Impact of cancer history on long-term outcome after elective neuro-endovascular treatment in patients aged 80 years or older: A retrospective multicenter observational study.

AIM: Assessing the indication for elective neuro-endovascular treatment (EVT) in older patients requires consideration of the impact of systemic comorbidities on their overall reduced life expectancy. The objective of this study was to determine the long-term outcomes of elective neuro-EVT in patients aged ≥80 years, and to investigate the impact of pre-existing cancer on their long-term outcomes. METHODS: Of the patients enrolled in multicenter observational registry, those aged ≥80 years undergoing elective neuro-EVT between 2011 and 2020 were enrolled. A history of cancer was defined as a pre-existing solid or hematologic malignancy at the time of EVT. The primary outcome was time to death from elective neuro-EVT. RESULTS: Of the 6183 neuro-EVT cases implemented at 10 stroke centers, a total of 289 patients (median age, 82 years [interquartile range 81-84 years]) were analyzed. A total of 58 (20.1%) patients had a history of cancer. A total of 78 patients (27.0%) died during follow up. The 5-year survival rate of enrolled patients was 64.6%. Compared with patients without a history of cancer, those with a history of cancer showed significantly worse survival (log-rank test, P = 0.001). Multivariate Cox proportional hazards analysis showed history of cancer was an independent predictor of time to death from elective neuro-EVT (HR 1.74, 95% CI 1.01-3.00, P = 0.047). Cancer was the leading cause of death, accounting for 25.6% of all deaths. CONCLUSIONS: The present study showed that history of cancer has a significant impact on time to death from elective neuro-EVT in patients aged ≥80 years. Geriatr Gerontol Int 2024; 24: 211-217.

Ultra-short Echo-time MR Angiography Combined with a Subtraction Method to Assess Intracranial Aneurysms Treated with a Flow-diverter Device.

A flow-diverter (FD) device is a well-established tool for the treatment of unruptured intracranial aneurysms. Time-of-flight (TOF) MR angiography (MRA) is widely used for postoperative assessment after the treatment with FD; however, it cannot fully visualize intra-aneurysmal and intrastent flow signals due to the magnetic susceptibility from the FD. Recently, the utility of MRA with ultra-short TE (UTE) sequence and arterial spin labeling technique in assessing the therapeutic efficacy of intracranial aneurysms treated with metallic devices has been reported, but long image acquisition time is one of the drawbacks of this method. Herein, we introduce a novel UTE MRA using the subtraction method that enables the reduction in susceptibility artifacts with a short image acquisition time.

Changes in cerebral oxygenation during hemodialysis before and after carotid artery stenting.

A 68-year-old man received hemodialysis (HD) for the treatment of end-stage renal failure for 6 years. Five years prior to carotid artery stenting (CAS), a neck ultrasound performed to screen for carotid atherosclerosis revealed an asymptomatic right internal carotid artery stenosis. One month prior, the stenotic lesion progressed to 74% by cerebral angiography; therefore, CAS was performed. To evaluate the influence of right internal carotid artery stenosis on the intradialytic cerebral circulation and oxygenation, cerebral regional oxygen saturation (rSO2) at bilateral forehead was measured using the INVOS 5100c oxygen saturation monitor (Covidien Japan, Japan) during HD before and after CAS. Before CAS, right cerebral rSO2 was maintained during HD, whereas left cerebral rSO2 gradually increased from the initiation to end of HD. However, the differences of intradialytic cerebral rSO2 changes between bilateral sides disappeared after CAS. In the present case, before CAS, the intradialytic increase in left cerebral rSO2 might reflect the increase in the left cerebral blood flow to compensate for the ultrafiltration-associated decreases in the right cerebral blood flow and perfusion pressure. Furthermore, the preserved right cerebral rSO2 before CAS might reflect the mechanism maintaining the right cerebral blood flow from the collateralized circle of Willis during HD. Throughout our experience, cerebral oxygenation monitoring during HD might disclose intradialytic changes in cerebral blood flow distribution between the ipsilateral and contralateral side in HD patients with carotid artery stenosis.

Endovascular Treatment for Acute Ischemic Stroke After Video-Assisted Thoracoscopic Pulmonary Lobectomy in Patients With Lung Cancer: A Report of Four Cases and Literature Review.

BACKGROUND: Postoperative cerebral embolic stroke is a serious complication of pulmonary lobectomy, occurring in 1.1% of patients undergoing lobectomy through video-assisted thoracoscopic surgery (VATS). The mechanism of this complication is thought to be embolic stroke caused by thrombus formed due to stagnation in the pulmonary vein stump after VATS lobectomy. There have been few reports demonstrating the utility of endovascular treatment (EVT) for cerebral embolic stroke after VATS lobectomy. CASE DESCRIPTION: In our case series, cerebral embolic stroke occurred after VATS pulmonary lobectomy for lung cancer, including the left upper lobe in three cases and the right lobe in one. The median duration of ischemic stroke after VATS was 4.5 days (interquartile range, 2-9 days). The median time from stroke onset to puncture was 130 min. Successful recanalization was achieved in all cases, and two patients achieved favorable clinical outcomes (modified Rankin scale, 0-2). CONCLUSION: We report a case series of four patients who underwent EVT for acute embolic stroke after VATS lobectomy for lung cancer. EVT is considered a reasonable and feasible therapeutic option for this condition.

A Case of Idiopathic Intracranial Hypertension Treated by Transverse Sinus Stenting.

Objective: We report a patient with chronic headache due to idiopathic intracranial hypertension (IIH) associated with transverse sinus (TS) stenosis. The symptom improved after stent placement at the site of stenosis. Case Presentation: The patient was a 37-year-old woman with progressive headache and diplopia as chief complaints. She had severe bilateral papilledema. Magnetic resonance imaging (MRI) and angiography revealed stenosis of the bilateral TS. Lumbar puncture demonstrated raised intracranial pressure and IIH was tentatively diagnosed. Visual impairment progressed despite oral acetazolamide therapy. A venous pressure gradient was monitored during stent placement. The pressure gradient improved after stenting. Dual antiplatelet therapy was initiated 1 week before the procedure. Papilledema and headache resolved immediately after the procedure. No in-stent stenosis or occlusion occurred during the follow-up period. Conclusion: Stent placement for TS stenosis can improve the cerebral venous return in IIH patients. Although restenosis is possible, venous sinus stenting is considered an effective treatment.

Reperfusion therapy of acute ischemic stroke in an all-in-one resuscitation room called a hybrid emergency room.

Acute ischemic stroke (AIS) caused by major vessel occlusion has potentially poor outcomes. Early successful recanalization after symptom onset is an important factor for favorable outcomes of AIS. We present the case of a 74-year-old man with AIS who underwent the entire process from diagnosis to thrombolysis and endovascular treatment in a hybrid emergency room (ER) equipped with a multidetector computed tomography (CT) scanner and an angiography suite set-up. A hybrid ER can facilitate evaluation and definitive interventions in patients with AIS more quickly and safely and in one place, without the requirement for transfer to a CT scanner or angiography suite set-up. In the present case, the door-to-puncture time and door-to-reperfusion time were 85 and 159 min, respectively, which were shorter than those in the group conventionally treated for stroke in our institution. Further study is needed to confirm the effect of the hybrid ER system.

Effects of propofol versus sevoflurane on cerebral circulation time in patients undergoing coiling for cerebral artery aneurysm: a prospective randomized crossover study.

Many neuroendovascular treatments are supported by real-time anatomical and visual hemodynamic assessments through digital subtraction angiography (DSA). Here we used DSA in a single-center prospective randomized crossover study to assess the intracranial hemodynamics of patients undergoing coiling for cerebral aneurysm (n = 15) during sevoflurane- and propofol-based anesthesia. Color-coded DSA was used to define time to peak density of contrast medium (TTP) at several intravascular regions of interest (ROIs). Travel time at a particular ROI was defined as the TTP at the selected ROI minus TTP at baseline position on the internal carotid artery (ICA). Travel time at the jugular bulb on the anterior-posterior view was defined as the cerebral circulation time (CCT), which was divided into four segmental circulation times: ICA, middle cerebral artery (MCA), microvessel, and sinus. When bispectral index values were kept between 40 and 60, CCT (median [interquartile range]) was 10.91 (9.65-11.98) s under propofol-based anesthesia compared with 8.78 (8.32-9.45) s under sevoflurane-based anesthesia (P < 0.001). Circulation times for the ICA, MCA, and microvessel segments were longer under propofol-based anesthesia than under sevoflurane-based anesthesia (P < 0.05 for all). Our results suggest that, relative to sevoflurane, propofol decreases overall cerebral perfusion.

[A Case of Pseudoaneurysm of the Lingual Artery that was Difficult to be Distinguished from Epistaxis].

We describe the case of a 75-year-old man with pharyngeal hemorrhage caused by a pseudoaneurysm of the lingual artery after accidentally swallowing his dentures. He developed sudden oral and nasal hemorrhage and was transported to a hospital near his residence. The doctors at the hospital diagnosed the case as epistaxis and treated the symptom with nasal packing. However, the bleeding did not stop and his blood pressure decreased. He was then transported to our hospital. We assumed that the bleeding was caused by epistaxis from branches of the internal maxillary artery, and tried to stop bleeding with the endovascular treatment using coils or liquid embolus materials. Angiography showed a pseudoaneurysm of the lingual artery. Coil embolization against the artery was effective in controlling bleeding. Correct diagnosis and appropriate treatments based on the correct diagnosis are essential in this case of swallowed dentures and bleeding of pseudoaneurysm of the lingual artery.

Successful coil embolization of a ruptured basilar artery aneurysm in a child with leukemia: a case report.

Ruptured intracranial aneurysms are rare in the pediatric population compared to adults. This has incited considerable discussion on how to treat children with this condition. Here, we report a child with a ruptured saccular basilar artery aneurysm that was successfully treated with coil embolization. A 12-year-old boy with acute lymphoblastic leukemia and accompanying abdominal candidiasis after chemotherapy suddenly complained of a severe headache and suffered consciousness disturbance moments later. Computed tomography scans and cerebral angiography demonstrated acute hydrocephalus and subarachnoid hemorrhage caused by saccular basilar artery aneurysm rupture. External ventricular drainage was performed immediately. Because the patient was in severe condition and did not show remarkable signs of central nervous system infection in cerebrospinal fluid studies, we applied endovascular treatment for the ruptured saccular basilar artery aneurysm, which was successfully occluded with coils. The patient recovered without new neurological deficits after ventriculoperitoneal shunting. Recent reports indicate that both endovascular and microsurgical techniques can be used to effectively treat ruptured cerebral aneurysms in pediatric patients. A minimally invasive endovascular treatment was effective in the present case, but long-term follow-up will be necessary to confirm the efficiency of endovascular treatment for children with ruptured saccular basilar artery aneurysms.

Clinical characteristics and surgical outcomes of patients with aneurysmal subarachnoid hemorrhage and acute subdural hematoma undergoing decompressive craniectomy.

OBJECTIVE: This report presents 12 consecutively managed patients with aneurysmal subarachnoid hemorrhage (SAH) associated with acute subdural hematoma (ASDH) who underwent decompressive craniectomy (DC) with special attention to their clinical characteristics and surgical outcomes. METHODS: We retrospectively reviewed medical charts, radiologic findings, surgical notes, and video records. RESULTS: Among these 12 patients (mean age 59.1 years, 4 men, 8 women), the Hunt and Kosnik clinical grade was grade V in 7 patients (58.3%), grade IV in 2 patients (16.7%), grade III in 2 patients (16.7%), and grade II in 1 patient (8.3%). The aneurysms were located on the internal carotid artery in four patients, the middle cerebral artery in six patients, and the anterior communicating artery in two patients. Computed tomography findings on admission revealed ASDH in all patients. In addition, SAH was seen in 11 patients. An intracerebral hematoma was found in eight patients, intraventricular hemorrhaging occurred in four, and an acute hydrocephalus was seen in one patient. All patients underwent a microsurgical clipping procedure and an additional DC. Symptomatic vasospasm was confirmed in six (50%), and eight patients with chronic hydrocephalus received a ventriculoperitoneal shunt (67%). The Glasgow Outcome Scale at discharge showed good recovery in five patients (41.7%), severe disability in four (33.3%), vegetative state in two (16.7%), and death in one patient (8.3%). A favorable outcome was achieved in five patients (41.7%). CONCLUSIONS: We suggest that the DC was effective for reducing morbidity and mortality in poor grade patients with SAH presenting with ASDH.

Middle cerebral artery occlusion resulting from hypereosinophilic syndrome.

Hypereosinophilic syndrome (HES) is a rare disorder that can cause ischemic stroke. We present a patient with middle cerebral artery (MCA) occlusion resulting from HES. Transarterial thrombolysis resulted in MCA recanalization and adjuvant therapy may have contributed to stabilization of the underlying HES in our patient.

Surgical outcome following a decompressive craniectomy for acute epidural hematoma patients presenting with associated massive brain swelling.

Acute epidural hematomas (AEDH) are generally managed with rapid surgical hematoma evacuation and bleeding control. However, the surgical outcome of patients with serious brain edema is poor. This study reviewed the clinical outcome for AEDH patients and evaluated the efficacy of the DC, especially in patients with associated massive brain swelling. Eighty consecutive patients surgically treated with AEDH were retrospectively assessed. The patients were divided into two groups: (a) hematoma evacuation (HE: 46 cases) and (b) HE+ an external decompression (ED: 34 cases). The medical charts, operative findings, radiological findings, and operative notes were reviewed. In the poor outcome group, there were 18 patients (72%), with a GCS score of less than 8 (severe injury), and 22 patients (88%) who showed pupil abnormalities. Many more patients showed a midline shift, basal cistern effacement, and brain contusion in comparison to the favorable outcome group. In the favorable outcome group, almost all of the patients (98%) showed less than 12 mm of a midline shift. The influential factors may be age, GCS, pupil abnormalities, size, midline shift, basal cistern effacement, coincidence of contusion and swelling. We conclude that an A DC may be effective to manage the AEDH patients with cerebral contusion or massive brain swelling.

Significance of monitoring the initial intracranial pressure on hematoma irrigation with trephination therapy for acute subdural hematomas in critical conditions.

Acute subdural hematoma (ASDH) patients presenting in a severe condition tend to have poor outcomes due to the significant brain edema required to maintain the ICP at less than 20-25 mmHg. This study compared the surgical outcomes of 16 critically ill patients with ASDH who underwent hematoma irrigation with trephination therapy (HITT) based on their initial ICP values. The initial mean GCS score upon admission was four. A unilateral dilated pupil was seen in one and bilateral dilated pupils were seen in seven patients. The co-existence of a brain contusion was seen in seven patients, brain swelling was noted in six patients, and both basal cistern effacement and a midline shift greater than 5 mm were observed in all patients. The mean initial ICP value was 45 mmHg (range: 3 to 85 mmHg). Ten patients (62.5%) underwent a rapid external decompression to evacuate the hematoma. By using the Glasgow Outcome Scale upon discharge a score of good recovery (GR) was assigned to two (12.5 %), moderate disability (MD) to four (25.0 %), vegetative state (VS) to two (12.5 %), and death (D) to eight (50.0 %) patients. All six patients who showed an initial ICP greater than 60 mmHg died despite intensive care. Eight patients who showed an initial ICP less than 40 mmHg had a favorable outcome, but two patients deteriorated due to a traumatic cerebrovascular disorder. It seems that the initial ICP monitoring with HITT for ASDH patients in critical condition may be an important factor for predicting both surgical outcome and clinical course.

Prognosis for severe traumatic brain injury patients treated with bilateral decompressive craniectomy.

PURPOSE: Decompressive craniectomy for traumatic brain injury patients has been shown to reduce intracranial hypertension, while it often results in increased brain edema and/or contralateral space-occupied hematoma. The purpose of this study was to determine the prognosis of bilateral decompressive craniectomy in severe head injury patients with the development of either bilateral or contralateral lesions after ipsilateral decompressive craniectomy. METHODS: Twelve patients underwent bilateral decompressive craniectomy among 217 individuals who had been treated with decompressive craniectomy with dural expansion from September 1995 to August 2006. The following patient data were retrospectively collected: age, neurological status at admission, time between injury and surgical decompression, time between first and second decompression, laboratory and physiological data collected in the intensive care unit, and outcome according to the Glasgow Outcome Scale. RESULTS: Patient outcomes fell into the following categories: good recovery (three patients); mild disability (one patient); severe disability (two patients); persistent vegetative state (one patient); and death (five patients). Patients with good outcomes were younger and had better pupil reactions and neurological statuses on admission. Other factors existing prior to the operation did not directly correlate with outcome. At 24 h post-surgery, the average intercranial pressure (ICP), cerebral perfusion pressure (CPP), glucose level, and lactate level in patients with poor outcomes differed significantly from those of patients with a good prognosis. CONCLUSION: Head injury patients with either bilateral or contralateral lesions have poor prognosis. However, bilateral decompressive craniectomy may be a favorable treatment in certain younger patients with reactive pupils, whose ICP and CPP values are stabilized 24 h post-surgery.

Hemorrhagic encephalitis associated with Epstein-Barr virus infection.

Epstein-Barr virus (EBV) encephalitis is a rare neurological complication, usually only reported in pediatric patients. We present a 20-year-old, previously healthy male who developed hemorrhagic encephalitis caused by EBV. He was admitted to our hospital with a 1-week history of fever, diarrhea, headache, and confusion. Brain T2-weighted MRI showed a focal area of increased signal in the right temporal lobe. Brain MRI and CT scans on day 2 revealed progression of the lesion, with partial hemorrhagic change, acute brain swelling, and severe midline shift. The patient underwent external decompression and external ventricular drainage. EBV DNA was identified in brain biopsy specimens by polymerase chain reaction. The postoperative course was uneventful. To our knowledge, this is the second report of hemorrhagic EBV encephalitis in an adult.

[Unusual distribution of blood in a ruptured aneurysm--case report].

Computed tomography (CT) is an important tool for the evaluation of subarachnoid hemorrhages caused by ruptured aneurysms. However, an unusual radiologic presentation of blood can result in the misdiagnosis of the rupture site. We report a case of ruptured right internal carotid-posterior communicating (IC-PC) artery aneurysm with an unusual radiologic presentation of hemorrhage. The CT scans images of this patient were indicative of blood clots in the cisterna magna and the ventricles with no blood collection in the suprasellar cistern or sylvian fissure. The intraventricular clots were mainly distributed in the fourth ventricle, with few clots in the lateral ventricles. On the basis of these findings, we suspected the origin of the hemorrhage was an unknown ruptured posterior fossa aneurysm. However, angiography revealed a right internal carotid-posterior communicating (IC-PC) artery aneurysm. Twenty-three days after onset, a repeat CT confirmed that the origin of the hemorrhage was the right IC-PC aneurysm. Possible factors involved in this case were: (1) formation of adhesions in the subarachnoid cisterns due to an earlier minor leakage, (2) the orientation of the aneurysm (posteroinferior direction), and (3) early wash out of the blood clot.

[Case of ruptured middle cerebral artery bifurcation aneurysm presenting as putaminal hemorrhage without subarachnoid hemorrhage].

Ruptured aneurysms typically present as subarachnoid hemorrhage (SAH); however, they can also cause intracerebral hemorrhage (ICH) that can be mistaken for hypertensive hemorrhage. We report a rare case of a ruptured middle cerebral artery bifurcation aneurysm presenting as putaminal hemorrhage without subarachnoid hemorrhage (SAH). A 47-year-old man, with a past history of hypertension, presented with a decreased level of consciousness. Neurological examination revealed hemiparesis of the right side. A CT scan on admission demonstrated left putaminal hemorrhage without SAH. Three-dimensional CT and conventional angiograms demonstrated a superiorly directing aneurysm of the M1/M2 portion of the left middle cerebral artery (MCA). We performed aneurysmal clipping and hematoma evacuation. The postoperative course was uneventful. This case suggested that ruptured aneurysms situated on the middle cerebral artery can present as putaminal hemorrhage without SAH.

[A case of traumatic middle meningeal arteriovenous fistula on the side of the head opposite to the injured side].

A rare case of a traumatic middle meningeal arteriovenous fistula on the side of the head opposite to the injured side was reported. A 21-year-old man was admitted to our hospital after a traffic accident in which the right side of his head was hit. CT scans and MR images on admission showed a right temporal bone fracture, traumatic subarachnoid hemorrhage, and a left frontal lobe contusion. Three months after the head injury, he complained of tinnitus and exophthalmos. One year after the head injury, left external carotid angiograms showed a dural arteriovenous fistula fed by the left dilated middle meningeal artery and draining into the middle meningeal vein. Early filling of the sphenoparietal sinus, cavernous sinus, superior ophthalmic vein, and the cortical vein were also detected. Transarterial embolization of the left middle meningeal fistula was performed, resulting in the disappearance of the lesion. The postoperative course was uneventful.