Ulceration location is associated with clinical course in carotid stenosis.

OBJECTIVE: Plaque ulceration in carotid artery stenosis is a risk factor for cerebral ischemic events; however, the characteristics that determine plaque vulnerability are not fully understood. We thus assessed the association between plaque ulceration sites and cerebrovascular ischemic attack. METHODS: We retrospectively collected the clinical data of 72 consecutive patients diagnosed with carotid artery stenosis with plaque ulcers. After excluding patients with pseudo-occlusion, a history of previous carotid endarterectomy (CEA) or carotid artery stenting (CAS) before the ulcer was first discovered, follow-up data of less than 1 month, or CEA or CAS performed within 1 month after the ulcer was first discovered, 60 patients were ultimately included. Patients were divided into proximal and distal groups based on the ulcer location relative to the most stenotic point. The primary endpoints were ipsilateral cerebrovascular ischemic events ("ischemic events"), such as amaurosis fugax, transient ischemic attack, or ischemic stroke due to carotid artery stenosis with plaque ulceration. The association between ulcer location and ischemic events was also assessed. RESULTS: In the patients with plaque ulcer, more patients had proximal than distal plaque ulcers (39 vs. 21, p=0.028). The median follow-up duration was 3.8 (interquartile range: 1.5-6.2) years. Nineteen patients (32%) experienced ischemic event. Ischemic events occurred more frequently in the distal than in the proximal group (18% vs. 59%; p=0.005). Kaplan-Meier curves demonstrated a significantly shorter event-free time in the distal group (log-rank p=0.021). In univariate analysis, distal ulcer location was associated with ischemic events (odds ratio [OR]: 2.94, 95% confidence interval [CI]: 1.13-7.65, p=0.03). Multivariate analysis using two different models also showed that distal ulcer location was independently associated with ischemic events (Model 1, OR: 3.85, 95%CI: 1.26-11.78, p=0.03; Model 2, OR: 4.31, 95%CI: 1.49-12.49, p=0.009). CONCLUSIONS: Patients with carotid artery stenosis and plaque ulcers located distal to the most stenotic point are more likely to experience cerebrovascular ischemic attacks. Therefore, carotid plaques with ulcers located distal to the most stenotic point may be a potential indication for surgical treatment.

One-Stage Combined Open and Endovascular Treatment Using a Hybrid Operating Room is Safe and Effective for Distal Middle Cerebral Artery Aneurysms.

BACKGROUND: Aneurysms located in the distal middle cerebral artery (DMCA) are relatively rare and lack an established treatment strategy. For DMCA aneurysms, we performed a one-stage combined procedure of endovascular parent artery occlusion (PAO) with coils and superficial temporal artery to middle cerebral artery (STA-MCA) bypass in a hybrid operating room (HOR). The aim of this study was to evaluate the safety and efficacy of this procedure. METHODS: Cases of unruptured DMCA aneurysms treated with the one-stage combined PAO and STA-MCA bypass in HOR were retrospectively examined, and patients' and aneurysmal backgrounds, surgical procedures, and treatment outcomes were analyzed. RESULTS: Six patients were included in the study. The average maximum diameter of the aneurysms was 14.4 mm. One aneurysm was located at M2 and five at M3. All aneurysms had a fusiform shape. No cases were associated with infection, trauma, or malignant tumors. In all 6 cases, the combined PAO and STA-MCA bypass was successfully completed. No postoperative hemorrhagic complications occurred. A symptomatic ischemic complication occurred in 1 case whose symptom disappeared in a week. Three months after surgery, complete obliteration of the aneurysm and patency of the bypass was confirmed in all cases. CONCLUSIONS: The one-stage combined PAO and STA-MCA bypass in the HOR is safe and effective for DMCA aneurysms, potentially serving as a treatment option for this complex aneurysm.

A Review of Current Flow Diverters.

Flow diverter (FD) devices are new-generation stents placed in the parent artery at the aneurysmal neck to obstruct intra-aneurysmal blood flow, thus favoring intra-aneurysmal thrombosis. In Japan, about eight years have passed since health insurance approval was granted for FD devices, and FD placement to treat aneurysms has become widespread. Treatment indications have also been expanded with the introduction of novel devices. At present, three types of FD (Pipeline, FRED, and Surpass Streamline) are available in Japan. This report represents a compilation of available FD technologies and describes the current consensus on this treatment.

Pathological changes in the lenticulostriate artery indicate the mechanisms leading to intracranial hemorrhage in Moyamoya disease: a case report.

This case report details the pathological findings of a vessel wall identified as the bleeding point for intracranial hemorrhage associated with Moyamoya disease. A 29-year-old woman experienced intracranial hemorrhage unrelated to hyperperfusion following superficial temporal artery-middle cerebral artery bypass surgery. A pseudoaneurysm on the lenticulostriate artery (LSA) was identified as the causative vessel and subsequently excised. Examination of the excised pseudoaneurysm revealed a fragment of the LSA, with a disrupted internal elastic lamina and media degeneration. These pathological findings in a perforating artery, akin to the circle of Willis, provide insights into the underlying mechanisms of hemorrhage in Moyamoya disease.

Plaque Ulcerations are Associated with Recurrence in Symptomatic Low-Grade Carotid Stenosis.

OBJECTIVE: Surgical indications for low-grade carotid stenosis have not yet been established. This study aimed to clarify the characteristics of low-grade carotid stenosis refractory to medical treatment. METHODS: We retrospectively analyzed 48 patients with symptomatic low-grade carotid stenosis (<50%). Recurrence was defined as an ipsilateral ischemic event in the symptomatic lesions during the follow-up period. Patient demographics and imaging findings were compared between the recurrence and nonrecurrence groups to investigate risk factors associated with medical treatment. RESULTS: The mean age was 74.1 (58-90 years), and the mean follow-up period was 35.4 months (2.0-97 months). Recurrence occurred in 15 of the symptomatic patients. Ulceration was significantly associated with recurrence under medical treatment (P = 0.001). The median time to recurrence was 26.1 months in patients with ulcers and 54.3 months in those without ulcers (P = 0.04). Pathological study with recurrence showed plaque rupture with multilayered lesions, indicating lesions refractory to medical treatment. CONCLUSIONS: In cases of low-grade carotid stenosis, lesions with ulcerations are likely refractory to medical therapy. Consideration of the indications for surgical treatment may be warranted for lesions with ulceration, even if the degree of stenosis is low.

Irreversible postoperative cognitive impairment after unruptured intracranial aneurysm treatment in the elderly.

PURPOSE: Postoperative cognitive dysfunction and recovery remain unclear in older patients undergoing interventional therapies for unruptured intracranial aneurysms (UIAs). This study aimed to compare changes in postoperative cognitive function between younger and older patients and to detect factors associated with non-recovery from postoperative cognitive dysfunction. METHODS: This study reviewed 59 consecutive patients with UIAs who underwent interventional therapies, including microsurgical clipping or endovascular treatment, from 2021 to 2022. All patients were divided into the older (aged ≥ 70 years) and younger (aged < 70 years) groups. Mini-Mental State Examination (MMSE) and Frontal Assessment Battery (FAB) were performed within 2 months before interventions, at 1 week postoperatively (POW1), and 3-6 months postoperatively (POM3-6). RESULTS: MMSE and FAB scores decreased more frequently in the older group than in the younger group at POW1 (older vs. younger: MMSE: 48% vs. 21%, p < 0.05; FAB: 56% vs. 18%, p < 0.01). In the older group, the FAB Z-score decreased in POW1 and recovered by POM3-6 (p < 0.01), while the MMSE Z-score continued to decrease (p = 0.04). Age and the preoperative MSME Z-score were significantly associated with non-recovery from decreased MMSE score at POM3-6 (recovery vs. non-recovery, age: 62 years old vs. 72 years old, p = 0.03, preoperative MMSE Z-score: 0.16 vs. - 0.90, p < 0.01). CONCLUSIONS: This retrospective study found that older patients were more likely to have a postoperative cognitive decline after UIA treatment and implicated that global cognitive function tended to decline more than executive function in the long term. In addition, this study demonstrated that lower preoperative cognitive function was associated with inadequate postoperative cognitive recovery. The findings potentially contribute to the establishment of indications for treating UIAs in older patients.

Impact of tailored multimodal treatment for unruptured brain arteriovenous malformation: comparison with a randomized trial of unruptured brain arteriovenous malformations.

PURPOSE: The first randomized controlled study on unruptured brain arteriovenous malformations (bAVM), the ARUBA trial, demonstrate the superiority of medical management; however, it failed to completely rule out the efficacy of therapeutic interventions due to several limitations. This study aimed to examine the outcomes of multimodal interventional treatment for bAVM in terms of safety and efficacy. METHODS: We reviewed 226 consecutive patients with unruptured bAVM admitted to our institute between 2002 and 2022. Treatment methods were divided into medical management and therapeutic intervention, including microsurgery, stereotactic surgery, and endovascular intervention. First, the choice of therapeutic modalities was assessed in the pre-ARUBA (before February 2014) and post-ARUBA (after March 2014) eras. Second, the incidence of symptomatic stroke or death and functional prognosis with a modified Rankin scale (mRS) score of ≥2 at 5 years was compared between the medical management and therapeutic intervention. RESULTS: In the pre- and post-ARUBA groups, 73% and 84% of patients underwent therapeutic interventions, respectively (p = 0.053). The rate of symptomatic stroke or death was lower in patients who underwent interventional therapies than in those who underwent medical management (9.7% vs. 22%, p = 0.022); however, the opposite was observed in the ARUBA trial (31% vs. 10%). The annual incidence of stroke or death was also lower in the interventional therapy group (4.3%/y vs. 1.8%/year, hazard ratio = 0.45, 95% confidence interval: 0.18-1.08, p = 0.032). The rate of mRS score of ≥2 after a 5-year follow-up was 18% and 6% in the medical treatment and intervention groups (p = 0.14). CONCLUSIONS: The therapeutic intervention rate did not decrease, even after the publication of the ARUBA trial. The rate of stroke or death was lower in the intervention group, indicating that a tailored choice of multimodality is safe and effective for managing unruptured bAVM.

[Changes in Gamma Knife Radiosurgery(GKRS)in Patients with Metastatic Brain Tumors before and after COVID-19].

The spread of coronavirus disease 2019(COVID-19)is a concern as it may delay the detection of malignant tumors due to delayed medical checkups. We examined changes in the treatment of metastatic brain tumors before and after COVID- 19. A retrospective review of 211 patients with metastatic brain tumors who underwent initial gamma knife radiosurgery between July 2019 and December 2021 was conducted. Data collected include patient age, gender, the Karnofsky performance status(KPS), primary tumor control, number, total volume, and outcome during the COVID-19 emergency declaration period and outside of it. The patient number was 164 outside of the emergency period and 47 during the period. Symptomatic cases(KPS<90)and poor control of the primary site increased during the COVID-19 period. The treatment number and volume of brain metastasis did not change. Metastatic control after 4 months of treatment also showed no difference. The number of symptomatic patients increased during the emergency declaration period, suggesting that COVID- 19 may have reduced the rate of asymptomatic patients being seen. However, these were not enough to affect the prognosis at 4 months. Overall, the COVID-19 pandemic had a small impact on the provision of stereotactic radiotherapy for metastatic brain tumors.

Impact of Morphological Factors on the Future Growth of Unruptured Posterior Communicating Artery Aneurysms.

BACKGROUND: No previous study has established the factors associated with intracranial aneurysm growth using imaging data obtained before the appearance of morphological changes. Therefore, we investigated the factors related to future aneurysm growth in posterior communicating artery (Pcom) aneurysms. METHODS: Using a longitudinal database of intracranial aneurysm cases, we reviewed the findings for consecutive patients with unruptured Pcom aneurysms admitted to our institute from 2012 to 2021. Magnetic resonance images obtained over time were used to evaluate aneurysm growth. Aneurysms showing growth over time (group G) and unchanged aneurysms (group U) were compared in terms of background data and morphological factors. RESULTS: 93 Pcom aneurysms (group G: 25 aneurysms, 25%; group U: 68 aneurysms, 75%) were eligible for the present study. Six aneurysm rupture events occurred in group G (24%). Among morphological factors, Pcom diameter (1.2 ± 0.3 mm vs. 0.8 ± 0.7 mm, P < 0.01), bleb formation (group G: 39% vs. group U: 10%; odds ratio, 5.6; P = 0.01), and the lateral projection of the dome (group G: 52% vs. group U: 13%; odds ratio, 3.2; P = 0.023) were significantly different between the 2 groups. The sensitivity and specificity of a cutoff Pcom diameter of 0.73 mm for predicting enlargement were 96% and 53%, respectively. CONCLUSIONS: Pcom diameter, bleb formation, and lateral dome projection were associated with growth of Pcom aneurysms. Aneurysms with these risk factors require careful follow-up imaging, which may facilitate early detection of aneurysm growth and prevention of rupture through therapeutic interventions.

Aspect Ratio Is Associated with Recanalization after Coiling of Unruptured Intracranial Aneurysms.

The rate of recanalization after coil embolization for unruptured intracranial aneurysms (UIAs) is reported to occur around 11.3%-49%. This study aims to investigate the factors that influence the recanalization after coil embolization for UIAs in our institution. We retrospectively investigated 307 UIAs in 296 patients treated at our institution between April 2004 and December 2016. The stent-used cases were excluded. Cerebral angiography and 3D time-of-flight magnetic resonance angiography (TOF MRA) were used for evaluation of the postoperative occlusion status. Volume embolization ratio (VER), aneurysmal size, neck width, and aspect ratio (AR) were compared between the recanalized and non-recanalized groups. The mean follow-up period ranged from 6 to 172 months (mean: 79.0 ± 39.8 months). Recanalization was noted in 78 (25.4%) aneurysms, and 19 (6.2%) aneurysms required retreatment. There was no aneurysmal rupture during the follow-up period. Univariate analysis showed that the aneurysm size (p < 0.001), neck width (p < 0.001), AR (p = 0.003), and VER (p = 0.012) were associated with recanalization. Multivariate logistic regression analysis showed that the AR (p =0.004) and VER (p =0.015) were significant predictors of recanalization. To summarize, a higher AR and a lower VER could lead to recanalization after coil embolization of UIAs. Careful follow-up is required for coiled aneurysms with these features.

A Case of Direct Carotid-Cavernous Fistulae Successfully Treated by Bidirectional Double Catheter Technique: A Technical Note.

Objective: Ruptured carotid-cavernous aneurysms (CCAs) are known to result in direct carotid-cavernous fistula (CCF). Although endovascular treatment is recognized as the first-line treatment for direct CCF, obliteration is sometimes difficult because of the high-flow shunt. In this report, we present a case of a direct CCF treated by the combination of transarterial and transvenous approaches. Case Presentation: A 57-year-old woman presented with conjunctival chemosis, exophthalmos, and tinnitus. Ophthalmological examination revealed increased intraocular pressure. DSA demonstrated a direct CCF due to a right ruptured CCA with retrograde shunted flow through the superior ophthalmic vein (SOV), superficial middle cerebral vein, basal vein of Rosenthal, and middle temporal vein. Two microcatheters were guided into the shunt segment from the internal carotid artery and SOV. In addition, a balloon catheter was placed at the neck of the aneurysm to assist coiling. Coil embolization for the CCF was performed using two microcatheters in the opposite direction, which enabled compact and tight packing of the shunt segment with only six coils. The CCF was eliminated. Two-year-follow-up MRA revealed no recurrence. Conclusion: The bidirectional double catheter technique is a useful approach to obliterate a shunt in a short segment with minimal coils.

Impact on Clinical Outcomes of Changes in the Practice of Mechanical Thrombectomy due to the COVID-19 Pandemic.

Objective: To evaluate whether changes in the practice of mechanical thrombectomy could affect the clinical outcomes during the coronavirus disease (COVID-19) pandemic. Methods: Patients who underwent mechanical thrombectomy from April 2019 to March 2021 for anterior circulation proximal large artery occlusion in our institute were divided into two groups of pre- and post-COVID-19, with April 2020 assumed to be the start of the COVID-19 era with the first declaration of a state of emergency. We compared patient characteristics, proportions of patient selection depending on rapid processing of perfusion and diffusion (RAPID) CT perfusion, outcomes including treatment variables such as time and reperfusion status, and patient independence at 3 months. Results: Data for 112 patients (median age, 79 years; 44 females) were included in the analysis. A total of 50 patients were assigned to the pre-COVID-19 group (45%). More patients were selected with RAPID CT perfusion in the post-COVID-19 compared with the pre-COVID-19 (69% vs. 16%; P <0.001). Treatment details and clinical outcomes did not differ between the groups, including the door-to-puncture time (median [interquartile range], 66 [54-90] min vs. 74 [61-89] min; P = 0.15), proportions of significant reperfusion (82% vs. 87%; P = 0.60), and modified Rankin scale score of ≤2 at 3 months (46% vs. 45%; P >0.99). Multivariate logistic regression analysis for the clinical outcome of modified Rankin scale score of ≤2 at 3 months was performed and included the following factors: age, sex, the onset-to-door time, significant reperfusion, and pre- and post-COVID-19. The treatment period did not influence the outcomes (post-COVID-19 group, odds ratio, 0.79; 95% confidence interval, 0.34-1.85, P = 0.59). Conclusion: In the setting of a limited access to emergency MRI during the COVID-19 pandemic, RAPID CT perfusion was performed significantly more often. Changes in the practice of mechanical thrombectomy with the protected code stroke did not bring the different level of treatment and clinical outcomes as before.

Coiling for Ruptured Aneurysms in the Vasospasm Period: Safety and Efficacy Based on a Propensity Score Analysis.

Objective: To evaluate the efficacy and safety of interventional radiology (IVR) for aneurysmal subarachnoid hemorrhage (SAH) later than 3 days after onset. Methods: A total of 71 patients between 2012 and 2017 who underwent endovascular coiling were divided into two groups according to the timing of treatment: Group E (treated within 3 days after onset) and group D (treated between 4 and 14 days after onset), and the outcomes between two groups were compared. A case-matched study was conducted to minimize the selection bias lying in this cohort. Results: There were 56 (78.9%) and 15 (21.1%) patients in groups E and D, respectively. In group D, all patients arrived at the hospital later than 3 days after onset. The rates of patients with WFNS grade 1, 2, 3 and the presence of vasospasm upon the access route to the targeted aneurysm at the time of IVR were significantly higher in group D than in group E (93.3% vs 60.7%; p = 0.027, 33.3% vs 3.6%; p = 0.0037, respectively). There were no significant differences in the rate of intraprocedural complications, symptomatic vasospasm, delayed cerebral infarction due to vasospasm, retreatment, or modified Rankin Scale (mRS) at discharge. After propensity score matching, there were no significant differences in the outcomes between two groups. Conclusion: Prompt coiling for patients with ruptured aneurysms who arrived later than 3 days after onset can be safely performed, even if they had vasospasm upon the access route.

Outcome of Endovascular Therapy Aiming for Single-session Obliteration of Intracranial Dural Arteriovenous Fistulas.

The goal of dural arteriovenous fistula (dAVF) treatment is obliteration of the arteriovenous shunt and/or retrograde leptomeningeal venous drainage (RLVD). Single-session obliteration could improve symptoms early and reduce risk of neurological sequelae. This study investigated the efficacy and adverse events of endovascular therapy (EVT) aiming for single-session obliteration in dAVF treatment. We retrospectively examined post-treatment arteriovenous shunt status, number of treatments per case, treatment-related complications, and long-term outcome in 92 dAVF patients who underwent initial EVT at our institution. Single-session obliteration was intended in all cases, but a second session was performed in cases of partial shunt occlusion or remaining RLVD. Complete occlusion was achieved in 85 cases (92.4%) after the single session; RLVD was obliterated in 66 of the 67 Borden type II and III cases combined (98.5%). A second session was necessary in seven cases (7.6%). Complete shunt obliteration was eventually achieved in all cases. The average number of treatments was 1.08 per case. dAVF-related stroke and mortality did not occur after the treatment. On the other hand, radiation-induced skin erythema and alopecia, although all symptoms were transient, occurred in 26 cases (28.3%). Over an average 60.2-month follow-up period, recurrence was observed in seven cases (7.6%). Single-session obliteration was successful in 92% of cases. Especially, single-session obliteration of RLVD may contribute to early prevent of future stroke events. However, reducing total radiation dose during each session is an issue of further study.

Hyperperfusion Syndrome Detected by 15O-Gas Positron Emission Tomography after Clipping of a Large Unruptured Internal Carotid Artery Aneurysm: A Case Report.

Cerebral hyperperfusion syndrome (CHS) after surgical clipping for cerebral aneurysm is a rare entity. The authors present a 76-year-old woman with a large left internal carotid-posterior communicating artery aneurysm. After successful clipping with temporary occlusion of the internal carotid artery, the patient exhibited motor aphasia. 15O-gas positron emission tomography (PET) showed extreme elevation of the regional cerebral blood flow (rCBF) along with a mildly decreased regional cerebral metabolic rate for oxygen (rCMRO2) and a remarkable decrease in the oxygen extraction fraction (OEF) in the territory of the ipsilateral superior trunk of the middle cerebral artery. These data indicated local hyperperfusion. She had fully recovered from the aphasia by postoperative day (POD) 18. PET showed normalization of CBF on POD 27. To our knowledge, this is the first case report to show hyperperfusion syndrome, clearly detected by 15O-gas PET, after aneurysmal neck clipping.

Postprandial cerebral infarction resolved by extracranial-intracranial bypass surgery.

A 51-year-old man with type 2 diabetes mellitus was admitted with a 2-month history of repeated episodes of transient aphasia and right hemiparesis after food intake. His blood pressure (BP) fell when the neurological deficits developed. The fall in BP after each meal was confirmed by 24-h ambulatory blood pressure monitoring (ABPM), which established the diagnosis of postprandial hypotension (PPH). Diffusion-weighted magnetic resonance imaging of the brain showed multiple high-intensity lesions at the borderzone between the anterior and middle cerebral artery (MCA) territories in the left hemisphere. Digital subtraction angiography showed tapered occlusion at the origin of the left internal carotid artery (ICA). Despite sufficient antiplatelet therapy and medication for PPH, the transient symptoms remained. Positron emission tomography scanning using H2 15O showed decreased cerebral blood flow with increased oxygen extraction fraction in the left MCA territory. As the symptomatic left ICA occlusion was intractable, an extracranial-intracranial (EC-IC) bypass surgery was conducted without any perioperative complications. Although PPH remained, cerebrovascular ischemic events including repeated transient ischemic attack disappeared for 2 months after surgery. The coincidence of stroke with ABPM-proved transient hypotension suggested that the brain infarcts were caused by hemodynamic changes related to PPH co-existent with the chronic left ICA occlusion. ABPM is useful in evaluating hemodynamic infarcts associated with BP fluctuation, and should be considered for patients with chronic ICA occlusion. In addition, EC-IC bypass may be a treatment option for symptomatic chronic ICA occlusion due to PPH.

Intracranial arterial stenosis associated with Hashimoto's disease: angiographic features and clinical outcomes.

BACKGROUND: Hashimoto's disease has reportedly been associated with stroke; however, cerebrovascular morphology and clinical course remain poorly documented. The present study aimed to determine the angiographic features and clinical outcomes of intracranial arterial stenosis (IAS) associated with Hashimoto's disease in a retrospective cohort. METHODS: Overall, 107 adult patients with IAS were screened for anti-thyroid antibodies; of these, 26 patients tested positive. The 42 affected hemispheres were classified into subgroups according to the steno-occlusion site and the development of abnormal collateral (moyamoya) vessels. These subgroups were dichotomized into moyamoya vessels positive (MM type) and negative (non-MM type). The initial presentation, IAS progression, and vascular events during the follow-up period were compared. RESULTS: The following sites of stenosis were identified: the bifurcation of the internal carotid artery in 11 (26.2%), M1 or A1 in 29 (69.0%), and more distal (M2-M4/A2-A4) in 2 (4.8%) hemispheres. Further, 17 hemispheres were categorized into the MM type and 25 were classified into the non-MM type. During the follow-up period (mean 2.5 years), IAS progression was identified in 8 (32%) hemispheres of the non-MM type and 0 (0%) hemispheres of the MM type (p = 0.041). Ischemic attacks occurred in 5 (20.0%) hemispheres of the non-MM type (4.6%/year) and 0 hemispheres of the MM type (p = 0.08). Further, 4 (23.5%) hemispheres of the MM type experienced intracerebral hemorrhage, whereas none of the non-MM type hemorrhaged (p = 0.012). CONCLUSIONS: Hashimoto's disease-associated IAS exhibits various angiographic morphologies, resulting in different clinical presentations. Screening for anti-thyroid antibodies and careful management based on vascular morphology appears important in adults with IAS.