A Case of Intracranial Vertebral Artery Stenosis Treated with Percutaneous Transluminal Angioplasty and Stenting Guided by Brain Oximetry.

Surgical treatment should be considered for patients with severe vertebrobasilar artery (VBA) stenosis or progressive symptoms, but there is currently no clear treatment algorithm. We report a case of symptomatic intracranial vertebral artery stenosis with repeated cerebral infarction treated by percutaneous transluminal angioplasty (PTA) and stenting and monitoring of oxygen saturation by a brain oximeter. The patient was a 76-year-old man referred to our hospital due to infarction in the right cerebellum. Angiography showed 60% stenosis in the right vertebral artery and 90% stenosis in the left vertebral artery with progressive stenosis in the left. The patient was treated with intravenous and oral triple antiplatelet therapy but had dizziness again with new cerebral infarctions in the left cerebellum and right pontine. We shaved the patient's hair up to the superior nuchal line and placed left and right oximeter probes on each cerebellar hemisphere (2 cm lateral and 2 cm caudal from the external occipital protuberance). Under evaluation of blood flow in the posterior circulation with INVOS Cerebral/Somatic Oximeter, PTA and stent placement were performed for left vertebral artery stenosis. Postoperatively, the dizziness disappeared, and the patient was discharged on his own with good outcome. He has not had a recurrent stroke in over 6 years. Although medical treatment is generally considered the first choice for VBA stenosis, recurrent cerebral infarction occurs at a high rate in symptomatic lesions, and the prognosis is poor. In addition, the perioperative complication rate is not low, and there is no established method for evaluating perfusion of posterior circulation. The brain oximeter is already known to be useful in carotid artery (CA) revascularisation. In this report, we were able to perform a minimally invasive evaluation of blood flow in the posterior circulation using the brain oximeter which might be useful for surgical revascularisation not only in CA but also in VBA.

[A Case of Traumatic Carotid Artery Dissection Treated with Mechanical Thrombectomy Followed by Carotid Artery Stenting].

Traumatic carotid artery dissection(TCAD)is often associated with severe traumatic brain injuries and has high rates of morbidity and mortality. Here, we report a case of TCAD that was treated with mechanical thrombectomy followed by carotid artery stenting(CAS). A 50-year-old man suffered from minor facial trauma due to a motorcycle accident and had disturbance of consciousness with left hemiplegia 2 hours after sustaining the injury. Magnetic resonance imaging scans revealed cerebral infarction in a part of the middle cerebral artery territory, and magnetic resonance angiography showed cervical internal carotid artery occlusion. The patient was diagnosed with TCAD and underwent acute revascularization. Complete recanalization was with a combined technique using a stent-retriever and an aspiration catheter. Carotid angiography revealed a dissection of the internal carotid artery on the right side, and CAS was performed on the right side. Postoperatively, the patient recovered from disturbance of consciousness and left hemiplegia and was discharged once he was ambulatory. In cases of worsening symptomatology or worsening imaging findings, an endovascular approach should be considered for the treatment of TCAD.

Fluctuations of Nutrition-Associated Markers After Decompressive Hemicraniectomy in Middle Cerebral Artery Occlusion Patients.

Cerebral infarction (CI) caused by middle cerebral artery occlusion exhibits a very high mortality rate. To reduce this rate, a decompressive hemicraniectomy (DHC) is performed clinically based on several randomized trials. In ischemic stroke, a state of malnutrition leads to poor outcomes. However, little evidence is available on nutrition state in the acute phase after DHC. This preliminary study focuses on serum markers, especially dynamic or static nutrition-associated markers including prealbumin, transferrin, retinol binding protein (RBP) and serum albumin under tube feeding with Peptamen®AF (Nestlé Health Science Japan). Blood samples were collected from four patients and analyzed at 6 time points over 14 days (preoperative day, post-operative day (POD) 1, POD 3, POD 7, POD 10, and POD 14). One-way analysis of variance (ANOVA), post hoc Least Significant Difference (LSD), was employed to analyze the blood levels at each time point. The prealbumin and RBP levels showed no significant difference between preoperation and POD 3, although they decreased gradually, while transferrin decreased significantly between the preoperative day and POD 3 (P < 0.05). The level increased significantly on POD 14 as compared to POD 3 (P < 0.05) for each dynamic marker, respectively. The albumin value decreased significantly on POD 3 to POD 7 as compared to the preoperational day (P < 0.05), while the total protein fell significantly on POD 3 (P < 0.05). The total cholesterol, HDL cholesterol, LDL cholesterol, triglyceride, glucose, transferrin, and C-reactive protein were also investigated. Some markers fluctuated significantly, especially on POD 3. The duration may represent a hypercatabolic phase for malignant cerebral infarction with DHC. Based on these findings, further investigations among these markers, the tube fed contents, physiological changes and disability could lead to better outcomes following malignant CI.

[Effectiveness of Kampo medicine Gorei-San for chronic subdural hematoma].

Chronic subdural hematomas (CSDHs) are basically treated by surgery. In some cases with no or minimum symptoms, however, they may be treated conservatively. In the present study, we evaluated the therapeutic effect of a Kampo medicine (Japanese traditional herbal medicine), Gorei-san, in the treatment of those CSDHs. Gorei-san 7.5 g t.i.d. was orally administered for 4 weeks in 22 patients with 27 CSDHs. Maximum thickness of the hematoma was followed up on CT scan for 4 to 29 weeks after administration of Gorei-san. In 7 of 22 patients, tranexamic acid and/or carbazochrome sodium sulfonate were also administrated. Gorei-san was effective in 23 of 27 CSDHs. In 12 of them, the hematoma was completely disappeared within 14 weeks after administration. In the other 11 CSDHs, the thickness was decreased. In those effective cases, thickness began to decrease 3 to 4 weeks after administration of Gorei-san. It was more effective in CSDHs with iso-/high or mixed density than with low density on CT. It was not effective in 4 out of 27 CSDHs. No apparent adverse effect was noted in the present series of patients. The present study suggests that a Kampo medicine, Gorei-san, is a useful option in the conservative treatment of CSDHs with no or minimum symptoms.