Safety of Tailored Transfemoral Carotid Artery Stenting for Symptomatic Elderly Patients: A Single Center Observational Study.

OBJECTIVE: Transfemoral carotid artery stenting (TFCAS) in symptomatic elderly patients (≥70 years old) may have a high periprocedural stroke rate. This study was performed to examine whether tailored TFCAS for symptomatic elderly patients is as safe as that for symptomatic nonelderly patients. METHODS: The subjects were 185 patients with symptomatic internal carotid artery stenosis. Tailored TFCAS including postoperative management was performed based on preoperative examinations of vascular anatomy, plaque imaging, platelet aggregation activity, and cerebral hemodynamic impairment. The major 30-day perioperative stroke rates were examined. RESULTS: The patients included 51 (27.6%) <70 (group Y) and 134 (72.4%) ≥70 (group E) years old. Group E included significantly more cases with an elongated aortic arch, tortuous target lesion, and longer plaques (all P < 0.05). Among all cases, 181 (97.8%) procedures were performed as per preoperative planning. Group E had more frequent use of a proximal embolic protection device and a closed-cell or dual-layer micromesh stent (all P < 0.05). Seven patients (3.8%) had major stroke. Rates of major ischemic stroke (2.0% vs. 3.0%, P = 1.00) and intracranial hemorrhage (2.0% vs. 0.8%, P = 0.48) were low and did not differ significantly between groups Y and E. CONCLUSIONS: Symptomatic elderly patients have several unfavorable factors. However, tailored TFCAS for each patient based on preoperative examinations in symptomatic elderly patients may be as safe as that in symptomatic nonelderly patients.

Progressive arteriopathy with vasospasm in focal cerebral arteriopathy in childhood: a case report.

BACKGROUND: Focal cerebral arteriopathy (FCA) is a clinically important disease that often causes progressive arteriopathy. We report a case of FCA with progressive arteriopathy due to arterial shrinkage of the outer diameter found on T2-weighted three-dimensional sampling perfection with application optimized contrasts using different flip angle evolutions (3D-SPACE) imaging. CASE PRESENTATION: The patient was a 9-year-old girl who developed right hemiparesis. Acute infarction was detected in the basal ganglia. Vascular images revealed stenosis from the distal internal carotid artery (ICA) to the middle cerebral artery (MCA). Intravenous heparin was administered for 8 days, and the symptoms improved. However, 29 days after onset, right hemiparesis transiently developed again and magnetic resonance angiography (MRA) showed progressive stenosis from the ICA to MCA, while 3D-SPACE showed similar shrinkage of the outer diameter. Aspirin was started, and there was no subsequent recurrence. After 12 months, MRA and 3D-SPACE showed improvement of stenosis and arterial shrinkage. CONCLUSIONS: Given the time course, the change in the outer diameter was thought to be vasospasm. Thus, vasospasm may be one of the causes of progressive arteriopathy in FCA.

Outcome prediction of pediatric moyamoya disease using midterm cerebral blood flow measured between staged anastomoses.

PURPOSE: Cognitive outcomes of pediatric moyamoya disease are variable and difficult to predict on the basis of initial neurological signs and examinations. To determine the best early time point for outcome prediction, we retrospectively analyzed the correlation between cognitive outcomes and the cerebrovascular reserve capacity (CRC) measured before, between, and after staged bilateral anastomoses. METHODS: Twenty-two patients aged 4-15 years were included in this study. CRC was measured before the first hemispheric surgery (preoperative CRC), 1 year after the first surgery (midterm CRC), and 1 year after the surgery on the other side (final CRC). The cognitive outcome was the Pediatric Cerebral Performance Category Scale (PCPCS) grade more than 2 years after the final surgery. RESULTS: The 17 patients with favorable outcomes (PCPCS grades 1 or 2) showed a preoperative CRC of 4.9% ± 11.2%, which was not better than that of the five patients with unfavorable outcomes (grade 3; 0.3% ± 8.5%, p = 0.5). The 17 patients with favorable outcomes showed a midterm CRC of 23.8% ± 15.3%, which was significantly better than that of the five patients with unfavorable outcomes (-2.5% ± 12.1%, p = 0.004). The difference was much more significant for the final CRC, which was 24.8% ± 13.1% in the patients with favorable outcomes and -11.3% ± 6.7% in those with unfavorable outcomes (p = 0.00004). CONCLUSION: Cognitive outcomes were first clearly discriminated by the CRC after the first-side unilateral anastomosis, which is the optimal early timing for the prediction of individual prognosis.

Endoscopically observed outer membrane of chronic subdural hematoma after endovascular embolization of middle meningeal artery.

Background: Embolization of the middle meningeal artery (MMA) has been established for chronic subdural hematoma (CSDH). Neuroendoscopic observation of the outer membrane of the hematoma was carried out after embolization. The treatment mechanism of embolization is discussed, focusing on the vasculature and inflammation of the membrane. Methods: Four patients with recurrent CSDH were included in this study. The MMA was embolized using Embosphere® particles in three patients. The outer membrane was observed with normal and narrow band images (NBIs). Results: The net-like vessels were not obstructed in the whole area of the outer membrane, but in a patchy fashion of embolized areas surrounded by nonembolized areas. In two patients, the nonembolized areas showed a hemorrhagic inflammatory red color. Histopathological examination confirmed hypertrophic dura with leukocyte infiltration. Dilated dural arteries and proliferated sinusoid arteries were located in the deep and superficial border cell layers. These arteries were visualized as green and brown on NBI, respectively. In the embolized area, the red membrane turned pink, indicating ischemia and subsiding inflammatory hyperemia. In the third patient, the outer membrane was white in both the nonembolized and embolized areas in endoscopic view, and the net-like vessels were sparse in both endoscopy and histology, indicating a scar inflammatory phase. The membrane transition was not observed in the patient that did not undergo embolization. Conclusion: Endoscopic observation revealed that embolization of the MMA blocked both the dural and sinusoidal arteries. Ischemic transformation causing the suppression of inflammation of the outer membrane is a suggested mechanism of MMA embolization.

Timing of Direct Oral Anticoagulants for Hemorrhagic Transformation After Endovascular Treatment in Acute Ischemic Stroke.

OBJECTIVES: The purpose of this study is to investigate the relationship between the timing of starting direct oral anticoagulants (DOACs) and subsequent clinical outcomes in patients with hemorrhagic transformation (HT) after endovascular treatment (EVT). MATERIALS AND METHODS: The subjects were patients with acute cardioembolic stroke who underwent EVT and received DOACs in our department from February 2017 to August 2021. Based on CT at 24 h after EVT, the patients were classified using European Collaborative Acute Stroke Study criteria into three groups: no HT, hemorrhagic infarction (HI), and parenchymal hematoma (PH). Outcomes were assessed for incidence of recurrent ischemic stroke (RIS), new intracranial hemorrhage (ICH), and worsened HT associated with DOACs. RESULTS: Of 111 patients, 29 (26.1%) had HT, including 16 (14.4%) with HI and 13 (11.7%) with PH. The start of DOACs was significantly delayed in the PH group (no HT: 1.0 (1.0-3.0) days vs. HI: 3.0 (2.0-5.0) days vs. PH: 7.0 (7.0-10.0) days, P < 0.01). The incidence of RIS did not differ significantly among the three groups, but tended to be higher in the PH group (no HT: 3.7% vs. HI: 6.3% vs. PH: 15.4%, p = 0.12). There were no cases of new symptomatic ICH. New asymptomatic ICH occurred in 2 cases in the no HT group. Worsened HT after initiation of DOACs did not occur in the HI or PH group. CONCLUSIONS: The timing of starting DOACs in patients with HT after EVT may be divided by subtypes of HI and PH. In patients with HI, early initiation of DOACs can prevent RIS and is unlikely to cause new ICH or worsened HI. In PH, initiation of DOACs within 14 days appears to be safe and does not exacerbate PH. The later the start of DOACs, the higher the frequency of RIS, so early initiation of DOACs is desirable.

Relationship between cerebral hyperperfusion syndrome and the immediate change of cerebral blood flow after carotid artery stenting evaluated by single-photon emission computed tomography.

PURPOSE: Cerebral hyperperfusion syndrome (CHS) is a critical complication after carotid artery stenting (CAS). However, few CAS studies have evaluated immediate and temporary changes in ipsilateral cerebral blood flow (CBF) quantitatively. The study was performed to evaluate immediate changes in CBF after CAS and subsequent CBF changes in patients with cerebral hyperperfusion (HP) using 123I-IMP SPECT. METHODS: The subjects were 223 patients with chronic extracranial carotid artery stenosis who underwent CAS in our department between March 2010 and March 2020. Quantitative CBF and cerebrovascular reactivity to acetazolamide in the middle cerebral artery were assessed before CAS by 123I-IMP SPECT. CBF was also measured immediately after CAS by 123I-IMP SPECT. When HP was detected, CBF was measured again 3 and 7 days after CAS. RESULTS: The median (interquartile range) ipsilateral quantitative CBF change after CAS was - 0.1% (- 9.5-8.2%), and the upper value of the 95% CI of the quantitative CBF change was 48.2%. Thus, we defined HP after CAS as an increase in quantitative CBF of > 48.2% compared with the preoperative value. Of 223 patients, 5 (2.2%) had HP, and 4 of these patients (80%) developed CHS. In the CHS patients, HP was maintained for about 3 days and improved after about 7 days. CONCLUSION: An immediate CBF increase of > 48.2% after CAS may lead to development of CHS. In CHS after CAS, HP persisted for about 1 week and postoperative management may be required for at least 1 week.

Cerebral hemodynamics associated with fluid-attenuated inversion recovery hyperintense vessels in patients with extracranial carotid artery stenosis.

PURPOSE: Fluid-attenuated inversion recovery hyperintense vessels (FHVs) are linked to sluggish or disordered blood flow. The purpose of this study is to compare FHVs with digital subtraction angiography (DSA) findings and cerebral hemodynamic changes on acetazolamide challenge SPECT and to determine the clinical and imaging metrics associated with FHVs in patients with extracranial carotid artery stenosis (ECAS). METHODS: The subjects were patients with chronic ECAS who underwent carotid artery stenting in our department between March 2011 and October 2018. Relationships of FHVs with age, sex, medical history, cerebral angiographic findings using DSA, and quantitative values of cerebral blood flow (CBF) were examined. The resting CBF (rCBF) and cerebrovascular reactivity (CVR) in the middle cerebral artery territory were measured quantitatively using SPECT with acetazolamide challenge. We used multivariate logistic regression analysis to identify independent predictors of FHVs. RESULTS: Of 173 patients included, 92 (53.2%) had FHVs. Patients with FHVs had more severe stenosis (P < 0.01) and more leptomeningeal collateral vessels (P < 0.01). FHV-positive cases had significantly reduced CVR compared with FHV-negative cases (P < 0.01), although there was no significant difference in rCBF between FHV-positive and FHV-negative cases. Logistic regression analysis showed that ipsilateral rCBF and ipsilateral CVR were significant predictors for FHVs (P < 0.01). CONCLUSION: In patients with ECAS, cerebral hemodynamic metrics, especially ipsilateral rCBF and ipsilateral CVR, are associated with the presence of FHVs.

Hounsfield Unit Value of Interpeduncular Cistern Hematomas Can Predict Symptomatic Vasospasm.

Background and Purpose- Symptomatic vasospasm is an important factor that affects the outcomes of aneurysmal subarachnoid hemorrhage. Subarachnoid blood volume can predict symptomatic vasospasm, and we postulated that the blood clot density would also be an important factor involved in such events. The present study aimed to determine the relationship between the incidence of symptomatic vasospasm and the Hounsfield unit (HU) value of the interpeduncular cistern that reflects the density of hematomas. Methods- Data from 323 patients admitted and treated at a single center between 2008 and 2017 within 24 hours of subarachnoid hemorrhage onset were retrospectively analyzed. Initial HU values of the interpeduncular cistern were measured using CT, then correlations with the incidence of symptomatic vasospasm and HU values as well as other variables were assessed. Results- Symptomatic vasospasm developed in 54 (16.7%) of the 323 patients. The incidence of symptomatic vasospasm was low (1.8%, 2/166) for HU <50, but this incidence increased greatly when the HU value exceeded 50 (23.7%, 22/93 for HU >50 to ≤60, and 45.3%, 29/64 for HU >60). The odds ratio for symptomatic vasospasm was 2.0 (95% CI, 1.6-2.4) per 5 HU increase. Symptomatic vasospasm correlated significantly with intraventricular hemorrhage (P=0.05) and with intracerebral hematoma (P=0.046) but even more significantly with the HU value of the interpeduncular cistern (P<0.0001). Conclusions- The HU value of the interpeduncular cistern on initial CT is an accurate and reliable predictor of symptomatic vasospasm.

Revascularization of Remaining Branch of Aorta in Advanced Takayasu Arteritis Protects Against Wide Range of Perfusion.

BACKGROUND: Stroke is a major factor of morbidity in the patients with Takayasu arteritis (TA). Restenosis is more common with endovascular intervention than after bypass surgery, but vascular anastomosis is difficult due to calcification involving the whole thickness of the arterial wall in the burned-out stage of TA. We report a case of advanced TA in which endovascular treatment of the left subclavian artery improved cerebral blood flow (CBF) over a wide range of perfusion in the posterior and anterior circulation. CASE DESCRIPTION: During medical treatment for TA, a 57-year-old male patient gradually developed ischemic symptoms of both upper limbs and dizziness. Angiography showed occlusion of the brachiocephalic artery and severe stenosis of the left common carotid artery and left subclavian artery. Preoperative single-photon emission computed tomography revealed reductions in the resting CBF and vascular reactivity in the area of the carotid artery and vertebral basilar artery. Chest computed tomography showed calcification of the aortic arch and its branches, and this advanced diffuse calcification indicated probable difficulties in bypass surgery. Therefore we performed percutaneous transluminal angioplasty and stenting for the left subclavian artery. Postoperative single-photon emission computed tomography showed increases in resting CBF in the area of the bilateral internal carotid artery, as well as the vertebrobasilar artery. The patient's various ischemic symptoms improved significantly. CONCLUSIONS: As collateral circulation is common in advanced TA, the ischemic area is large when the remaining proximal large vessels are occluded. Therefore revascularization of the remaining branch of the aorta in advanced TA may protect against a wide range of perfusion.

Impact of Frailty on Medium-Term Outcome in Asymptomatic Patients After Carotid Artery Stenting.

OBJECTIVE: There are few reports on the relationship between carotid artery stenting (CAS) and frailty. In this study, medium-term outcome after CAS in patients with asymptomatic carotid artery stenosis was examined to see the effect of frailty itself. METHODS: A retrospective study was performed in 71 consecutive patients who were treated with CAS for asymptomatic lesions from January 2007 to June 2014. In this study, only patients without neurologic symptoms before treatment were included. Frailty was defined on the basis of the presence of ≥2 of the 5 items on the Cardiovascular Health Study (CHS) Index. The relationship of frailty with a composite endpoint of the incidence of stroke, disease requiring hospital admission, and death for 3 years after CAS was examined. RESULTS: There were 23 cases (average age 73.9 years, median CHS index 3) with frailty and 48 (average age 70.9 years, median CHS index 0) without frailty. There were no differences in comorbidities or CAS perioperative complications between these groups. However, there was a significantly higher incidence of the composite endpoint in patients with frailty (13/23 vs. 4/48, P < 0.001), and in multivariate analysis, frailty was strongly associated with this endpoint (odds ratio 28.24, 95% confidence interval 4.62-172.71). CONCLUSIONS: In CAS conducted for asymptomatic lesions, perioperative complications had no relationship with frailty. However, frailty is likely to be associated with lower activity of daily life in the medium term after CAS, and consideration of underlying diseases is required in patients with frailty.

Idiopathic basal ganglia calcification associated with cerebral micro-infarcts: a case report.

BACKGROUND: Idiopathic basal ganglia calcification (IBGC) is a rare neurodegenerative disorder characterized by symmetric intracranial calcium deposition. We report a patient with IBGC associated with cerebral infarction due to impairment of cerebrovascular reactivity based on single-photon emission computed tomography (SPECT) with acetazolamide challenge. CASE PRESENTATION: A 66-year-old male presented with right conjugate deviation, right hemiparesis and total aphasia due to a convulsive seizure. Brain computed tomography showed symmetric calcifications in the bilateral basal ganglia, thalamus, cerebellar dentate nuclei, which were consistent with IBGC. Diffusion-weighted brain magnetic resonance imaging showed multiple small infarctions in the bilateral cerebral subcortical area. In the search for the cause of cerebral infarction, SPECT with acetazolamide challenge revealed heterogeneous impairment of cerebrovascular reactivity in the whole brain, despite the absence of evidence for steno-occlusive changes in proximal arteries. CONCLUSION: Cerebrovascular insufficiency due to the lack of elasticity caused by microvascular calcification might have been one of the pathophysiological features of IBGC in this case. Thus, vascular calcification may cause cerebrovascular disturbance and could lead to ischemic stroke in patients with IBGC.

A primary extradural malignant rhabdoid tumor at the craniovertebral junction in a 3-year-old boy.

INTRODUCTION: Malignant rhabdoid tumor (MRT) is a highly aggressive childhood neoplasm and mainly presents in kidney and brain. We report the case of a patient with extrarenal extracranial MRT in the craniovertebral junction (CVJ). CASE REPORT: A 3-year-old boy presented with tetraparesis that had rapidly developed for 2 weeks. The tumor was located in the ventral side of the C1 and C2 extradural space and had invaded the lower clivus. The symptom recovered after subtotal resection of the tumor through a lateral approach with removal of bilateral lateral masses at C1 and instrumental occipital-C2 posterior fusion. Definite histological diagnosis of the extradural tumor was difficult; however, a metastatic lesion in the rib showed a proliferation of INI1/SMARCB1-negative spindle and rhabdoid cells, indicating the tumor was MRT. Stereotactic CyberKnife radiotherapy with a marginal dose of 26 Gy contributed to control of local regrowth of the tumor before histopathological confirmation and induction of chemotherapy with ifosfamide, cisplatin, and etoposide. The patient survived for 29 months without local recurrence of the tumor and with independent activity, however then died of multiple metastases. CONCLUSION: Treatment strategies for MRT in the CVJ should include an optimal surgical approach for reduction of tumor volume and stabilization of the spine, followed by high dose chemotherapy. Stereotactic radiotherapy may be useful for local control.