Intramedullary feeder aneurysm of a cervical epidural arteriovenous fistula causing myelopathy: a case report and literature review.

While a craniocervical junction (CCJ) epidural arteriovenous fistula (EDAVF) may present with hemorrhagic myelopathy from an associated feeder aneurysm on rare occasions, non-hemorrhagic myelopathy from such an aneurysm remains unreported. A woman in her late sixties presented with cervical myelopathy due to a non-hemorrhagic intramedullary aneurysm associated with CCJ-EDAVF. The intramedullary aneurysm originated from the spinal pial artery supplied by the anterior spinal artery. Direct surgical fistula coagulation and feeder obliteration resulted in the disappearance of the aneurysm and myelopathy improvement. This report illustrates the first case of a non-hemorrhagic intramedullary aneurysm associated with CCJ-EDAVF successfully treated with direct surgery.

A rare adult case of asymptomatic double aortic arch accompanied by the right vertebral artery directly originating from the aortic arch.

INTRODUCTION: A double aortic arch (DAA) is a rare congenital vascular anomaly. No case of DAA with a direct aortic origin of the right vertebral artery (VA) has been reported in adults. Here, we report a rare case of an asymptomatic DAA accompanied by the right VA directly originating from the right aortic arch in an adult. CASE PRESENTATION: A DAA and right VA directly originating from the right aortic arch were identified in a 63-year-old man using digital subtraction angiography and computed tomography angiography. The patient underwent digital subtraction angiography for evaluation of an unruptured cerebral aneurysm. Intraprocedural selection of vessels branching from the aorta with the catheter was difficult. To confirm the bifurcation of the aorta, aortography was performed, which revealed a DAA. Following digital subtraction angiography, computed tomography angiography was performed, which showed that the right VA originated directly from the right aortic arch. The trachea and esophagus were located in the vascular ring of the DAA; however, they were not compressed by the aorta. This was consistent with the lack of symptoms related to the DAA. CONCLUSIONS: This is the first adult case of an asymptomatic DAA with an unusual origin of the VA. A rare asymptomatic vascular anomaly, such as a DAA, can be incidentally identified using angiography.

Ruptured saccular aneurysm of the lenticulostriate artery embolized without parent artery occlusion in a case of moyamoya disease.

In cases of moyamoya disease, an aneurysm of the lenticulostriate artery (LSA) is a rare finding. Preventive management of rebleeding from a ruptured aneurysm of the LSA is important to avoid poor outcomes. Endovascular embolization of a ruptured LSA aneurysm with parent artery occlusion has been reported in previous cases of moyamoya disease; however, to the best of our knowledge, a ruptured aneurysm treated only with coil embolization has not been described. A 42-year-old woman presented with sudden onset of dysarthria and right hemiparesis. Putaminal hemorrhage from a ruptured aneurysm in the left LSA was detected. Angiographically, moyamoya vessels were revealed. The aneurysm in the left LSA was saccular type and seemed to be related to moyamoya disease. As the aneurysm was successfully approached with a microcatheter, coil embolization without parent artery occlusion was performed. Rebleeding from the embolized aneurysm in the LSA did not occur. This is the first report of a ruptured LSA aneurysm embolized using coils through a flow-guiding microcatheter without parent artery occlusion in a case of moyamoya disease.

Cavernous sinus dural arteriovenous fistula embolized via a rare anastomosis between the facial vein and the superficial temporal vein.

A cavernous sinus dural arteriovenous fistula (CSdAVF) is an abnormal communication between the dural branches of the internal and external carotid arteries and the cavernous sinus. Transvenous embolization is the first choice to resolve CSdAVFs, and various venous access routes have been reported. However, transvenous embolization of a CSdAVF through a rare venous anastomosis between the facial and superficial temporal veins using a quadruple coaxial catheter system is scarce in the literature. A 30-year-old woman presented with a typical triad of CSdAVF that was supplied by the inferolateral and meningohypophyseal trunks and several dural branches of the external carotid artery. CSdAVF was solely draining through the right superior ophthalmic vein to the bilateral facial veins. The right facial vein had a rare anastomosis, with the superficial temporal vein terminating in the external jugular vein. Transvenous targeted embolization of CSdAVF was performed through the right superior ophthalmic vein. The rare anastomosis between the right superficial temporal vein and the right facial vein was used as the access route for CSdAVF. The quadruple coaxial catheter system was effective in overcoming the long and tortuous access route and stabilizing the movement of the microcatheter for target embolization. CSdAVF was successfully embolized with microcoils. This is the first report of a CSdAVF embolized via a rare anastomosis between the facial vein and the superficial temporal vein. A quadruple coaxial catheter system can overcome this unusual access route.

Rare anastomosis between the bilateral internal carotid arteries via the recurrent arteries branching from the first segment of the ophthalmic artery.

Although anastomoses between the arterial branches arising from the internal carotid artery (ICA) can develop as collateral pathways between the bilateral ICAs in cases of dysgenesis of the ICA, anastomosis of the recurrent arteries branching from the first segment of the ophthalmic artery (OphA) has not been described. Herein, we report two cases of this rare anastomosis. In a 36-year-old man with left segmental dysgenesis of the ICA, an anastomosis between the bilateral ICAs developed around the sella turcica. In a 39-year-old woman with dysgenesis of the bilateral distal ICAs, an anastomosis between the superior hypophyseal trunk and bilateral ICAs was identified. The anastomoses in both cases were also supplied by recurrent arteries branching from the first segment of the OphAs. This is the first report describing recurrent arteries from the OphAs that form the anastomosis between bilateral ICAs.

Clopidogrel response predicts thromboembolic events associated with coil embolization of unruptured intracranial aneurysms: A prospective cohort study.

OBJECTIVE: Periprocedural thromboembolic events are a serious complication associated with coil embolization of unruptured intracranial aneurysms. However, no established clinical rule for predicting thromboembolic events exists. This study aimed to clarify the significance of adding preoperative clopidogrel response value to clinical factors when predicting the occurrence of thromboembolic events during/after coil embolization and to develop a nomogram for thromboembolic event prediction. METHODS: In this prospective, single-center, cohort study, we included 345 patients undergoing elective coil embolization for unruptured intracranial aneurysm. Thromboembolic event was defined as the occurrence of intra-procedural thrombus formation and postprocedural symptomatic cerebral infarction within 7 days. We evaluated preoperative clopidogrel response and patients' clinical information. We developed a patient-clinical-information model for thromboembolic event using multivariate analysis and compared its efficiency with that of patient-clinical-information plus preoperative clopidogrel response model. The predictive performances of the two models were assessed using area under the receiver-operating characteristic curve (AUC-ROC) with bootstrap method and compared using net reclassification improvement (NRI) and integrated discrimination improvement (IDI). RESULTS: Twenty-eight patients experienced thromboembolic events. The clinical model included age, aneurysm location, aneurysm dome and neck size, and treatment technique. AUC-ROC for the clinical model improved from 0.707 to 0.779 after adding the clopidogrel response value. Significant intergroup differences were noted in NRI (0.617, 95% CI: 0.247-0.987, p < .001) and IDI (0.068, 95% CI: 0.021-0.116, p = .005). CONCLUSIONS: Evaluation of preoperative clopidogrel response in addition to clinical variables improves the prediction accuracy of thromboembolic event occurrence during/after coil embolization of unruptured intracranial aneurysm.

Factors associated with the new appearance of cerebral microbleeds after endovascular treatment for unruptured intracranial aneurysms.

PURPOSE: Endovascular treatment of unruptured intracranial aneurysms may increase cerebral microbleeds (CMBs) in postprocedural T2*-weighted MRIs, which may be a risk for future intracerebral hemorrhage. This study examined the characteristics of postprocedural CMBs and the factors that cause their increase. METHODS: The patients who underwent endovascular treatment for unruptured intracranial aneurysms from April 2016 to February 2018 were retrospectively analyzed. Treatment techniques for endovascular treatment included simple coiling, balloon-assisted coiling, stent-assisted coiling, or flow diverter placement. To evaluate the increase in CMBs, a head MRI including diffusion-weighted imaging and T2*-weighted MRIs was performed on the preprocedural day; the first postprocedural day; and at 1, 3, and 6 months after the procedure. RESULTS: Among the 101 aneurysms that were analyzed, 38 (37.6%) showed the appearance of new CMBs. In the multivariate analysis examining the causes of the CMB increases, chronic kidney disease, a higher number of preprocedural CMBs, and a higher number of diffusion-weighted imaging-positive lesions on the first postprocedural day were independent risk factors. Furthermore, a greater portion of the increased CMBs was found in cortical and subcortical lesions of the treated vascular perfusion area within 1 month after the procedure. CONCLUSION: In endovascular treatment for unruptured intracranial aneurysms, CMBs tended to increase in patients with small vessel disease before the procedure, and it was also implicated in hemorrhagic changes after periprocedural microinfarction.

Symptomatic Cavernous Internal Carotid Artery Aneurysm Complicated by Simultaneous Rapid Growth of the Intra-aneurysmal and Parent Artery Thromboses.

Cavernous internal carotid artery (ICA) aneurysm complicated by simultaneous and spontaneous formation of thromboses in the aneurysm and the parent artery is a rare clinical condition. Although the majority of patients have good outcomes, some patients experience severe ischemic stroke. Here, we report a case of symptomatic large cavernous ICA aneurysm complicated by rapid growth of an intra-aneurysmal thrombosis with simultaneous parent artery thrombosis. A 68-year-old female presented with sudden-onset diplopia, right ptosis, right conjunctival hyperemia, and paresthesia of the right face. Magnetic resonance imaging (MRI) and digital subtract angiography (DSA) revealed the presence of a large partially thrombosed aneurysm in the cavernous portion of the right ICA. We planned endovascular embolization using a flow-diverting (FD) stent. Dual-antiplatelet therapy (DAPT) with aspirin and clopidogrel was started 2 weeks prior to treatment. Although the neurological state was stable, DSA conducted on the day of the endovascular treatment showed rapid growth of an intra-aneurysmal thrombosis and de novo thrombosis in the parent artery. Direct aspiration was performed via a distal support catheter with proximal blood flow arrest using a balloon-guide catheter, and the FD stent was successfully deployed. The patient's symptoms improved postoperatively and DSA obtained 12 months after the procedure confirmed complete occlusion of the aneurysm. Although the exact mechanism of simultaneous thrombosis formation of the aneurysm and its parent artery remains unclear, it is important to recognize that rapid growth of the thrombosis increases the risk of ischemic stroke.

Treatment of Aneurysms in Persistent Primitive Trigeminal Arteries with Stent-Assisted Coil Embolization.

Objective: Persistent primitive trigeminal artery (PPTA) is a rare condition in which a fetal carotid-basilar anastomosis persists into adulthood. PPTA aneurysms often necessitate endovascular treatment and adjunctive techniques, such as stent- or balloon-assisted techniques, are sometimes selected. This case report describes two women in their sixties with unruptured right PPTA aneurysms who underwent stent-assisted coil embolization procedures, with consideration of the anatomical features in each case. Case Presentations: One patient presented with an aneurysm at the bifurcation of the PPTA and the basilar artery (BA), which was classified as Saltzman type 1 with a hypoplastic vertebral artery (VA)-BA system. A stent was deployed from the BA to the PPTA to cover the neck of the aneurysm and coil embolization was performed. The second patient presented with an aneurysm at the bifurcation of the PPTA and the internal carotid artery (ICA), which was classified as Saltzman type 2 with a hypoplastic VA-BA system. A stent was deployed from the PPTA to the petrous segment of the ICA covering the neck of the aneurysm and coil embolization was performed. In both patients, the 1-year follow-up digital subtraction angiography (DSA) showed that the aneurysms had not recurred. Conclusion: The PPTA aneurysms were successfully treated with stent-assisted coil embolization. The treatment strategy should be devised in accordance with both the lesion site and the PPTA variant.

Intracranial Subdural Abscess Caused by Actinomyces meyeri Related to Dental Treatment: A Case Report.

Intracranial subdural abscess is a rare condition. Although brain abscess is often reported in relation to dental infection, reports of intracranial subdural abscess are few. Actinomyces spp. forms part of the normal flora of the oral, gastrointestinal, and genital tract, and is rarely the cause of intracranial infection; moreover, the pathogen Actinomyces meyeri is very rare. We report an exceptional case of intracranial subdural abscess caused by A. meyeri and related to dental treatment. A 57-year-old woman initially presented with a 5-day history of headache. Because left arm numbness and weakness became apparent, she was admitted to our department. She had a history of hypertension and dental problems requiring tooth extractions. Diffusion-weighted imaging (DWI) showed a 1-cm right convexity hyperintense mass above the postcentral gyrus. A post-gadolinium T1-weighted image showed a thin hypointense area with peripheral rim enhancement in the right subdural space that appeared to partially thicken in the same location as the DWI-positive mass. She underwent emergent navigation-guided drainage and 4 mL of pus was obtained. Postoperatively, left arm numbness and weakness disappeared. Cultures showed growth of A. meyeri and Fusobacterium nucleatum. She was started on intravenous penicillin G and metronidazole. After a 4-week course of the intravenous antibiotics, her headache gradually improved and the abscess in the subdural space subsided. To our best knowledge this is the first case report of intracranial subdural abscess caused by A. meyeri associated with dental treatment.

Long-term Outcomes After Intraprocedural Aneurysm Rupture During Coil Embolization of Unruptured Intracranial Aneurysms.

BACKGROUND: The long-term outcomes of patients with intraprocedural aneurysm rupture (IPR) during endovascular coiling of unruptured intracranial aneurysms (UIAs) remain unclear. We investigated the long-term outcomes and predictors of neurological outcomes in patients who sustained IPR during coil embolization of UIAs. METHODS: We retrospectively analyzed the medical record of 312 untreated UIAs in 284 patients who underwent endovascular coiling between April 2013 and July 2018. RESULTS: The mean follow-up period for the entire cohort was 25.6 months. Twelve patients (3.8%) experienced IPR. The mean aneurysm size in the IPR cohort was significantly smaller than that in the no-IPR cohort (P = 0.045). The IPR cohort had a higher percentage of earlier subarachnoid hemorrhage from another aneurysm (P = 0.019), anterior communicating artery (AComA) aneurysm (P < 0.001), and basilar artery (BA) aneurysm (P = 0.022) than the no-IPR cohort. Neurologic deterioration was observed in 3 patients. The morbidity and mortality rates of the IPR cohort were 25% and 8.3%, respectively. Patients with IPR during coil embolization for AComA aneurysm did not develop neurological deterioration. Two of the 3 patients (66.7%) with a BA aneurysm had neurological deterioration. The proportion of patients with an mRS score of 0-2 at the last follow-up did not differ between the 2 cohorts (P = 0.608). CONCLUSIONS: The proportion of functionally independent patients did not differ between patients with and without IPR. Patients with BA aneurysms who developed an IPR tended to exhibit more unfavorable clinical courses than patients with AcomA aneurysms.

A Visual Task Management Application for Acute Ischemic Stroke Care.

Background: To maximize the effect of intravenous (IV) thrombolysis and/or endovascular therapy (EVT) for acute ischemic stroke (AIS), stroke centers need to establish a parallel workflow on the basis of a code stroke (CS) protocol. At Kokura Memorial Hospital (KMH), we implemented a CS system in January 2014; however, the process of information sharing within the team has occasionally been burdensome. Objective: To solve this problem using information communication technology (ICT), we developed a novel application for smart devices, named "Task Calc. Stroke" (TCS), and aimed to investigate the impact of TCS on AIS care. Methods: TCS can visualize the real-time progress of crucial tasks for AIS on a dashboard by changing color indicators. From August 2015 to March 2017, we installed TCS at KMH and recommended its use during normal business hours (NBH). We compared the door-to-computed tomography time, the door-to-complete blood count (door-to-CBC) time, the door-to-needle for IV thrombolysis time, and the door-to-puncture for EVT time among three treatment groups, one using TCS ("TCS-based CS"), one not using TCS ("phone-based CS"), and one not based on CS ("non-CS"). A questionnaire survey regarding communication problems was conducted among the CS teams at 3 months after the implementation of TCS. Results: During the study period, 74 patients with AIS were transported to KMH within 4.5 h from onset during NBH, and 53 were treated using a CS approach (phone-based CS: 26, TSC-based CS: 27). The door-to-CBC time was significantly reduced in the TCS-based CS group compared to the phone-based CS group, from 31 to 19 min (p = 0.043). Other processing times were also reduced, albeit not significantly. The rate of IV thrombosis was higher in the TCS-based CS group (78% vs. 46%, p = 0.037). The questionnaire was correctly filled in by 34/38 (89%) respondents, and 82% of the respondents felt a reduction in communication burden by using the TCS application. Conclusions: TCS is a novel approach that uses ICT to support information sharing in a parallel CS workflow in AIS care. It shortens the processing times of critical tasks and lessens the communication burden among team members.

Thrombosis of Large Aneurysm Induced by Flow-Diverter Stent and Dissolved by Direct Factor Xa Inhibitor.

BACKGROUND: Antiplatelet agents are typically administered before and after treatment using flow-diverter stents (FDS) to prevent thrombotic complications, but the effects of anticoagulants are unclear. We present a patient with a giant aneurysm treated with an FDS. The thrombus within the aneurysm was dissolved when a direct factor Xa inhibitor was administered to treat lower limb venous thrombosis that occurred secondary to steroid use. CASE DESCRIPTION: A 60-year-old woman with a 30-mm giant thrombosed aneurysm in the cavernous segment of the right internal carotid artery presenting with headache and right abducens nerve palsy was treated by placing an FDS. Diplopia and increased pain in her right eye appeared on postoperative day 7, and both were alleviated by continuous oral administration of prednisolone. Angiography 3 months postoperatively revealed that the aneurysm thrombosis had progressed, and there were signs of healing. However, at the same time, lower limb venous thrombosis occurred, which was treated by continuous edoxaban. Six months after surgery, her headaches worsened and angiography showed that the aneurysm was again contrast enhanced and that the thrombus within the aneurysm had dissolved. After discontinuing edoxaban 9 months after surgery, the aneurysmal thrombosis had again rapidly progressed. CONCLUSIONS: Administration of a direct factor Xa inhibitor during healing after placing an FDS may cause dissolution of an existing thrombus; therefore factor Xa inhibitors must be used with caution.

Factors Associated with Postprocedural Diffusion-Weighted Imaging-Positive Lesions in Endovascular Treatment for Unruptured Cerebral Aneurysms.

BACKGROUND: In endovascular treatment for cerebral aneurysms, the appearance of asymptomatic thromboembolic lesions detected by postprocedural diffusion-weighted imaging (DWI) can be a surrogate marker for estimating the potential risk of symptomatic thromboembolism. The aim of this study was to clarify factors associated with postprocedural DWI-positive lesions in endovascular treatment for unruptured cerebral aneurysms. METHODS: Patients with untreated unruptured cerebral aneurysms undergoing endovascular treatment were consecutively enrolled. Treatment techniques were classified into simple coiling, balloon-assisted coiling, stent-assisted coiling, and flow-diverter placement. Head magnetic resonance imaging was performed within 3 months before and 24 hours after the procedure to assess the appearance of DWI-positive lesions. RESULTS: Among 376 aneurysms in 355 patients that were analyzed, 232 (61.7%) had postprocedural DWI-positive lesions. In univariate analyses, age (P = 0.001), dome size (P < 0.001), neck size (P < 0.001), treatment technique (P = 0.029), and total procedural time (P < 0.001) were significantly associated with postprocedural DWI-positive lesions. In the multiple logistic regression model, older age (odds ratio, 1.33; 95% confidence interval, 1.10-1.60; P = 0.003; per decade), flow-diverter placement (odds ratio, 4.93; 95% confidence interval, 1.33-20.92; P = 0.016; compared with simple coiling), and longer procedural time (odds ratio, 1.66; 95% confidence interval, 1.26-2.21; P < 0.001; per hour) were associated with postprocedural DWI-positive lesions. CONCLUSIONS: Older age, flow-diverter placement, and longer procedural time were associated with postprocedural DWI-positive lesions in endovascular treatment for unruptured cerebral aneurysms.

The proneural bHLH genes Mash1, Math3 and NeuroD are required for pituitary development

Multiple signaling molecules and transcription factors are required for pituitary development. Activator-type bHLH genes Mash1, Math, NeuroD (Neurod) and Neurogenin (Neurog) are well known as key molecules in neural development. Although analyses of targeted mouse mutants have demonstrated involvement of these bHLH genes in pituitary development, studies with single-mutant mice could not elucidate their exact functions, because they cooperatively function and compensate each other. The aim of this study was to elucidate the roles of Mash1, Math3 and NeuroD in pituitary development. Mash1;Math3;NeuroD triple-mutant mice were analyzed by immunohistochemistry and quantitative real-time RT-PCR. Misexpression studies with retroviruses in pituisphere cultures were also performed. The triple-mutant adenohypophysis was morphologically normal, though the lumen of the neurohypophysis remained unclosed. However, in triple-mutant pituitaries, somatotropes, gonadotropes and corticotropes were severely decreased, whereas lactotropes were increased. Misexpression of Mash1 alone with retrovirus could not induce generation of hormonal cells, though Mash1 was involved in differentiation of pituitary progenitor cells. These data suggest that Mash1, Math3 and NeuroD cooperatively control the timing of pituitary progenitor cell differentiation and that they are also required for subtype specification of pituitary hormonal cells. Mash1 is necessary for corticotroph and gonadotroph differentiation, and compensated by Math3 and NeuroD. Math3 is necessary for somatotroph differentiation, and compensated by Mash1 and NeuroD. Neurog2 may compensate Mash1, Math3 and NeuroD during pituitary development. Furthermore, Mash1, Math3 and NeuroD are required for neurohypophysis development. Thus, Mash1, Math3 and NeuroD are required for pituitary development, and compensate each other.

Dural and Pial Arteriovenous Fistulas Connected to the Same Drainer in the Middle Cranial Fossa: A Case Report.

BACKGROUND: Dural arteriovenous fistulas (AVFs) in the middle cranial fossa are rare. Pial AVFs are similarly rare but differ from dural AVFs in that they derive their arterial supply from pial or cortical arterial vessels and do not lie within the intradural region. We report an extremely rare case of dural and pial AVF connected to the same drainer in the middle cranial fossa. CASE DESCRIPTION: In a 58-year-old man with a subcortical hemorrhage in the right temporal lobe, digital subtraction angiography showed a dural AVF in the middle cranial fossa fed by the middle meningeal artery (MMA) and draining into the sphenopetrosal vein. A combination with a small pial AVF connected to the same sphenopetrosal vein was suspected. Open surgery was performed to directly observe the shunt points. Transarterial indocyanine green (ICG) angiography using the MMA via the superficial temporal artery on a skin flap was performed to repeatedly and distinctly evaluate the dural shunt points and to prevent cerebral thromboembolism. Although the dural supply was completely disconnected, the sphenopetrosal vein remained arterialized. ICG angiography revealed pial AVF, which was fed by the cortical arteries draining into the same drainer. The pial supply was completely disconnected, and disappearance of the dural and pial AVF was confirmed. CONCLUSIONS: We report an extremely rare case of dural and pial AVF connected to the same drainer in the middle cranial fossa. To our knowledge, this is the first such case report described in the literature.

Long-term outcomes of coil embolization of unruptured intracranial aneurysms.

OBJECTIVELong-term follow-up results of the treatment of unruptured intracranial aneurysms (UIAs) by means of coil embolization remain unclear. The aim of this study was to analyze the frequency of rupture, retreatment, stroke, and death in patients with coiled UIAs who were followed for up to 20 years at multiple stroke centers.METHODSThe authors retrospectively analyzed data from cases in which patients underwent coil embolization between 1995 and 2004 at 4 stroke centers. In collecting the late (≥ 1 year) follow-up data, postal questionnaires were used to assess whether patients had experienced rupture or retreatment of a coiled aneurysm or any stroke or had died.RESULTSOverall, 184 patients with 188 UIAs were included. The median follow-up period was 12 years (interquartile range 11-13 years, maximum 20 years). A total of 152 UIAs (81%) were followed for more than 10 years. The incidence of rupture was 2 in 2122 aneurysm-years (annual rupture rate 0.09%). Nine of the 188 patients with coiled UIAs (4.8%) underwent additional treatment. In 5 of these 9 cases, the first retreatment was performed more than 5 years after the initial treatment. Large aneurysms were significantly more likely to require retreatment. Nine strokes occurred over the 2122 aneurysm-years. Seventeen patients died in this cohort.CONCLUSIONSThis study demonstrates a low risk of rupture of coiled UIAs with long-term follow-up periods of up to 20 years. This suggests that coiling of UIAs could prevent rupture for a long period of time. However, large aneurysms might need to be followed for a longer time.

Cerebral Hyperperfusion Syndrome After Endovascular Reperfusion Therapy in a Patient with Acute Internal Carotid Artery and Middle Cerebral Artery Occlusions.

BACKGROUND: Cerebral hyperperfusion syndrome (CHS) is known to be a rare but devastating complication of carotid artery revascularization. Because patients with acute ischemic stroke due to acute major cerebral and/or cervical artery occlusion treated with endovascular reperfusion therapy may have impaired autoregulation in the cerebral vasculature, these patients may also develop CHS. Despite the growing number of endovascular reperfusion procedures for acute ischemic stroke, this complication has only rarely been reported. CASE DESCRIPTION: A 77-year-old man developed acute cerebral infarction as the result of occlusions of the right internal carotid artery and right middle cerebral artery. After systemic intravenous injection of recombinant tissue-type plasminogen activator, endovascular reperfusion therapy was initiated. The occluded arteries were successfully recanalized with thrombectomy by using a stent retriever for the middle cerebral artery and stent placement for the origin of the internal carotid artery. However, head computed tomography obtained 12 hours after treatment showed acute intracranial hemorrhage that did not involve the ischemic lesions. Under evaluation with transcranial near-infrared spectroscopy and single-photon emission computed tomography, the hemorrhage was considered to have been caused by CHS after reperfusion therapy. CONCLUSIONS: CHS may lead to unfavorable outcomes after reperfusion therapy for acute ischemic stroke. Recognizing clinical deterioration caused by CHS can be challenging in patients with neurologic disorders of acute ischemic stroke. Therefore, it is important to perform routine monitoring of regional cerebral oxygen saturation by using near-infrared spectroscopy, perform single-photon emission computed tomography promptly to evaluate cerebral blood flow, and maintain strict antihypertensive therapy to prevent CHS after reperfusion therapy.

Improving treatment times for patients with in-hospital stroke using a standardized protocol.

BACKGROUND: Previous reports have shown significant delays in treatment of in-hospital stroke (IHS). We developed and implemented our IHS alert protocol in April 2014. We aimed to determine the influence of implementation of our IHS alert protocol. METHODS: Our implementation processes comprise the following four main steps: IHS protocol development, workshops for hospital staff to learn about the protocol, preparation of standardized IHS treatment kits, and obtaining feedback in a monthly hospital staff conference. We retrospectively compared protocol metrics and clinical outcomes of patients with IHS treated with intravenous thrombolysis and/or endovascular therapy between before (January 2008-March 2014) and after implementation (April 2014-December 2016). RESULTS: Fifty-five patients were included (pre, 25; post, 30). After the implementation, significant reductions occurred in the median time from stroke recognition to evaluation by a neurologist (30 vs. 13.5min, p<0.01) and to first neuroimaging (50 vs. 26.5min, p<0.01) and in the median time from first neuroimaging to intravenous thrombolysis (45 vs. 16min, p=0.02). The median time from first neuroimaging to endovascular therapy had a tendency to decrease (75 vs. 53min, p=0.08). There were no differences in the favorable outcomes (modified Rankin scale score of 0-2) at discharge or the incidence of symptomatic intracranial hemorrhage between the two periods. CONCLUSION: Our IHS alert protocol implementation saved time in treating patients with IHS without compromising safety.