Subarachnoid Hemorrhage Revealing Moyamoya Syndrome in a Patient With May-Hegglin Anomaly.

INTRODUCTION: Moyamoya syndrome is a rare progressive cerebrovascular occlusive disease for which several associated conditions have been described. CASE REPORT: We report the case of a 76-year-old woman with a history of May-Hegglin anomaly who presented with an isolated unusual diffuse headache. Initial laboratory investigations showed only thrombocytopenia (platelet count 95000/µL). Unenhanced brain computed tomography scan revealed a small subarachnoid hemorrhage in the left frontal lobe. Computed tomography angiography showed occlusion of the terminal portion of the left internal carotid artery (ICA) and narrowing of the terminal portion of the right ICA with abnormal collateral vessels. Conventional angiography confirmed the tight stenosis of the extremity of the right ICA, and the occlusion of the left ICA, associated with an extensive collateral network consistent with moyamoya syndrome. No aneurysm was identified. CONCLUSIONS: The rarity of these 2 diseases makes a fortuitous association very unlikely. We thus concluded that this observation could be the first reported case of May-Hegglin anomaly as a cause of moyamoya syndrome.

Impact of Mechanical Thrombectomy on the Organization of the Management of Acute Ischemic Stroke.

BACKGROUND: Several trials and meta-analyses have recently demonstrated the superiority of endovascular therapy over standard medical treatment in patients presenting with acute ischemic stroke. In order to offer the best possible treatment to a maximum number of patients, many stroke care networks probably have to be reorganized. After analyzing the reliability of data in the literature, an algorithm is suggested for a pre-hospital and in-hospital alert system to improve the timeliness of subsequent treatment: a drip-and-ship approach. SUMMARY: Five recent well-designed randomized studies have demonstrated the benefit of endovascular therapy associated with intravenous fibrinolysis by recombinant tissue plasminogen activator (rt-PA) for acute ischemic stroke with confirmation by recent meta-analyses. The keys for success are a very short time to reperfusion, within 6 h, a moderate to severe pre-treatment deficit (National Institute of Health around 17), cerebral imaging able to identify proximal large vessel occlusion in the anterior circulation, a limited infarct core and a reversible penumbra, the use of the most recent devices (stent retriever) and a procedure that avoids general anesthesia, which reduces blood pressure. To meet these goals, every country must build a national stroke infrastructure plan to offer the best possible treatment to all patients eligible for intravenous fibrinolysis and endovascular therapy. The plan may include the following actions: inform the population about the first symptoms of stroke, provide the call number to improve the timeliness of treatment, increase the number of comprehensive stroke centers, link these to secondary and primary stroke centers by telemedicine, teach and train paramedics, emergency doctors and radiologists to identify the stroke infarct, proximal large vessel occlusion and the infarct core quickly, train a new generation of endovascular radiologists to improve access to this therapy. KEY MESSAGE: After 20 years of rt-PA, this new evidence-based therapy is a revolution in stroke medicine that will benefit patients. However, a new robust and multi-disciplinary care strategy is necessary to transfer the scientific data into clinical practice. It will require reorganization of the stroke infrastructure, which will include comprehensive stroke centers and secondary and primary stroke centers. The winners will be patients with severe stroke.

Spontaneous resolution of perforator aneurysms of the posterior circulation.

The authors present the cases of 3 patients with ruptured perforator aneurysms of the posterior circulation. Patients were 39, 55, and 59 years old. None of the patients had relevant past medical or family history. All presented with World Federation of Neurosurgical Societies Grade I and Fisher Grade 2 or 3 subarachnoid hemorrhage. Initial angiography results were normal. A second cerebral angiogram in each case revealed a small (< 3 mm) aneurysm of perforator arteries of the posterior circulation. Patients were successfully managed conservatively. None of the patients developed symptomatic vasospasm, rebleeding, or hydrocephaly. Control angiograms at 3 months showed spontaneous resolution of the aneurysm in all cases. Rupture of perforator aneurysms of the posterior circulation is a rare condition and it may be underdiagnosed because of limitations of imaging techniques. Treatments can lead to complications in highly functional territories and should be considered wisely, especially due to the fact that the causes and natural history of such aneurysms are unknown and spontaneous healing remains a possibility.

Collateral circulation in acute stroke: assessing methods and impact: a literature review.

Collateral circulation plays an important role in the clinical and radiological outcome after acute ischemic stroke. Several modalities are used to evaluate these alternative pathways with a growing interest in recent years. We conducted a literature review of studies evaluating collaterals at the acute phase of a carotid territory ischemic stroke. Most of them were based on conventional angiography and CT angiography, several on the basis of MRI and transcranial Doppler and, more recently, on the basis of dynamic CT angiography, which seems to be the most appropriate modality. Populations studied in these publications are often heterogeneous (especially concerning the occlusion site and the treatments performed) and many classifications have been proposed.

Solitaire FR as a first-line device in acute intracerebral occlusion: a single-centre retrospective analysis.

INTRODUCTION: Analysing the clinical and angiographical effectiveness of the Solitaire FR as a mechanical thrombectomy device in acute intracerebral occlusion. METHODS: Sixty-two patients were retrospectively included between January 2010 and March 2012. All of them underwent mechanical thrombectomy with the Solitaire FR device with or without intravenous thrombolysis. Twenty-five patients had an occlusion of the basilar artery, 1 had a posterior cerebral artery occlusion. There were 16 M1 middle cerebral artery occlusions, 9 carotid T occlusions and 11 tandem occlusions. Clinical status was evaluated using the National Institute of Health Stroke Scale (NIHSS) before and 24 hours after treatment and at discharge. The Modified Rankin Scale (mRS) was evaluated at 3 months. RESULTS: Mean age of patients was 64.8 years. Mean NIHSS score on admission was 19.8. Stand-alone thrombectomy was used in 47 patients (75.8%). Recanalization was successful (TICI score 2b or 3) in 23 of 26 (88.5%) patients with posterior circulation occlusion and in 23 of 36 (63.9%) patients with anterior circulation occlusion. NIHSS improved by more than 10 points for 15 of 59 patients with initial NIHSS over 10. MRS was 0-2 in 25 of 62 patients (40.3%). Overall, 23 patients out of 62 died (37%). No complications related to the Solitaire device occurred. CONCLUSION: These results confirm that the Solitaire FR device is safe and effective in stand-alone thrombectomy.