine the association between population changes and the number of mechanical thrombectomies. Results: Overall, the number of mechanical thrombectomies increased from 15.1 to 19. However, a significant decrease was noted in Toya Lake and Sobetsu/Toyoura. Furthermore, there was a significant negative linear correlation between the overall population reduction rate and the number of mechanical thrombectomies and a positive linear correlation between the increased proportion of the population aged >65 years and the number of mechanical thrombectomies. Conclusion: The number of mechanical thrombectomies may decrease in areas where the overall population reduction rate exceeds 8% or the increased rate of the population aged >65 years is <4%. However, it is necessary to continue establishing a system for MT in areas that have yet to reach these levels.
Objective: The purpose of this study was to investigate the efficacy of percutaneous transluminal angioplasty (PTA) for symptomatic middle cerebral artery stenosis by analyzing cerebral blood flow (CBF). Methods: Between January 2016 and December 2018, six patients with symptomatic middle cerebral artery stenosis underwent CBF analysis by single-photon emission computed tomography (SPECT) with acetazolamide challenge before and after PTA for stenosis. They were retrospectively reviewed, and the blood flow in the area of the affected middle cerebral artery before and after angioplasty was compared. Results: The mean stenosis rate and length of lesion before angioplasty were 76.4 ± 5.4% and 6.5 ± 2.1 mm, respectively. Balloon angioplasty without stenting was performed on all patients. The mean residual stenosis rate just after angioplasty was 45.4 ± 9.3%. No periprocedual complications developed, and there were no notable cerebral ischemic events during the postprocedural follow-up period. One patient underwent repeat angioplasty for restenosis. Although there was only a mild decrease in blood flow at rest, the cerebrovascular reserve (CVR) in the area of the affected middle cerebral artery was markedly decreased before angioplasty (mean, 3.6 ± 4.3%). After angioplasty, the CVR was significantly improved (mean, 18.0 ± 4.7%, p <0.01). Conclusions: PTA for symptomatic middle cerebral artery stenosis can be safely performed using appropriate interventional techniques for select patients. Reduced CVR due to stenosis can be improved after angioplasty, which may reduce the risk of cerebral ischemic events.
Objective: The purpose of this study was to demonstrate the efficacy of a 14-coil (Target XL) for framing in coil embolization of small cerebral aneurysms. Methods: Between January 2017 and December 2018, 46 patients underwent coil embolization of a small cerebral aneurysm that was less than 5 mm in maximum diameter. They were categorized into 26 patients in whom only 10-coils were used and 20 in whom Target XL was used for framing. The volume embolization rate (VER) and recanalization rate were compared between the two groups. Results: Although there were two patients in whom Target XL was replaced with a 10-coil for framing, no adverse events associated with the use of Target XL were noted. The mean VER of the first framing coil was significantly higher in aneurysms that were framed with Target XL than in those framed with a 10-coil (Target XL 22.6 ± 4.5%, 10-coil 17.9 ± 8.4%; p = 0.03). Furthermore, the mean VER at the end of the procedure was significantly higher in aneurysms with Target XL used for framing than in those embolized using only 10-coils (14-coil: 36.8 ± 7.8%, 10-coil: 32.0 ± 6.5%; p = 0.03). No recanalization was observed in aneurysms for which Target XL was used for framing, whereas five aneurysms embolized using only 10-coils were recanalized. Conclusion: Target XL may be safe and feasible as a framing coil in coil embolization of small cerebral aneurysms, which may result in a high VER, low recanalization rate, and good outcome.
Objective: There have been no delayed ischemic complications related to stent-assisted coil embolization (SACE) of cerebral aneurysms at our institution. We demonstrate our strategies for stent placement and postoperative management of antiplatelet therapy to reduce the risk of ischemic complications. Methods: We analyzed 57 cases of SACE retrospectively. In the procedure, an appropriate stent was selected and placed to fit the arterial wall without impeding on small arterial branches. Two different antiplatelet drugs, including clopidogrel, were used. Six to twelve months after surgery, follow-up angiography was performed to assess the safety of terminating antiplatelet therapy. In cases in which antiplatelet therapy was tapered, the two antiplatelet drugs were switched to clopidogrel alone, and it was subsequently tapered and finally discontinued. Results: There were 49 cases of SACE in which postoperative antiplatelet therapy was tapered. Among these cases, antiplatelet therapy was discontinued in 35 cases. The mean duration of dual antiplatelet therapy was 10.6 ± 2.8 months, and the mean duration of total antiplatelet therapy was 15.0 ± 2.1 months. Three patients developed SACE-related ischemic stroke, which developed in the early phase after surgery in all. Conclusion: Antiplatelet therapy can safely be terminated in most cases of SACE. In order to reduce the risk of ischemic complications, stent selection, stent placement, and management of antiplatelet therapy should be performed appropriately. Furthermore, careful follow-up should be continued even after the termination of antiplatelet therapy.
