[A Case Report of Subacute Thrombosis after Carotid Stenting Caused by Food Allergy].

An 89-year-old man underwent carotid artery stenting for symptomatic left internal carotid artery stenosis. His postoperative course was uneventful;however, on postoperative day 4, he developed a food allergy rash throughout his body after consuming sushi. He developed right hemiplegia and aphasia the following day, and magnetic resonance imaging revealed left internal carotid artery occlusion. Angiography revealed stent thrombosis, and endovascular thrombectomy achieved partial recanalization;however, right hemiplegia and aphasia persisted. Eosinophilia and increased platelet aggregation suggested allergic stent thrombosis(Kounis syndrome type 3).

[A Case Report of Endovascular Thrombectomy for Internal Carotid Artery Thromboembolism after Left Upper Lobectomy of Lung Cancer].

A 76-year-old man underwent a left upper lobectomy due to lung cancer. On postoperative day 3, he developed a cerebral infarction(NIHSS:17). MR and right carotid angiography demonstrated a right internal carotid artery occlusion. The patient underwent an endovascular thrombectomy without intravenous administration of recombinant tissue plasminogen activator. Complete recanalization was achieved and the symptoms almost disappeared except for a slight dysarthria. The patient subsequently continued cancer treatment by administration of edoxaban. Reports of cerebral emboli due to a thrombus migrating from the stump of the pulmonary vein after a left upper lobectomy are increasing. Several reports indicate that left upper lobectomy carries a high risk of thromboembolism. The current prospective study demonstrates that a mechanical thrombectomy can significantly improve both neurological and cognitive functions of patients after acute ischemic stroke. Endovascular neurosurgeons should prepare for and await an opportunity for thrombectomy for patients undergoing pulmonary resection.

[A Case of Spontaneous Intracranial Hypotension Successfully Treated with Repetitive Epidural Blood Patch after Warfarin Reversal].

We report a case of spontaneous intracranial hypotension successfully treated with repetitive epidural blood patch after warfarin reversal. A 75-year-old man presented with a 2-week history of headache. He was being treated with warfarin for atrial fibrillation. Neurological examination on admission showed mild disorientation. Prothrombin time-international normalized ratio(PT-INR)was elevated to 2.43. Initial magnetic resonance images of the brain demonstrated bilateral subdural hematomas, distortion of midbrain and diffuse pachymeningeal enhancement. Conservative treatments with bed rest and hydration were administered. On the third posthospital day, he became lethargic and emergently underwent epidural blood patch(EBP)at lumbar level. Consciousness disturbance improved immediately but reappeared 12 hours after the EBP. The second EBP was performed but consciousness level decreased again 12 hours later. The effect of warfarin was reversed by administration of vitamin K and fresh frozen plasma before the third EBP. After the procedure, he became alert. The findings of neurological examination did not change but a CT on day 12 revealed increase in volume of left-sided subdural hematoma. He underwent EBP and evacuation of hematoma. The neurological findings remained unchanged. A CT on the 17th posthospital day showed increase of right-sided subdural hematoma, and EBP and evacuation of hematoma were then performed. After the 5th EBP, the clinical course was uneventful. Predictors for successful EBP are not fully clarified. In patients who undergo anticoagulation therapy, EBP may be ineffective and normalization of coagulability required.

[A Case Report of Basilar Artery Thromboembolism from Severe Stenosis of the Vertebral Artery Ostium].

We report a case of basilar artery embolism from the large thrombus of the right vertebral artery with severe stenosis of the vertebral artery ostium. Intravenous recombinant tissue plasminogen activator treatment and thrombectomy by catheter with reverse blood flow using a proximal subclavian artery blocking balloon(intentional subclavian artery steal phenomenon)were performed. A large thrombus along with other small thrombi were removed by an aspiration catheter. Additional stent placement was performed for residual vertebral artery stenosis, at ten days after the thrombectomy. Finally, the patient was discharged without any neurological deficits.

[A Case Report of Congenital Protein C Deficiency with Cerebral Venous Sinus Thrombosis during Early Pregnancy Period].

A 35-year-old woman at eight weeks of gestation in her second pregnancy presented with generalized seizures. Magnetic resonance images revealed a small hemorrhagic infarction in the left frontal lobe, and magnetic resonance venography indicated cerebral venous sinus thrombosis. After hospitalization, anticoagulant therapy was continued, and a low protein C level was confirmed, which was also confirmed in both her mother and her sister. Follow-up magnetic resonance venography performed on day 27 confirmed that the cerebral venous sinuses had undergone recanalization. After a completed gestation period, the patient gave birth to healthy girl uneventfully.

[Cerebral Venous Sinus Thrombosis Following Cisplatin-Based Chemotherapy for Testicular Tumor].

A man in his 30s who presented with an enlarged right testicle was diagnosed with a germ cell tumor via orchiectomy. Adjuvant chemotherapy with cisplatin, etoposide and bleomycin(BEP)was initiated. He developed a headache 8 days later, followed by neurological deficits 10 days later. Magnetic resonance imaging(MRI)and magnetic resonance venography(MRV)showed thrombotic occlusion at the superior sagittal sinus. Anticoagulant therapy with heparin was initiated. However, a generalized epileptic seizure occurred 11 days later, and an antiepileptic drug therapy was initiated. The headache and neurological deficits gradually improved, and MRI findings showed that the superior sagittal sinus had re-canalized. The main cause of the sinus thrombosis in this patient was considered dehydration and cisplatin-induced hypercoagulability. Five courses of BEP therapy were carried out with care to avoid dehydration. The patient has remained free of testicular tumor recurrence, metastasis, and cerebral sinus thrombosis for 2 years. Cisplatin-based chemotherapy is an established risk factor for venous thromboembolism(VTE), and cerebral sinus thrombosis is a rare but dangerous complication. Therefore, cerebral sinus thrombosis should be considered when patients with testicular cancer who undergo cisplatin-based chemotherapy start to develop neurological symptoms. Clinicians should be aware of this treatable complication.

[A Case of Paradoxical Cerebral Embolism Developed during in vitro Fertilization Treatment].

A 35-year-old woman with a history of infertility, was presented to our hospital because of impaired consciousness and cerebellar ataxia, 14 days after in vitro fertilization. She received an embryo transfer under controlled ovarian hyper-stimulation. Magnetic resonance images revealed acute infarction in the cerebellum and brainstem. Magnetic resonance angiography showed a basilar artery occlusion at the end point. Following immediate intravenous rt-PA treatment, the symptoms disappeared completely. A transesophageal echocardiography revealed an atrial septal defect with a continuous left to right shunt. In addition, a Valsalva maneuver trans-esophageal echocardiography with injected saline showed the presence of jet bubbles in the left atrium crossing via the atrial septal defect. She was diagnosed with paradoxical cerebral embolism. Anticoagulant therapy was continued and she gave birth to a healthy baby. Deep vein thrombosis was associated with the ovarian hyper-stimulation syndrome that occurred during infertility treatment. As anti-phospholipid antibodies were weakly positive, the possibility of anti-phospholipid antibody syndrome was suggested. If a woman of childbearing age is presented because of stroke, it is important to administer initial therapy by keeping fertility in mind. Thrombolytic therapy for pregnant women should be carefully considered, because of the associated hazards; however, it is a very important treatment for maternal function after birth.

Acquired pial and dural arteriovenous fistulae following superior sagittal sinus thrombosis in patients with protein S deficiency: a report of two cases.

Two patients with protein S deficiency with acquired multiple pial and dural arteriovenous fistulae (AVFs) following superior sagittal sinus (SSS) thrombosis are reported. Case 1 is a 38-year-old male with protein S deficiency who developed generalized seizure due to SSS thrombosis. Local fibrinolysis was achieved in the acute stage. His 10-month follow-up angiogram revealed an asymptomatic acquired dural AVF arising from the middle meningeal artery and the anterior cerebral artery with drainage to the thrombosed cortical vein in the right frontal lobe. Furthermore, his 2-year follow-up angiogram revealed a de novo pial AVF from the middle cerebral artery in the Sylvian fissure with drainage to the cortical vein initially thrombosed. However, this asymptomatic pial AVF caused bleeding in the ipsilateral cerebral hemisphere 12 years after onset, whereas the dural AVF spontaneously disappeared. Surgical disconnection was successfully performed to eliminate the source of hemorrhage. Case 2 is a 50-year-old male with a past history of SSS thrombosis with protein S deficiency who developed pulsatile tinnitus and generalized seizure. His angiogram showed a cortical dural AVF in the left parietal lobe and a sporadic dural AVF involving the right sigmoid sinus. The parietal lesion was eliminated by transarterial embolization followed by craniotomy. However, a de novo pial AVF emerged from the middle cerebral artery adjacent to the previously treated lesion. Of four cortical AVFs in two patients, thrombosis of cortical veins caused by protein S deficiency might play an important role in their formation. Long-term follow-up is required because this peculiar disorder has an unusual clinical course.

Remora technique to approach the affected, difficult to approach sinus at transvenous embolization for dural arteriovenous fistulae: case report.

BACKGROUND AND IMPORTANCE: We describe a novel technique that uses a goose neck snare for microcatheterization at transvenous embolization (TVE) for dural arteriovenous fistulae (dAVF). We have named our method the "remora technique." CLINICAL PRESENTATION: A 48-year-old man reported with dizziness. Angiography disclosed a transverse-sigmoid sinus (T-SS) dAVF with proximal sigmoid sinus occlusion, an open distal transverse sinus, narrow multiple divided confluence sinus, and multiple retrograde leptomeningeal venous drainage. We attempted TVE via the confluence sinus from the contralateral open side; it was narrow, steep, and divided into cavities, rendering the procedure very difficult. Although we were able to pass a 0.035-inch guidewire to the affected transverse sinus, we could not advance via the same route with the microguidewire. One month later we attempted transfemoral TVE again using the remora technique. We caught the 0.035-inch guidewire in the left internal jugular vein with a goose neck micro snare bearing a microcatheter. By advancing the 0.035-inch wire across the confluence sinus to the affected sinus, we were able to pass the microcatheter through the lesion using the snare like a remora. We then performed transvenous coil packing. CONCLUSION: In TVE for dAVF, passage of the microguidewire is often difficult. Even if the affected sinus can be reached with the stiff 0.035-inch guidewire, it may not be possible to follow with the microguidewire. We report on a patient with T-SS dAVF who underwent successful microcatheterization in which we used our remora technique with a goose neck snare.