Combination of Exoskeletal Upper Limb Robot and Occupational Therapy Improve Activities of Daily Living Function in Acute Stroke Patients.

PURPOSE: Previous studies have suggested that upper limb rehabilitation using therapeutic robots improves motor function of stroke patients. However, the effect of upper limb robotic rehabilitation on improving functioning in activities of daily living (ADL) remains unclear. The present study aimed to determine whether upper limb rehabilitation using single joint Hybrid Assistive Limb (HAL-SJ) affects ADL function and the use of a hemiparetic arm in ADLs of acute stroke patients. MATERIALS AND METHODS: Twelve acute stroke patients participated in the study and were randomly divided into group A or group B. The patients in group A followed an A-B-A-B design and those in group B followed a B-A-B-A design. The patients received combination HAL-SJ and occupational therapy during A and conventional occupational therapy during B. RESULTS: Upper limb motor function and ADLs, in particular, dressing the upper body, were improved during combination HAL-SJ and occupational therapy. Interestingly, the use of a hemiparetic arm in daily life evaluated using the motor activity log was also significantly improved during A in group A. CONCLUSIONS: Combination HAL-SJ and occupational therapy affects ADL function and real use of a hemiparetic arm in the daily life of acute stroke patients.

A Comparison of Computed Tomography-Based Scales with and without Consideration of the Presence or Absence of Intraventricular Hemorrhage in Patients with Aneurysmal Subarachnoid Hemorrhage.

OBJECTIVE: There has been controversy as to whether intraventricular hemorrhage (IVH) after aneurysmal subarachnoid hemorrhage (SAH) contributes to angiographic cerebral vasospasm (aCV) and delayed cerebral ischemia (DCI). Computed tomography-based SAH scales that did and did not consider IVH were compared in terms of ability to predict aCV, DCI, and outcome. METHODS: We reviewed 390 patients with ruptured aneurysms who had been treated surgically by day 3 by the same surgeon (T.I.). aCV was graded as 0-4. Outcome at 6 months was classified using the Glasgow Outcome Scale. Inagawa SAH grades and scores, for which only SAH was evaluated, were compared with scales that evaluated both SAH and IVH (Fisher, Claassen, and Frontera grades, and Hijdra score). The area under the receiver operating characteristic curve was calculated to compare severe aCV (grade 3-4), DCI, or poor outcome (Glasgow Outcome Scale score 1-3). RESULTS: The Inagawa grade showed constant and significant intergrade differences in both aCV and DCI. The Inagawa grade area under the receiver operating characteristic curve values were highest among the scales examined. In the Fisher, Claassen, and Frontera grades, IVH was unlikely to be related to aCV and DCI. There was no significant difference in aCV grade or DCI occurrence between the Inagawa and Hijdra scores. In contrast, the presence of IVH was significantly associated with poor outcome. CONCLUSIONS: In patients with aneurysmal SAH, IVH is an important factor affecting patient outcome, whereas computed tomography-based SAH scales that do not consider IVH are superior to scales that do consider it for prediction of aCV or DCI.

Open-cell Stent Deployment across the Wide Neck of a Large Middle Cerebral Aneurysm Using the Stent Anchor Technique.

We describe a case of successful open-cell stent deployment across the wide neck of a large middle cerebral artery aneurysm using the stent anchor technique. A microcatheter was looped through the aneurysm and navigated into a distal vessel across the aneurysm neck. Although the loop of the microcatheter in the aneurysm straightened as it was gently withdrawn, the microcatheter again protruded into the aneurysm by open-cell stent navigation. The stent was partially deployed in a vessel distal to the aneurysm neck, withdrawn slowly to straighten the loop of the microcatheter in the aneurysm, and completely deployed across the aneurysm neck. After successful stent deployment, stent-assisted coil embolization was performed without complications. The stent anchor technique was successfully used to deploy an open-cell stent across the aneurysm neck in this case of microcatheter protrusion into the aneurysm during stent navigation.

[A Case Report of Stereotactic Craniotomy for the Cerebral Cavernous Angioma].

A 59-year-old woman presented with right sensory loss and right hemiparesis. In February 2013, she was admitted to Araki Neurosurgical Hospital. A magnetic resonance imaging was performed that revealed a left temporal lobe hemorrhage. The image also showed a chronic stereotype hematoma. After 14 days of hospitalization, she underwent a stereotactic craniotomy. Subsequently, by postoperative pathological evaluation, the hematoma was diagnosed as a cavernous angioma. She had no postoperative complications. She was provided rehabilitation support and was discharged 28 days after the admission following which she rejoined work. A stereotactic craniotomy device is very useful in surgeries involving deep lesions. We present a case of stereotactic craniotomy and a few investigation reports.

Usefulness of dual protection combined with blood aspiration for distal embolic protection during carotid artery stenting.

BACKGROUND: We describe dual protection (simultaneous flow reversal and distal filter) combined with blood aspiration as a novel technique to provide distal embolic protection during carotid artery stenting (CAS). METHODS: Between July 2011 and August 2014, 190 patients with internal carotid artery (ICA) stenosis underwent 190 CAS procedures as follows. After post-dilation of the stent using dual protection, the aspiration catheter was placed between the distal filter and the proximal end of the stent, and the blood was aspirated several times from the ICA. We assessed hyper-intensity spots in diffusion-weighted images (DWI), and major adverse events (MAE) defined as major stroke, myocardial infarction and death after CAS. We then assessed visible debris captured in aspirated blood, the distal filter and a blood filter during flow reversal. RESULTS: The overall technical success rate was 100 %, and all stenoses were dilated. Hyper-intense spots were found in 33 (17.3 %) of 190 DWI. The rate of MAE within 30 days was 1.05 % (2/190). Visible debris in 175 of 190 CAS procedures was captured in 92 (52.5 %) of these 175. In 25 (27.2 %) of these 92, visible debris was captured in all of aspirated blood, the distal filter and the blood filter during flow reversal, only the blood filter during flow reversal (n = 19; 20.7 %), only the distal filter (n = 14; 15.2 %), only aspirated blood (n = 11; 12 %), aspirated blood and the blood filter during flow reversal (n = 10; 10.8 %), aspirated blood and the distal filter (n = 7; 7.6 %) and the distal filter and blood filter during flow reversal (n = 6; 6.5 %). CONCLUSIONS: Adding a distal filter and blood aspiration to flow reversal during CAS could provide effective distal embolic protection.

Carotid artery stenting using the proximal or dual protection method for near occlusion of the cervical internal carotid artery.

The treatment for patients with near occlusion of the cervical internal carotid artery (ICA) is controversial. The aim of this study was to examine the results of carotid artery stenting (CAS) as a surgical treatment for ICA near occlusion. Between April 2008 and September 2012, 14 patients (all men; mean age, 75.4 years) with ICA near occlusion were treated with CAS. This represents 5.2% of a total of 267 patients treated with CAS during the study period. All patients were treated with CAS using an embolic protection device. The proximal balloon protection method was performed in five patients, and the dual protection method using a proximal balloon and distal filter protection was used in nine patients. We examined the change of stenotic lesion, hyperintensity spot in diffusion-weighted imaging (DWI), and perioperative complications after CAS. All near occlusions were successfully dilated. Among 2 of 14 patients, DWI showed 1 and 4 hyperintensity spots. Transient and persistent complications, including neurological deficits, did not occur in any patients. In this small number of cases, CAS using the proximal or dual embolic protection method seems to be a safe and beneficial treatment for ICA near occlusion.

Carotid artery stenting in a patient with right-sided aortic arch with an aberrant left subclavian artery.

A right-sided aortic arch with an aberrant left subclavian artery is a rare anatomical variation. We report a case treated with carotid artery stenting (CAS) for a patient with a right-sided aortic arch with an aberrant left subclavian artery. A 72-year-old man presented right hemiparesis due to acute brain infarction. Neck CT angiography showed 70% stenosis in the left internal carotid artery (ICA). We diagnosed acute brain infarction as artery-to-artery embolism due to ICA stenosis and decided to perform carotid artery stenting (CAS) for symptomatic ICA stenosis. CT angiography to evaluate an access route to the lesion incidentally showed the right-sided aortic arch with an aberrant left subclavian artery. An intraoperative aortogram showed a right-sided aortic arch. The guiding catheter was carefully introduced up to the left common carotid artery. CAS was performed with a proximal balloon and distal filter protection. The stenotic area was restored, and the patient was discharged without suffering recurrent attacks. Although a right-sided aortic arch with an aberrant left subclavian artery is a very rare anatomical variation, it can be encountered in neuroendovascular treatment, and therefore knowledge of this anatomical variation is important.

Endovascular coil embolization for ruptured aneurysm associated with persistent primitive anterior choroidal artery--case report.

An 18-year-old man presented with a rare case of a ruptured internal carotid artery (ICA)-persistent primitive anterior choroidal artery (PPAchA) manifesting as sudden onset of headache. Computed tomography (CT) showed subarachnoid hemorrhage. Three-dimensional CT angiography showed a saccular aneurysm at the right ICA-AchA region. Right internal carotid angiography showed a PPAchA and saccular aneurysm. Endovascular treatment of the aneurysm achieved complete aneurysm occlusion.

Cerebral angiography using gadolinium as an alternative contrast medium in a patient with severe allergy to iodinated contrast medium.

We report cerebral digital subtraction angiography (DSA) using Gadolinium in a patient allergic to iodinated contrast media. A 77-year-old woman was admitted to our hospital for surgical resection of a brain tumor. Although a DSA was requested as a preoperative examination, the patient had a history of allergic reaction to non-ionic iodinated contrast medium. Therefore, DSA was performed using Gadolinium. The DSA showed no tumor stain and normal venous drainage. The patient underwent surgical resection of the tumor and was discharged with no new neurological deficit. DSA using Gadolinium was useful in a patient with an anaphylactic reaction to iodinated contrast media.

Evaluation of dural arteriovenous fistulas of cavernous sinus before and after endovascular treatment using time-resolved MR angiography.

Digital subtraction angiography (DSA) is the preferred method for confirming dural arteriovenous fistulas (DAVFs), but it has the disadvantage of being invasive. In contrast, time-resolved magnetic resonance angiography (TR-MRA) is a useful, noninvasive imaging technique. The aim of this study was to compare the evaluation of DAVFs of the cavernous sinus (CS) using TR-MRA and DSA. TR-MRA and DSA were obtained in six patients with CS-DAVFs treated with endovascular surgery. TR-MRA and DSA before and after treatment were reviewed by one neuroradiologist without previous knowledge of the existence of CS-DAVFs for the detection and characterization (feeding artery and venous drainage) of CS-DAVFs. DSA showed six CS-DAVFs in the six patients. TR-MRA demonstrated a hyperintensity area in the CS at the arterial phase in six patients. DSA revealed feeding arteries and a drainage vein in all CS-DAVFs. In contrast, the feeding arteries could not be identified with TR-MRA. The details regarding venous drainage could only be speculated upon with TR-MRA as it was only partly visible on the TR-MRA images. DSA after embolization showed no CS-DAVFs in any of the six patients. TR-MRA showed no hyperintensity areas in the CS at the arterial phase in any of the six patients, and with no coil artifacts. In summary, TR-MRA could detect and diagnose CS-DAVF. However, the detail regarding anatomical feeders and draining veins remains poorly visualized by TR-MRA. In this small number of cases, TR-MRA can be a useful screening tool to detect CS-DAVF and possibly also to confirm persistent obliteration following definitive treatment.

Ruptured vertebral artery dissecting aneurysms treated with endovascular treatment.

Intracranial vertebral artery (VA) dissecting aneurysms often present with severe subarachnoid hemorrhage (SAH) and a subsequent high rate of mortality. We retrospectively studied the treatment efficacy and outcomes of 26 patients with ruptured VA dissecting aneurysms treated with endovascular surgery. Twenty-six patients with ruptured VA dissecting aneurysms were enrolled. Fifteen patients presented with poor-grade SAH and eleven with good-grade SAH. All patients were treated with endovascular treatment. We reviewed modes of therapy, complications and clinical outcomes. Coil occlusion of the artery at the dissecting aneurysm was performed in 24 patients. Proximal parent artery occlusion was performed in 2 patients. Obliteration of the dissecting aneurysm on postoperative angiogram was found in all patients. No patient sustained permanent complications associated with endovascular treatment. Regarding clinical outcome, although five patients died due to severe SAH, 19 patients had a good recovery or moderate disability. Ruptured VA dissecting aneurysms can be managed safely with coil occlusion of the lesion and/or parent artery.

Traumatic anterior communicating artery pseudoaneurysm with cavernous sinus fistula.

A traumatic carotid-cavernous fistula and an intracranial pseudoaneurysm are uncommon but well-known complications of head trauma. A rare subtype of arteriovenous fistula may occur from a pseudoaneurysm of the anterior communicating artery (AcoA) instead of the internal carotid artery. We describe a patient with a traumatic pseudoaneurysm of the AcoA with a cavernous sinus fistula treated with endovascular treatment. A 68-year-old man presented with a severe head injury after a fall. Coronal view multiplanar reformatted images with contrast medium showed gradual expansion of the pseudoaneurysm of the AcoA and the enhanced area of the cavernous sinus. Five weeks after the injury, the patient had a subarachnoid hemorrhage. A cerebral angiogram showed a fistula between the pseudoaneurysm of the AcoA and the cavernous sinus. The AcoA, left anterior cerebral artery and part of the pseudoaneurysm were obliterated by coil embolization. A postoperative angiogram showed no flow through the pseudoaneurysm and the cavernous sinus fistula. A traumatic AcoA pseudoaneurysm with a cavernous sinus fistula may occur as an extremely rare complication of head injury.

Ruptured subclavian artery pseudo-aneurysm associated with Neurofibromatosis type 1.

OBJECTIVE: A subclavian artery aneurysm associated with Neurofibromatosis type 1 (NF 1) is extremely rare. We report a ruptured pseudo-aneurysm of the subclavian artery in a patient with NF 1 treated with endovascular surgery. CLINICAL DESCRIPTION: A 51 year old man with NF 1 presented with initially sudden left neck pain and continuous dysphagia. Radiological examination showed a pseudo-aneurysm of the left subclavian artery. Endovascular stenting and coil embolisation was performed to prevent rebleeding and the lesion was completely obliterated. Follow-up angiography at 3 months revealed good flow through the stent without flow into the pseudo-aneurysm. CONCLUSION: Our patient is the first reported example of successful endovascular treatment for a ruptured subclavian artery pseudo-aneurysm associated with NF 1. Endovascular stenting and coil embolisation for the ruptured subclavian artery pseudo-aneurysm was very effective.

Endovascular coil occlusion of ruptured vertebral artery dissecting aneurysm: A case report

Ruptured vertebral artery dissecting aneurysm is more prone to re-bleeding and thus needs immediate surgical management. We present a case of 47 years old male with ruptured vertebral artery dissecting aneurysm which was immediately treated by endovascular surgery. Coil occlusion of the vertebral artery at the aneurysm site was performed. As emergency open surgery is often not possible, this case shows that endovascular surgery is an effective and helpful alternative.

Multiple concurrent anastomotic procedures in the management of moyamoya disease: a case report with review of literature.

It has already been proved by many studies that surgical revascularization definitely helps in curing the symptoms of moyamoya vasculopathy. In this regard, we present a case of moyamoya disease which was cured by concurrent multiple anastomotic procedures, namely superficial temporal artery (STA), middle cerebral artery (MCA) anastomosis, encephalomyosynangiosis (EMS) and encephalogaleosynangiosis (EGS). A 24-year-old woman presented with symptoms of cerebral ischemia. Thorough investigation with MRA and MRI revealed moyamoya vasculopathy and was confirmed by cerebral angiogram. Multiple concurrent combined anastomotic procedures on both sides relieved the symptoms, which was also confirmed angiographically. A Combination of multiple direct and indirect procedures covers the whole ischemic cortical area and provides effective neovascularization.

Course of apparent diffusion coefficient values in cerebral edema of dural arteriovenous fistula before and after treatment.

Apparent diffusion coefficient (ADC) values at magnetic resonance imaging (MRI) are useful to distinguish vasogenic and cytotoxic edema due to cerebovascular diseases. Dural arteriovenous fistulas (DAVFs) with retrograde leptomeningeal venous drainage may cause cerebral edema by venous congestion. We report herein the course of ADC values of cerebral edema before and after endovascular treatment in DAVFs. A 65-year-old woman with transverse-sigmoid (T-S) sinus DAVFs with retrograde leptomeningeal venous drainage presented with severe edema in cerebellar hemisphere and brainstem. In preoperative MRI, increased ADC values were observed in the edema area. The isolated sinus was obliterated completely by transvenous embolization. On the following day after treatment, the ADC values in cerebral edema area increased slightly without any new neurological deficits and improved at 1 week later. Rapid resolution of venous congestion due to DAVFs may cause a slight, transient progression of vasogenic edema.

Transient headache related to enlargement of the contralateral vertebral artery after vertebral artery occlusion.

BACKGROUND: Endovascular proximal parent artery occlusion has been performed for VA dissection. We describe a case that presented with headache associated with transient enlargement of contralateral VA after VA occlusion. CASE DESCRIPTION: A 54-year-old man presented with constant occipital headache on the left due to left VA dissection. Proximal parent artery occlusion of the left VA with detachable coils was performed, and the headache disappeared after coil occlusion. However, the patient presented with occipital headache on the right 1 week later. The MRI showed enlargement of the right VA compared with before the procedure. Four weeks later, the right occipital headache disappeared, and MRI showed improvement of enlargement of the right VA. CONCLUSION: The patient might present with right occipital headache related to transient enlargement of contralateral VA after VA occlusion. Careful postoperative neuroradiological examination of the contralateral VA is required because contralateral VA enlargement may be caused by hemodynamic stress after VA occlusion.

Expression of vascular endothelial growth factor in dura mater of patients with moyamoya disease.

Vascular endothelial growth factor (VEGF) has been found to be involved in vasculogenesis in different intracranial lesions. We investigated meningeal cellularity and VEGF expression in dura mater of patients with and without moyamoya disease. Nine dural specimens from nine cerebral hemispheres of seven patients with moyamoya disease and four control dural specimens from four non-moyamoya patients were collected during surgery and investigated. Dural specimens were immunohistochemically stained with VEGF antibody, and then meningeal cellularity and VEGF expression in dural tissue were analyzed. The mean+/-standard error (SE) of total number of meningeal cells (meningeal cellularity) in dural tissue was 21.5+/-3.0 in the moyamoya disease patients, whereas it was 2.7+/-0.7 in control patients. The mean+/-SE of VEGF expression was 51.1+/-4.9% in the moyamoya disease patients, whereas it was 13.8+/-5.9% in control patients. The meningeal cellularity and VEGF expression were statistically significantly higher in the moyamoya group in comparison to control group (p<0.0001). Meningeal cellularity and VEGF expression are significantly increased in dura mater of the patients with moyamoya disease.

Angiographic neovascularization after bypass surgery in moyamoya disease: our experience at Hiroshima University Hospital.

In this study, we investigated the effect of different bypass procedures on postoperative neovascularization in patients with moyamoya disease at Hiroshima University Hospital. Fourteen cerebral hemispheres of seven patients with moyamoya disease were investigated. Five of the 14 hemispheres underwent direct bypass surgery and the remaining 9 underwent indirect bypass. The neovascularization after bypass surgery was evaluated by cerebral angiography. The extent of angiographic neovascularization after direct or indirect bypass surgery was graded as good, fair or poor. Postoperative neovascularization status (good, fair or poor) was compared with the bypass procedure (direct and indirect bypass). Good neovascularization was observed in 8 hemispheres and the remaining 6 had poor neovascularization. Direct bypass surgery was significantly more effective for angiographic neovascularization than the indirect procedure in moyamoya patients (chi2-test, p<0.05). Therefore, we concluded that the direct bypass procedure is a better choice for moyamoya disease as evidenced by angiographic neovascularization.