Ischemic stroke patients with low DWI ASPECTS scores require puncture to recanalization within 30 min for large vessel occlusion.

BACKGROUND: The clinical benefits of faster recanalization in acute large vessel occlusion are well recognized, but the optimal procedure time remains uncertain. The aim of this study was to identify patient characteristics that necessitate puncture-to-recanalization (P-R) time within 30 min to achieve favorable outcome. METHODS: We evaluated the patients from a prospective, multicenter, observational registry of acute ischemic stroke patients. The study included patients who underwent endovascular therapy for ICA or MCA M1 occlusion and achieved successful recanalization. Patients were categorized into subgroups based on pre-treatment characteristics and the frequency of favorable outcomes was compared between P-R time < 30 min and ≥ 30 min. Interaction terms were incorporated into the models to assess the correlation between each patient characteristic and P-R time. RESULTS: A total of 1053 patients were included in the study. Univariate analysis within each subgroup revealed a significant association between P-R < 30 min and favorable outcomes in patients with DWI ASPECTS ≤6, age > 85 and NIHSS ≥16. In the multivariable analysis, NIHSS, age, time from symptom recognition to puncture, and DWI ASPECTS were significant independent predictors of favorable outcomes. Notably, only DWI ASPECTS exhibited interaction terms with P-R < 30 min. The multivariable analysis indicated that P-R < 30 min was an independent predictor for favorable outcome in DWI ASPECTS ≤6 group, whereas not in DWI ≥7. CONCLUSIONS: P-R time < 30 min is predictive of favorable outcomes; however, the effect depends on DWI ASPECTS. Target P-R time < 30 min is appropriate for patients with DWI ASPECTS ≤6.

Increased door-to-puncture time during off-duty hours results in poor treatment outcomes for acute ischemic stroke: A subanalysis of the K-NET registry.

BACKGROUND: For patients who undergo endovascular treatment for acute ischemic stroke, the total time for treatment may increase during off-duty hours leading to worse outcomes. The present study compared endovascular treatment outcomes for on-duty and off-duty hours and examined factors that could be responsible for the prolonged treatment of patients in a multicenter registry. METHODS: The study group comprised 1571 patients listed in the multicenter stroke registry (K-NET) who had undergone endovascular treatment between January 2018 and June 2020. The modified Rankin Scale (mRS), evaluated at 90 days after stroke onset, was utilized as the primary outcome. Patients were divided into on-duty and off-duty patients based on admission time. Multivariate logistic regression analysis was used to identify the independent factors that increased the time from admission to puncture during the off-duty period. RESULTS: The mean mRS score at 90 days after stroke onset was 2.9, similar in both on-duty and off-duty patients, with no significant difference (p = 0.77); however, significant differences were observed in time from door-to-puncture (74.7 vs. 88.8, p < 0.01). Additionally, the mRS score at 90 days worsened significantly for door-to-puncture time >60 min in the off-duty period. Multivariate logistic regression analysis revealed that a low National Institute of Health Stroke Scale (NIHSS) score, high pre-mRS score, posterior circulation, and diabetes were independent indicators of door-to-puncture time >60 min during the off-duty period. CONCLUSION: Door-to-puncture time >60 min during off-duty hours was associated with poor outcomes related to low NIHSS, high pre-mRS, posterior circulation, and diabetes.

Efficacy and safety of thrombectomy for acute ischaemic stroke in patients with pre-stroke mRS scores of 2-3: Real-world evaluation from an open-label, prospective, multicentre, observational study.

BACKGROUND: This study assessed the efficacy and safety of thrombectomy for acute ischaemic stroke in a population with pre-stroke modified Rankin scale (mRS) scores of 2-3 using real-world data. METHODS: Our sample set included 2313 consecutive patients enrolled in the Kanagawa Registry of Intravenous and Endovascular Treatment of Acute Ischemic Stroke registry between January 2018 and June 2020 in 40 stroke centres in Kanagawa Prefecture, Japan. Patients treated with intravenous tissue plasminogen activator (t-PA), thrombectomy, or both were included. Patients with pre-stroke mRS scores of 4-5 and those treated only with intra-arterial thrombolysis were excluded. The primary outcome of this study was an mRS score of 0-3 at 90 days after onset to assess the efficacy of thrombectomy for pre-stroke disabled individuals. We performed multivariate logistic regression analyses to investigate independent factors for a 90-day mRS score of 0-3. We also performed nearest-neighbour within-calliper matching between thrombectomy and t-PA only. RESULTS: After excluding patients meeting the exclusion criteria, we analysed data of 2136 consecutive patients, of which 315 (14.7%) had pre-stroke disabilities (mRS score 2-3). A 90-day mRS score of 0-3 was achieved by 33.3% of patients with pre-stroke mRS scores of 2-3. According to multivariate analysis, the National Institutes of Health Stroke Scale (NIHSS) score was an independent factor. Furthermore, after propensity-score matching, thrombectomy showed considerable superiority for achieving a 90-day mRS score of 0-3. CONCLUSION: Intravenous t-PA and especially thrombectomy were safe and effective for the population with pre-stroke disabilities, particularly for patients with low NIHSS scores.

Left Distal Transradial Approach for the Treatment of a Sacral Extradural Arteriovenous Fistula: A Technical Note and Literature Review.

BACKGROUND: Sacral extradural arteriovenous fistula (SEAVF) is relatively rare, and its etiology is unknown. They are mostly fed by the lateral sacral artery (LSA). For endovascular treatment, both the stability of the guiding catheter and accessibility of the microcatheter to the fistula, distal to the LSA are required for sufficient embolization of the fistulous point. Cannulation of these vessels requires either crossover at the aortic bifurcation or retrograde cannulation using the transfemoral approach. However, atherosclerotic femoral and tortuous aortoiliac vessels can make the procedure technically difficult. Although the right transradial approach (TRA) can reduce this difficulty by straightening the access route, a potential risk remains for cerebral embolism because it passes the aortic arch. Herein, we present a case of successful embolization of a SEAVF using a left distal TRA. METHODS: We report a case of a 47-year-old man with SEAVF treated with embolization using a left distal TRA. Lumbar spinal angiography showed a SEAVF with an intradural vein through the epidural venous plexus fed by the left LSA. A 6-French guiding sheath was cannulated into the internal iliac artery via the descending aorta using the left distal TRA. A microcatheter could be advanced into the extradural venous plexus over the fistula point from the intermediate catheter placed at the LSA. Embolization with coils and n-butyl cyanoacrylate was successfully performed. RESULTS: The SEAVF completely disappeared on neuroimaging, and the patient gradually recovered. CONCLUSIONS: Left distal TRA could be a useful, safe, and less invasive option for the embolization of SEAVF, especially for patients with high-risk factors for aortogenic embolism or puncture site complications.

Primary results of mechanical thrombectomy for acute ischemic stroke: The K-NET registry in the Japanese metropolitan area.

BACKGROUND: Endovascular treatment (EVT) for acute large vessel occlusion has proven to be effective in randomized controlled trials. We conducted a prospective cohort study to evaluate the real-world efficacy of EVT in a metropolitan area with a large number of comprehensive stroke centers and to compare it with the results of other registries and randomized controlled trials (RCTs). METHODS: We analyzed the Kanagawa Intravenous and Endovascular Treatment of Acute Ischemic Stroke registry, a prospective, multicenter observational study of patients treated by EVT and/or intravenous tissue-type plasminogen activator (tPA). Of the 2488 patients enrolled from January 2018 to June 2020, 1764 patients treated with EVT were included. The primary outcome was a good outcome, which was defined as a modified Rankin Scale (mRS) of 0-2 at 90 days. Secondary analysis included predicting a good outcome using multivariate logistic regression analysis. RESULTS: The median age was 77 years, and the median National Institute of Health Stroke Scale (NIHSS) score was 18. Pretreatment mRS score 0-2 was 87%, and direct transport was 92%. The rate of occlusion in anterior circulation was 90.3%. Successful recanalization was observed in 88.7%. The median time from onset to recanalization was 193 min. Good outcomes at 90 days were 43.3% in anterior circulation and 41.9% in posterior circulation. Overall mortality was 12.6%. Significant predictors for a good outcome were as follows: age, male, direct transfer, NIHSS score, Alberta Stroke Program Early Computed Tomography Score, intravenous tPA, and successful recanalization. CONCLUSION: EVT in routine clinical use in a metropolitan area showed comparable good outcomes and lower mortality compared to previous studies, despite the high proportion of patients with older age, pretreatment mRS score of >2, posterior circulation occlusion, and higher NIHSS. Those results may have been associated with more direct transport and faster onset-to-recanalization times.

Initial Experience with Left Transradial Neurointerventions for Cerebral Aneurysms Using the 6-French Simmons Guiding Sheath.

OBJECTIVE: The use of a transradial approach utilizing a Simmons-shaped catheter for neurointervention has been steadily increasing. Although the right radial artery is commonly used, in interventional cardiology, the left transradial approach offers clear clinical benefits for right-handed patients. To the best of our knowledge, no previous studies have examined intracranial aneurysm embolization with the routine use of the left transradial approach. The aim of this study was to evaluate the technical feasibility of left transradial intracranial aneurysm embolization. METHODS: We conducted a retrospective review of a prospective database of consecutive patients who had undergone left transradial intracranial aneurysm coiling using a 6-French Simmons guiding sheath between January and August 2021. The following outcome variables were then analyzed: whether the catheterization was successful, the angiographical results, and the presence of any procedure-related complications. RESULTS: In total, 25 patients underwent left transradial coiling for 15 anterior and 10 posterior circulation aneurysms. The Simmons guiding sheath could be successfully shaped and cannulated into the targeted vessel in all patients. All aneurysms were completely embolized without any complications. Immediate postoperative angiograms showed Raymond 1 in 10 aneurysms (40.0%), Raymond 2 in 12 (48.0%), and Raymond 3a in 3 (12.0%). None of the patients required crossover to the right radial or femoral arteries, and no radial artery spasms or occlusions were observed. CONCLUSION: The results of this study suggest that the left transradial approach for intracranial aneurysm coiling is not only safe, effective, and technically feasible, but also provides improved comfort to right-handed patients.

Left Transradial Neurointerventions Using the 6-French Simmons Guiding Sheath: Initial Experiences with the Interchange Technique.

BACKGROUND: The transradial approach using a Simmons-shaped catheter has been increasingly used for diagnostic cerebral angiography and neurointervention. In the transradial approach for neurointervention, the right radial artery is mainly used. However, in interventional cardiology, there are apparent clinical benefits with the left transradial approach for right-handed patients. To our knowledge, no studies have reported on neurointervention with the routine use of the left transradial approach. We therefore devised a novel technique for cases with an unachievable form of the Simmons shape using the standard technique, which we named the "interchange technique." The purpose of this study was to evaluate the technical feasibility of the left transradial neurointervention. METHODS: This study is a retrospective review of our prospective database of consecutive patients who underwent a left transradial neurointervention, using a 6-French Simmons guiding sheath, performed from January through April 2021. The outcome variables studied were successful catheterization and procedure-related complications. RESULTS: Twenty-one patients underwent a left transradial neurointervention including cerebral aneurysm coiling, carotid artery stenting, and meningioma embolization. The Simmons shape could not be formed with the standard technique for 3 patients, for whom we successfully formed the Simmons shape with our new interchange technique. The procedure was completely achieved in all 21 patients. No patients required crossover to the right radial or femoral arteries, and there were no radial artery spasms or occlusions or any procedural complications. CONCLUSIONS: The left transradial approach for neurointervention is a technically feasible, safe, and effective alternative while providing more comfort to right-handed patients.

Analysis of postprocedural microembolic infarctions and global oxygen extraction fraction during balloon-protected carotid artery stenting: Preliminary study.

BACKGROUND: Atherosclerotic carotid stenosis with impaired cerebral perfusion is a risk factor for cerebral ischemia. In major carotid stenoocclusive diseases, increased oxygen extraction fraction (OEF) is associated with ischemic stroke. Balloon-protected carotid artery stenting (CAS) is valuable for high-grade carotid stenosis. However, while balloon-protected CAS can effectively reduce the occurrence of ischemic complications by blocking carotid flow, cerebral hypoperfusion may result in simultaneous cerebral ischemia. We sought to evaluate whether increased OEF during balloon-protected CAS can predict postprocedural microembolic infarction (MI). METHODS: Eighty-four patients who underwent balloon-protected CAS were enrolled. Initial, intraprocedural, and postprocedural OEFs were calculated from the cerebral arteriovenous oxygen differences obtained from blood sampled just before the temporary occlusion and reperfusion of the internal carotid artery during and after the procedure. MIs were evaluated by diffusion-weighted imaging (DWI). Patients were classified into two groups based on the presence or absence of new MIs, and the relationship between the OEF and postprocedural MIs was analyzed. RESULTS: New DWI-positive lesions were found in 37 cases (44.0%). Age, signal intensity ratio (SIR) of carotid plaque on T1-weighted black blood magnetic resonance imaging, and intraprocedural OEF were significantly higher in the DWI-positive group. The high SIR and intraprocedural OEF were significantly associated with the development of postprocedural MIs in multivariate analysis. MIs were correlated with the increase in OEF. CONCLUSION: Increased intraprocedural OEF, obtained by blood sampling during balloon-protected CAS, could predict the incidence of postprocedural MIs. Patients with carotid stenosis could be hemodynamically compromised by carotid flow blockage during balloon-protected CAS.

Delayed Iatrogenic Dissection Caused by a Carotid Stent: A Case Report.

Iatrogenic dissection (ID) is a well-known complication of neuroendovascular treatments. ID is predominantly attribute to endothelial injury by the manipulation of wires and/or catheters, and is generally detected in angiography during the procedure. We present a rare case with delayed ID due to deployment of a carotid stent. A 71-year-old man presented with transient motor weakness in the right extremity. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) showed previous multiple cerebral infarctions without a diffusion sign, stenosis with vulnerable plaque in the left common carotid artery (CCA), and an extremely flexed internal carotid artery (ICA). On dual antiplatelet medication, carotid artery stenting (CAS) was completed with favorable dilation of the carotid lumen. Computed tomography angiography 4 days after the procedure revealed high-grade stenosis at the ICA adjacent to the distal edge of the deployed stent. ID with intramural hematoma was diagnosed on MRI. The ID was conservatively treated and remarkably diminished 4 months after the procedure. The patient was asymptomatic during the entire clinical course. This delayed ID was considered to be due to an endothelial injury caused by the distal edge and the constant radial force of the open-cell stent against the flexed vessel and exacerbated by dual antiplatelet therapy. Even in a patient with favorable arterial dilation in CAS procedure, the possibility of a delayed ID should always be considered.

Risk Factors of Cerebellar Microembolic Infarctions After Carotid Artery Stenting.

BACKGROUND: This study analyzes the incidence of microembolic infarctions (MIs) in the cerebellum after carotid artery stenting (CAS) to determine the risk factors. METHODS: From 2012 to 2019, 162 CASs in 155 patients were performed at our hospital. Fifty-seven patients (35.7%) showing new MIs on diffusion-weighted imaging after CAS were enrolled. Patients were assigned to either the cerebellar group (n = 14, 8.8%) if their MIs were in the cerebellum and/or cerebrum or the cerebral group (n = 43, 26.9%) if their MIs were only in the cerebrum. Patient characteristics, anatomic features, and clinical data were retrospectively compared between the 2 groups. RESULTS: Advanced age, right-sided carotid stenosis, severe calcification of aortic arch and brachiocephalic trunk, and vertebral artery narrowing with intraprocedural hemodynamic depression (IHD) significantly increased the development of cerebellar MIs. On multivariate analysis, advanced age, right-sided carotid stenosis, and vertebral artery narrowing with IHD were independent predictors of developing new cerebellar MIs. Cerebellar MIs after CAS were not uncommon. CONCLUSIONS: Catheter maneuvering in the aortic arch or the brachiocephalic trunk could be the main cause of thromboemboli in cerebellar MIs. Careful attention should be paid to catheter maneuvering, especially in older patients with right-sided carotid lesions. In addition, cerebellar hypoperfusion caused by vertebral artery narrowing with IHD might reduce washout of debris, a cause of cerebellar MIs.

Spinal Cord Infarction after Transcatheter Embolization of Pelvic Arteriovenous Malformation.

An 80-year-old woman presented with abdominal and right lower limb pain. Radiological examination revealed pelvic arteriovenous malformations (pAVMs). Although transarterial embolization was repeated, dilation of the common iliac vein worsened. Four sessions of embolization were performed for the internal iliac vein. Paraplegia gradually occurred a day after the final procedure. Magnetic resonance imaging revealed thoracic spinal cord edema and paraspinal vasodilatation, suggesting spinal cord infarction. Additional angiography revealed a radiculomedullary vein draining into the spinal canal from the pAVM; hence, surgical interruption was performed. Incomplete venous embolization of the pAVM caused spinal cord congestion and infarction.

[Carotid Artery Stenting for Non-bifurcating Cervical Carotid Artery Stenosis:A Case Report].

INTRODUCTION: Non-bifurcating cervical carotid artery(NBCCA)is a rare carotid artery anomaly, occurring at a rate of only 0.2%. We report a case in which carotid artery stenting(CAS)was performed for NBCCA stenosis. CASE REPORT: In a 69-year-old man had noted bilateral carotid artery stenosis was noted by chance during treatment for myocardial infarction. Carotid angiography revealed stenosis in both cervical carotid arteries, and the right side did not bifurcate(i.e. it was an NBCCA). Silent ischemia was observed in the left cerebral hemispheres in an MRI, and CAS was performed. A subsequent ultrasound examination revealed an increase in the peak systolic velocity in the right carotid artery, and CAS was planned for the right side. As it was not possible to use a guide-wire to guide into the external carotid artery, we planned to introduce it directly, approaching from the right brachial artery using a 6Fr Simmons guiding sheath. Angiography during distal balloon occlusion revealed significant retrograde flow from the facial and maxillary arteries to the internal carotid artery via the ophthalmic artery. Considering this finding, we decided to perform CAS with a femoral artery approach and flow reversal using distal and proximal balloon occlusion. Intraoperative embolism was prevented, and a successful treatment outcome was obtained. CONCLUSION: There are few reports of NBCCA stenosis treated with carotid endarterectomy or CAS. As CAS to treat NBCCA stenosis has several drawbacks, such as the impossibility of anchoring the wire in the external carotid artery. It is important to take appropriate steps to prevent distal embolism.

A case of tandem stenoses at the proximal common and internal carotid arteries treated with transbrachial stenting: a case report.

The transfemoral approach is a common technique for carotid artery stenting. However, it has the risk of distal embolism when stenting for a stenosis of the proximal common carotid artery because of poor stability of the guiding catheter resulting in difficulty in setting the embolic protection device prior to stenting. We present a novel therapeutic approach and technique for the treatment of tandem carotid stenoses including the proximal common carotid artery. A 63-year-old man presented with double stenoses at the common carotid artery and internal carotid artery. We used a transbrachial sheath guide that had a 6 Fr (2.24 mm, 0.088 inch) internal diameter and was 90 cm long, and was specifically designed for direct cannulation to the common carotid artery, like a modified Simmons catheter. Because the sheath guide positioned in the aortic arch made it possible to introduce safely the embolic protection device distal to the internal carotid artery stenosis without touching the plaque at the stenosis with no use of any coaxial catheters or guidewires, carotid artery stenting for tandem stenoses could be successfully carried out. The postoperative course was uneventful. In carotid artery stenting, especially for stenosis of the proximal common carotid artery, the sheath guide designed for transbrachial carotid cannulation was useful in stenting the tandem carotid stenoses.

Surgical removal of an arteriovenous malformation in the anterior perforated substance in a pregnant woman.

BACKGROUND: A tailor-made treatment is often required in arteriovenous malformations (AVMs) depending on the individual situation. In most cases, treatment strategy is usually determined according to the patient's Spetzler-Martin grade. However, in the present case, we were not able to treat the patient following the usual guidelines because of neurological symptoms and pregnancy. CASE DESCRIPTION: We describe a rare case of a 31-year-old woman in the 15th week of gestation who presented with an AVM in the anterior perforated substance (APS). She suffered a sudden coma and hemiplegia. A computed tomographic scan showed an enhanced mass and a huge hematoma in the basal ganglia and temporal lobe. The hematoma was successfully evacuated in an endoscopic procedure. Angiography showed that a 25-mm nidus in the APS was fed by the anterior choroidal arteries (AChAs) and the lenticulostriate arteries (LSAs). Therefore, we attempted to remove the nidus because the patient became alert with mild aphasia and hemiparesis 10 days after hemorrhage. The feeding arteries were cut under motor evoked potential (MEP) monitoring, and the nidus was totally resected leaving two of four AChAs and a single artery with several LSAs. The postoperative course was uneventful, and she gave birth to a healthy baby by caesarian delivery 122 days after the hemorrhage with only minor sequelae. CONCLUSIONS: Surgical strategy with a device-administered anesthesia are suitable for removing large AVMs even in pregnant women and for the successful outcome of their pregnancies. Even after recovering from a coma and hemiplegia, MEP monitoring is effective for removing large AVMs even when located in the APS.

Risk Factors of Contralateral Microembolic Infarctions Related to Carotid Artery Stenting.

This study sought to analyze the incidence of contralateral microembolic infarctions (MIs) on diffusion-weighted imaging (DWI) following protected carotid artery stenting (CAS) and compared the difference of risk factors between ipsilateral and contralateral lesions. From April 2010 to March 2017, 147 CASs in 140 patients were performed. All the patients underwent DWI within 1 week before and 24 hrs after the procedures. CAS was successfully completed in 145 (98.6%) of the 147 procedures. Forty-nine (33.8%) patients with new MIs revealed on postprocedural DWI were enrolled. They were divided into ipsilateral and contralateral groups based on the side of the CAS and MIs. The ipsilateral group indicates patients with MIs exclusively on the side of CAS. The contralateral group includes patients with MIs on the opposite side of the CAS or both sides. Patients with MIs at vertebrobasilar territory were excluded. Patient characteristics, morphology of the carotid artery and aortic arch, and procedural data were retrospectively assessed and compared between the two groups. Twenty-two (15.2%) and 14 (9.7%) patients were assigned to the ipsilateral and contralateral groups, respectively. Advanced age, left-sided stenosis, severe aortic arch calcification (AAC) on chest X-ray and contralateral carotid occlusion significantly increased the occurrence of contralateral MIs. On multivariable logistic regression analysis, severe AAC was statistically more frequent in the contralateral group. In the present study, the incidences of contralateral MIs after CAS is relatively not low. Advanced aortic atherosclerosis is statistically predictive for contralateral MIs. AAC on chest X-ray is a useful finding for estimating aortic atherosclerosis in candidates for CAS.

Clinical significance of thickened sphenoid sinus mucosa in Rathke's cleft cyst.

BACKGROUND: To determine the clinical significance of thickening of the sphenoid sinus mucosa (TSSM) in Rathke's cleft cyst (RCC). METHODS: We retrospectively reviewed patients with pituitary lesions. A total of 99 patients, who underwent surgery of pituitary lesions between 2008 and 2015, were analyzed to evaluate the clinical significance of TSSM using magnetic resonance imaging. The patients with TSSM were evaluated for their characteristics. RESULTS: Of the 99 operations, 15 patients with paranasal sinusitis, direct invasion to the sellar floor, and/or a history of transsphenoidal surgery were excluded. There were 51 pituitary adenomas (PAs), 18 RCCs, and 15 other tumors. TSSM was observed in 6 patients (7.1%). Pathologies included 3 RCCs (16.7%), 1 PA (2.0%), and 2 other lesions. Three RCCs were especially analyzed. The pituitary dysfunction was found in all 3 patients with TSSM, whereas that was noted in 2 of 15 patients (13.3%) without TSSM. The sensitivity was 60%, specificity was 86.7%, and the positive predictive value was 100%. There was no significant difference in the age, thickness of TSSM, symptoms, and squamous metaplasia between patients with and without TSSM. CONCLUSIONS: TSSM occurs more frequently in RCCs than in PAs. TSSM can potentially suggest hypopituitarism in RCCs. The surgical and/or endocrinological interventions are required for preventing further endocrine deterioration.

[A Case of Multiple Atherosclerotic Fusiform Cerebral Aneurysms with Repeated Subarachnoid Hemorrhage].

Pure fusiform aneurysms without dissection are considered to have a low risk of rupture. Furthermore, aneurysm wall with atherosclerotic change tends to be less susceptible to rupture. We present a rare case of multiple atherosclerotic fusiform aneurysms associated with repeated subarachnoid hemorrhage(SAH)during a 9-year observation period. A 34-year-old woman was admitted to our hospital because of SAH. SAH with a temporal hematoma due to a fusiform aneurysm of the right middle cerebral artery(MCA)was detected using computed tomography(CT). Associated fusiform aneurysms were observed in the left posterior cerebral artery(PCA)and the left MCA. The right MCA aneurysm was occluded with angioplastic clipping. Eight years after the first onset, angioplastic clipping was performed on the other two fusiform aneurysms because of their growth. Intraoperative findings showed atherosclerotic change in the parent artery wall, similar to the right MCA aneurysms. The right MCA aneurysm ruptured again 1 year later. The aneurysm was treated with proximal occlusion combined with a bypass from the occipital artery to the distal MCA. The patient was in a stable state, although, she was disabled because of SAH damage. The effects of atherosclerotic fusiform aneurysms, which are rarely encountered, are not well known. Some studies have reported the risk of hemorrhage from these aneurysms. This case suggests the necessity of long-term follow-up for the prediction of aneurysm growth and bleeding. Moreover, proximal occlusion combined with an external bypass is better for the treatment of this type of aneurysm because angioplastic clipping is not curative.

Steroid-resistant Tolosa-Hunt syndrome with a de novo intracavernous aneurysm: A case report.

BACKGROUND: We report a case of steroid-resistant Tolosa-Hunt syndrome (THS) with recurrent bilateral painful ophthalmoplegia, accompanied with sphenoid sinusitis, pituitary abscess, and an aneurysm arising from the cavernous portion of the internal carotid artery. CASE DESCRIPTION: A 53-year-old woman suffered severe left painful ophthalmoplegia. A magnetic resonance image (MRI) revealed thickness of the left cavernous sinus (CS). Steroid was administrated under the diagnosis of THS, and the symptom transiently diminished. However, painful ophthalmoplegia fluctuated bilaterally after tapering the steroid. An MRI showed development of bilateral cavernous lesions associated with sphenoid sinusitis, pituitary abscess, and an aneurysm in the left C4 segment. Biopsy and drainage of the lesions were performed with an endoscopic transsphenoidal procedure. The histological examination showed nonspecific granulomatous inflammation. The methotrexate (MTX) was effective to reduce the CS and pituitary lesions; however, the aneurysm slightly increased and remained unchanged in size thereafter. CONCLUSIONS: To our knowledge, this is the first report of a growing de novo C4 aneurysm in THS. Surgical intervention and administration of MTX should be attempted in steroid-resistant THS. Careful observation with serial MRI and MR angiography is important to manage the complicated THS.

Ruptured dermoid cyst of the lateral cavernous sinus wall with temporary symptoms: a case report.

BACKGROUND: Dermoid cysts are non-neoplastic tumors that arise from defects in the separation of the neuroectoderm. Cyst rupture rarely occurs spontaneously and the most common symptom is headache, followed by seizure. Although many cases of ruptured dermoid cysts present with symptoms, reports of cases that are asymptomatic, or where symptoms disappear, are rare. CASE PRESENTATION: We report the case of a 66-year-old Asian man with a history of sudden onset headache who was found to have high amounts of fat material in the subarachnoid space and a fat suppression mass in the left cavernous sinus. He underwent oral steroid therapy. Five days after starting medication his headache symptoms disappeared. Routine neurological imaging was then performed without surgical procedure. Magnetic resonance imaging revealed evidence of the remains of a static lesion 6 months after his first visit. He has remained headache free for 10 months since the initial event. CONCLUSIONS: Although cases of ruptured dermoid cysts presenting with consistent symptoms have been commonly reported, until now there were few reports on asymptomatic cases or cases where symptoms disappeared. We believe that surgical intervention is unnecessary for ruptured dermoid cysts with minimal symptoms.