Direct carotid-cavernous fistula presenting with intracranial hemorrhage without ocular symptoms.

Herein, we report a unique case of nontraumatic direct carotid-cavernous fistula presenting with intracerebral hemorrhage without any ocular symptoms. A 90-year-old woman was found unconscious and vomiting due to a subcortical hemorrhage in the temporal lobe. Magnetic resonance angiography revealed a direct carotid-cavernous fistula of Barrow type A. Extensive cortical venous reflux from the superficial middle cerebral vein was observed and identified as a probable contributor to the cerebral hemorrhage. We performed successful embolization using combined transarterial and transvenous approaches. We first occluded the dangerous venous drainage via the transvenous approach, followed by selective occlusion of the direct carotid-cavernous fistula via the transarterial approach. This strategy provided that the dangerous venous drainage was completely occluded first in case complete obliteration could not be achieved with the transarterial approach.

Successful shrinkage of a recurrent partially thrombosed symptomatic large basilar tip aneurysm using a Target 3D Coil.

Background: Standalone coil embolization is often less effective for partially thrombosed intracerebral aneurysms (PTIA) because of the risk of frequent recurrence if the coil migrates into the thrombus. This report describes a case of PTIA at the basilar tip in which simple coil embolization using a Target 3D Coil resulted in sustained remission without recurrence during long-term follow-up. Case Description: The patient was a 63-year-old male who presented with right oculomotor nerve palsy after having undergone direct surgery for a basilar artery aneurysm 15 years earlier. Recurrence with partial thrombosis of the basilar artery aneurysm was diagnosed. Target 3D Coil embolization with frame construction in the aneurysmal sac was performed, resulting in the complete disappearance of the aneurysm and improvement of the oculomotor nerve palsy. Magnetic resonance imaging at five years postoperatively confirmed that the thrombus had completely disappeared, and there was no recurrence of the aneurysm. The closed loops in the Target 3D Coil may have contributed to the cohesive mass of coils remaining in the sac of the PTIA, potentially leading to healing. Conclusion: The characteristics of the Target 3D Coil may have prevented migration of the coil into the thrombus, potentially contributing to the successful resolution of the aneurysm.

2-Hydroxyglutarate magnetic resonance spectroscopy in adult brainstem glioma.

OBJECTIVE: Adult brainstem gliomas (BSGs) are rare tumors of the CNS that are poorly understood. Upregulation of the oncometabolite 2-hydroxyglutarate (2HG) in the tumor indicates the mutation of isocitrate dehydrogenase (IDH), which can be detected by magnetic resonance spectroscopy (MRS). Although histological examination is required for the definitive diagnosis of BSG, 2HG-optimized MRS (2HG-MRS) may be useful, considering the difficult nature of brainstem lesion biopsy. The aim of this study was to evaluate the utility of 2HG-MRS for diagnosing IDH-mutant adult BSG. METHODS: Patients with a radiographically confirmed brainstem tumor underwent 3T MRS. A single voxel was set in the lesion with reference to the T2 or fluid-attenuated inversion recovery image and analyzed according to the 2HG-tailored MRS protocol (point-resolved spectroscopic sequence; echo time 35 msec). All patients underwent intraoperative navigation-guided or CT-guided stereotactic biopsy for histopathological diagnosis. The status of IDH and H3K27M mutations was confirmed by immunohistochemistry and direct DNA sequencing. In addition, the authors examined the relationship between patients' 2HG concentrations and survival time. RESULTS: Ten patients (7 men, 3 women; median age 33.5 years) underwent 2HG-MRS and biopsy. Four patients had an H3K27M mutation and 4 had an IDH1 mutation (1 R132H canonical IDH mutation, 2 R132S and 1 R132G noncanonical IDH mutations). Two had neither H3K27M nor IDH mutations. The H3K27M and IDH mutations were mutually exclusive. Most tumors were located in the pons. There was no significant radiological difference between mutant H3K27M and IDH on a conventional MRI sequence. A 2HG concentration ≥ 1.8 mM on MRS demonstrated 100% (95% CI 28%-100%) sensitivity and 100% (95% CI 42%-100%) specificity for IDH-mutant BSG (p = 0.0048). The median overall survival was 10 months in IDH-wild-type BSG patients (n = 6) and could not be estimated in IDH-mutant BSG patients (n = 4) due to the small number of deaths (p = 0.008). CONCLUSIONS: 2HG-MRS demonstrated high sensitivity and specificity for the prediction of IDH-mutant BSG. In addition, 2HG-MRS may be useful for predicting the prognosis of adult BSG patients.

Endovascular Treatment of Tandem Atherosclerotic Cervical Internal Carotid Artery Occlusion in the Setting of Acute Ischemic Stroke.

BACKGROUND: Among tandem occlusions, atherosclerotic cervical internal carotid artery occlusion (ACICAO) can be technically challenging and associated with its unique complications. We evaluated our experience with endovascular treatment (EVT) of ACICAO in the setting of acute ischemic stroke. METHODS: In total, 154 consecutive patients who underwent EVT for acute anterior circulation stroke at our institute were retrospectively reviewed. Patients with tandem ACICAO were analyzed in this study. Procedures, recanalization rates, complications, and prognoses were evaluated. RESULTS: Ten patients (6%) of all 154 patients had ACICAO. In nine (90%) of the 10 patients, cervical lesions were successfully crossed and intervened upon. Four patients underwent stenting and five underwent angioplasty alone, followed by intracranial procedure. Eight patients (80%) achieved successful recanalization following mechanical thrombectomy for intracranial occlusion. However, one patient had massive subarachnoid hemorrhage during the procedure and another patient developed massive intracranial hemorrhage after EVT, both after stenting. Four of the five patients who initially underwent angioplasty alone subsequently underwent staged endarterectomy or stenting for residual stenosis on or after the next day. The single patient in whom the cervical lesion could not be crossed and another with reocclusion after EVT underwent a rescue bypass procedure due to persistent ischemic symptoms. After 90 days, four patients (40%) were functionally independent (modified Rankin scale score 0-2). CONCLUSIONS: Our experience suggests that EVT for ACICAO is technically feasible; however, it involves the potential risk of several significant complications. To avoid serious hemorrhagic complications, cervical lesions may be better treated with angioplasty alone first.

Iatrogenic intracranial vessel dissection during mechanical thrombectomy rescued by emergent stenting: 2 case reports.

Intracranial vessel dissection is a procedural complication associated with endovascular treatment. However, there have been few reports on its potential causes and management during mechanical thrombectomy. In approximately 250 cases of mechanical thrombectomy over the past 5 years at our institution, iatrogenic intracranial dissection occurred in 2 patients (0.8%). In this report, we described these 2 cases that were rescued through emergent stenting. Mechanical thrombectomy, using both a stent retriever and an aspiration catheter, was performed for acute middle cerebral artery M2 occlusion in Patient 1 (a 69-year-old man) and for distal M1 occlusion in Patient 2 (an 83-year-old woman). In both cases, recanalization was achieved with the procedure, but irregular stenosis developed at the initially nonoccluded, but mildly arteriosclerotic, M1, after recanalization. During the thrombectomy procedure, the aspiration catheter sifted up to the arteriosclerotic M1. In both cases, the lesions were considered vessel dissection, due to a shift of the aspiration catheter tip into the arteriosclerotic vessel wall. Repeated percutaneous angiography with antithrombotic therapy failed to improve the lesions and to maintain the antegrade blood flow. Finally, lesions in each patient were successfully rescued through the use of emergent stenting. A drug-eluting stent for coronary use was deployed in Patient 1, and an Enterprise stent was applied in Patient 2. Inadvertent shift of the aspiration catheter into arteriosclerotic vessels can cause a serious intracranial vessel dissection. When performing mechanical thrombectomy, intracranial stents need to be available as rescue treatment devices to manage refractory iatrogenic intracranial vessel dissection.

Impact of introducing endovascular treatment on acute ischemic stroke outcomes: A shift from an era of medical management to thrombectomy in Japan.

BACKGROUND: Endovascular treatment (EVT) has increasingly become the standard treatment of acute cerebral large vessel occlusion (LVO). We evaluated the impact of introducing EVT on LVO therapy in a single center where intravenous thrombolysis (IVT) had been the only recanalization therapy. MATERIALS AND METHODS: Between April 2013 and March 2017, 354 consecutive patients with LVO admitted to our institution were analyzed. We compared outcomes between two chronological groups before (Pre-EVT group) and after (Post-EVT group) introducing EVT in April 2015. We assessed prognostic factors for favorable outcomes (modified Rankin scale score ≤2 at 90 days). RESULTS: In the Pre-EVT group, all 140 patients were treated medically, including 30 patients (21%) undergoing IVT. In the Post-EVT group, 118 patients (55%) underwent EVT, and the remaining 96 patients treated medically, including six patients (3%) undergoing IVT. The proportion undergoing recanalization therapy with IVT or EVT significantly increased after introducing EVT (21% versus 58%, p < 0.001). The rate of patients achieving favorable outcomes also significantly increased (14% versus 31%, p < 0.001). In multivariate regression analysis, introducing EVT was an independent predictive factor after adjusting for age, stroke severity and extent, and time (p = 0.005). The arrival time in patients with helicopter transport was significantly shorter than that with ground ambulance for a distance of more than 10 km (p < 0.001). CONCLUSIONS: This study demonstrated that the introduction of EVT improved outcomes of acute LVO patients, increasing the opportunity to receive recanalization therapy. Further efforts to establish medical systems to provide EVT are required throughout the country.

Mechanical Thrombectomy Using the Trevo ProVue in 50 Consecutive Patients with Anterior Circulation Stroke: A Single-Center Experience after Approval of the Stent Retriever in Japan.

Mechanical thrombectomy using the stent retriever has been proven to be effective for select patients with acute ischemic stroke. We evaluated our early experience using the device after its approval in 2014 in Japan, with a special emphasis on the occlusion site. Fifty consecutive endovascular revascularization procedures for treating anterior acute large vessel occlusion were performed using the Trevo ProVue as the first-line device at our institute between April 2015 and March 2016. Focusing on the involvement of the M1-M2 bifurcation with deployment or retrieval of the stent retriever, we regarded the middle cerebral artery M1 mid-portion as the boundary and divided the cases into proximal (n = 26) and distal (n = 24) groups. We assessed the overall clinical outcome and compared the outcome between the two groups. Among 50 patients (median age, 80 years; National Institutes of Health Stroke Scale score (NIHSS) score, 20), successful (modified Thrombolysis in Cerebral Infarction score (TICI) 2b or 3) or complete revascularization (TICI 3) was achieved in 41 patients (82%; 88% in the proximal group vs 75% in the distal group, P = 0.28) and in 27 patients (54%; 73% vs 33%, P = 0.01), respectively. Symptomatic intracranial hemorrhage occurred in three patients (6%; 4% vs 8%, P = 0.60). A good outcome (mRS score 0 to 2) was obtained in 25 patients at 90 days (50%; 54% vs 46%, P = 0.78). Mechanical thrombectomy using the Trevo ProVue was safe and effective in patients with acute cerebral artery occlusion, especially for proximal occlusions. The efficacy of the procedure for distal occlusions was somewhat inferior to those for proximal occlusions, which might be resolved by next generation devices.

[Association of Deep Venous Thrombosis with D-dimer Values in Patients with Hemorrhagic Stroke].

Pulmonary embolism(PE)in the early phase of stroke worsens the prognosis. It is necessary to detect deep venous thrombosis(DVT)to avoid PE. We conducted the D-dimer screening in order to detect DVT at an earlier stage. We retrospectively analyzed the clinical data of patients with hemorrhagic stroke who were admitted to the local stroke center, and investigated the complication rates of DVT, PE, D-dimer values, and risk factors of DVT. From October 2012 to August 2014, 261 patients were included. DVT was detected in 46 patients(17.6%)and anticoagulant therapy was started in 5 patients with central DVT. PE did not occur during this observation period. The D-dimer cutoff value for estimating the presence of the DVT was 8.9µg/mL, and the risk factors for DVT were older age, severe neurological disability, prolonged hospital stays, and subarachnoid hemorrhage. D-dimer screening is very useful to make earlier diagnosis and treatment of DVT.

[Two cases of cerebral infarction due to focal irradiation for glioma in adults].

Radiation-induced vasculopathy is a complication of radiation therapy. Most reports regarding post-irradiation ischemic stroke with intracranial tumors are restricted to pediatric cases. Here we report two adult cases of delayed brain infarction due to anterior and middle cerebral artery stenosis or occlusion seemingly caused by focal radiation therapy for malignant glioma. Although radiation-induced ischemic stroke in adults is relatively uncommon, it is possible that the morbidity rate of radiation-induced stroke in malignant glioma patients will increase with prolonged survival due to advances in therapy. Therefore, regular evaluation of intracranial vasculature following radiation therapy is necessary.