Improvement of cerebral blood flow after balloon angioplasty and stenting for symptomatic middle cerebral artery stenosis.

OBJECTIVE: Although reports of endovascular treatment for intracranial arterial stenosis have been increasing recently, their efficacy remains to be elucidated. This study aimed to investigate the changes in cerebral hemodynamics of severe middle cerebral artery (MCA) stenosis patients by performing CT perfusion (CTP) after endovascular treatment. METHODS: Subjects were those who underwent balloon angioplasty and stenting for symptomatic MCA M1 stenosis refractory to medical therapy at our hospital between 2008 and 2022. We included 36 patients (mean age 63.69 ± 15.24 years, 20 males) who underwent CTP before and within three weeks after treatment. The CTP parameters such as relative cerebral blood flow (rCBF), relative cerebral blood volume (rCBV), and relative mean transit time (rMTT) were calculated as ipsilateral values divided by contralateral value. RESULTS: Endovascular treatment consisted of 26 balloon angioplasty and 10 stenting procedures performed at an average of 1 month from onset. CTP was performed at an average of 5.5 days postoperatively. The mean overall stenosis rate decreased from 79.0% to 30.3%. In the balloon angioplasty group, it decreased from 77.6% to 35.3%, and in the stent group, it decreased from 82.7% to 17.5%. After treatment, rCBF and rMTT measured by CTP improved significantly (both p < 0.001), whereas there was no significant change in rCBV. The improvement rates of rCBF and rMTT were mild higher in the stent group, but not significantly so. CONCLUSION: Balloon angioplasty and stenting for symptomatic MCA improved cerebral hemodynamics, resulting in significantly increased rCBF and decreased rMTT.

Long-term outcome and factors associated with restenosis after combination therapy of balloon angioplasty and stenting for symptomatic intracranial stenosis.

BACKGROUND: The optimal treatment for intracranial artery stenosis (ICAS) has not been established. We retrospectively examined the initial and long-term outcomes associated with restenosis of a combination therapy of balloon angioplasty and stenting for symptomatic atherosclerotic ICAS. METHODS: Consecutive patients who underwent balloon angioplasty and/or stenting for ≥ 70% ICAS between 2006 and 2020 were analyzed. Patients within 48 h of stroke onset were excluded. The following procedures were established as standards at our institution: (1) primary balloon angioplasty alone was initially performed; (2) stenting for insufficient dilatation, recoiling, or dissection was conducted; and (3) stenting was considered for restenosis. Intracranial ischemic and hemorrhagic complications within 30 days after treatment were used to evaluate periprocedural safety. Recurrent ischemic events, restenosis and restenosis related factors were used to be evaluate the long-term outcome. RESULTS: A total of 160 patients were recruited. Initial treatment consisted of balloon angioplasty (n = 101) and stenting (n = 59). Intracranial complications within 30 days after treatment were ischemic in five (3.1%) and hemorrhagic in four patients (2.5%). The incidence of these complication was 3.1% in the stenting group and 2.5% in the balloon angioplasty group. The mean follow-up period was 53.9 months. Restenosis was found in 42 patients (26%). Recurrent ischemic events during follow-up were noted in 14 patients (8.8%), of which six patients had TIA and eight patients had ischemic stroke. Restenosis-associated factors included diabetes, coronary artery disease, percent stenosis after treatment, and balloon angioplasty in logistic univariate analysis. Multivariate Cox regression analysis showed that diabetes (HR: 2.084, CI: 1.039-4.180, p = 0.0386), length of lesion (HR; 1.358, CI: 1.174-1.571, p < 0.0001), and balloon angioplasty (HR: 4.194, CI: 1.083-16.239, p = 0.0379) were independent predictors for restenosis. CONCLUSION: Combination therapy of balloon angioplasty and stenting for symptomatic ICAS had a low perioperative stroke rate and may improve long-term outcome. Balloon angioplasty, diabetes, and length of lesion were significantly associated with restenosis.

The Influence of Experience on Gazing Patterns during Endovascular Treatment: Eye-Tracking Study.

Objective: In various fields, differences in eye-gazing patterns during tasks between experts and novices have been evaluated. The aim of this study was to investigate gazing patterns during neuro-endovascular treatment using an eye-tracking device and assess whether gazing patterns depend on the physician's experience or skill. Methods: Seven physicians performed coil embolization for a cerebral aneurysm in a silicone vessel model under biplane X-ray fluoroscopy, and their gazing patterns were recorded using an eye-tracking device. The subjects were divided into three groups according to experience, highly experienced (Expert) group, intermediately experienced (Trainee) group, and less experienced (Novice) group. The duration of fixation on the anterior-posterior (AP) view screen, lateral (LR) view, and out-of-screen were compared between each group. Results: During microcatheter navigation, the Expert and Trainee groups spent a long time on fixation to AP, while the Novice group split their attention between each location. In coil insertion, the Expert group gazed at both the AP and the LR views with more saccades between screens. In contrast, the Trainee group spent most of their time only on the AP view screen and the Novice group spent longer out-of-screen. Conclusion: An eye-tracking device can detect different gazing patterns among physicians with several experiences and skill levels of neuroendovascular treatment. Learning the gazing patterns of experts using eye tracking may be a good educational tool for novices and trainees.

A Case Report of Contrast-Induced Encephalopathy after Repeated Percutaneous Transluminal Angioplasty for Acute Middle Cerebral Artery Occlusion.

Objective: We report a case of contrast-induced encephalopathy (CIE) after repeated percutaneous transluminal angioplasty (PTA) for acute middle cerebral artery (MCA) occlusion. Case Presentation: An 88-year-old woman with left hemiparesis was transferred to our hospital by ambulance. MRI revealed acute MCA M1 occlusion. We performed intravenous tissue plasminogen activator therapy and PTA for right MCA occlusion, leading to complete recanalization and improvement in hemiparalysis. After approximately one week, restenosis of right MCA developed and PTA was performed again on day 11. However, her left hemiparesis exacerbated shortly thereafter. CT demonstrated leakage of contrast medium, and an extensive high-intensity area (HIA) on the white matter in the right cerebral hemisphere was noted on MRI FLAIR. The HIA on MRI and neurological deficits gradually improved after conservative treatment, but diffuse atrophy of the right cerebral hemisphere occurred and higher brain dysfunction remained. Conclusion: Repeated ischemia and reperfusion, and the frequent use of contrast media were considered the causes of CIE.

A Case of Acute Ischemic Stroke Treated with Endovascular Treatment for Tandem Occlusion of the Common Carotid Artery and Internal Carotid Artery Terminal Portion Related to Takayasu Arteritis.

Objective: This report presents a case of mechanical thrombectomy for left internal carotid artery (ICA) terminal portion occlusion performed by left common carotid artery recanalization during hospitalization after diagnosing bilateral common carotid artery occlusion due to Takayasu arteritis. Case Presentation: A 25-year-old woman with fever and cervix pain a few months ago visited our department after repeated transient aphasic attacks. Magnetic resonance imaging (MRI) demonstrated diffuse infarction in the left middle cerebral artery (MCA) area, and she was diagnosed with Takayasu arteritis due to bilateral common carotid artery occlusion and left subclavian artery stenosis. On the 20th day of hospitalization, the terminal portion of the left ICA was occluded and thrombectomy was performed after balloon dilation of the left common carotid artery. Lastly, left common carotid artery stenting was performed. Aphasia and sensory disturbance remained, but she was transferred to a rehabilitation hospital with a modified Rankin Scale (mRS) of 2 on the 65th day of hospitalization. Antithrombotic and immunosuppressive therapy were performed, and restenosis did not develop. Conclusion: Angioplasty and stenting of common carotid artery occlusion can be effective treatments in thrombectomy for intracranial occlusion due to Takayasu disease.

Utility of transoral pharyngeal ultrasonography for puncture drainage of peritonsillar abscess.

Puncture drainage is usually needed to treat peritonsillar abscess. However, inadvertent carotid artery puncture may result in devastating complications. Preoperative transoral carotid ultrasonography (TOCU) is useful to delineate the anatomical relationship between the abscess and carotid artery. We present a case of peritonsillar abscess illustrating the utility of TOPU for safe drainage.

The utility of superb-microvascular imaging for evaluating the full length of carotid artery stents.

Transoral carotid ultrasonography (TOCU) is a powerful tool for evaluating internal carotid artery (ICA) lesions located from the carotid bifurcation up to the level of the second cervical vertebra. Superb-microvascular imaging (SMI) is a new Doppler imaging technique whose algorithm analyze tissue movements to minimize motion artifacts by eliminating clutter signals. SMI significantly reduces motion artifacts and allows visualization of low-velocity blood flow even in minute vessels. TOCU with SMI produces clear intraluminal image of the distal extracranial ICA, which is not possible with conventional carotid artery ultrasonography (CUS). CUS with SMI and TOCU with SMI were performed in a patient with a history of carotid artery stenting for symptomatic left ICA stenosis, providing images of the full length of the stents with intimal hyperplasia.

Utility of Duranta, a wireless patch-type electrocardiographic monitoring system developed in Japan, in detecting covert atrial fibrillation in patients with cryptogenic stroke: A case report.

RATIONALE: Subcutaneous implantable electrocardiographs are highly effective in detecting covert atrial fibrillation (AF) in cryptogenic stroke. However, these invasive devices are not indicated for all cryptogenic stroke patients, and noninvasive improvements over conventional Holter-type ambulatory electrocardiography are needed. We evaluated the clinical application and effectiveness of Duranta (ImageONE Co., Ltd.), a wireless patch-type electrocardiographic monitoring system developed in Japan for chronically ill patients or home-based patients at the end of life. A Duranta device was used to detect covert AF in patients with acute ischemic stroke of undetermined source with no sign of AF during cardiographic monitoring ≥24 hours postadmission. PATIENT CONCERNS: A 72-year-old man with severe aortic stenosis was admitted to our hospital with dysarthria and right upper limb weakness. Diffusion-weighted plain head magnetic resonance imaging (MRI) showed acute cerebral infarctions across the left middle cerebral artery territory. Twelve-lead electrocardiography, Holter-type ambulatory electrocardiography, and cardiographic monitoring for ≥24 hours revealed no AF, indicating a probable diagnosis of artery-to-artery embolism following left common carotid artery stenosis detected by carotid ultrasound imaging and cerebral angiography. INTERVENTIONS: However, because of high blood brain natriuretic peptide (BNP) and valvular heart disease, continuous monitoring using Duranta was performed from the 2nd to 13th days after onset to exclude possible cardioembolic stroke. Waveform and heart rate trend graph analysis showed paroxysmal AF (PAF) occurred on the 5th and 9th days after onset. PAF did not occur at any other time during the observation period. The quality of the cardiograms sufficed for analysis and diagnosis of AF. The lightweight compact device can be placed quickly with no movement restriction. These features and our findings show the usefulness of the Duranta device for long-term continuous monitoring. LESSONS: A noninvasive wireless patch-type electrocardiographic monitoring system, Duranta, placed at the precordium, was useful in detecting covert AF in cryptogenic stroke patients, warranting further investigation.