Acute Ischemic Stroke due to Internal Carotid Artery Dissection in a 10-Year-Old Child.

A 10-year-old girl was transferred to our hospital with left hemiparesis. Diffusion-weighted magnetic resonance imaging (MRI) of the brain showed a signal lesion in the right posterior limb of the internal capsule and magnetic resonance angiography showed poor visualization of the right internal carotid artery (ICA), and a defect area was present in a part of the supraclinoid portion of the right ICA. Based on the clinical and radiological findings, the patient was diagnosed with ischemic stroke due to right ICA dissection (ICAD). She received 5 days of intravenous argatroban followed by oral aspirin. A month later, her hemiparesis markedly improved. As early diagnosis of ICAD is crucial for prompt treatment in children with unexplained gross neurologic abnormalities, this disease should be suspected and MRI should be performed even without a history of blunt trauma to the head and neck.

Predictors of Very Poor Outcome after Mechanical Thrombectomy for Acute Basilar Artery Occlusion.

Prognosis for patients with acute basilar artery occlusion (BAO) remains poor. Successful revascularization is a main predictor of favorable clinical outcomes after mechanical thrombectomy for BAO. However, even if mechanical thrombectomy is successful, some patients have a poor clinical outcome, including vegetative state and mortality. This study investigated the factors that are predictive of extremely poor clinical outcomes despite successful revascularization after mechanical thrombectomy for BAO. We evaluated 35 consecutive patients who presented with acute ischemic stroke due to BAO and who were successfully treated with mechanical thrombectomy. A very poor outcome was defined as a modified Rankin Scale (mRS) score of 5 or 6 at 3 months after treatment. The associations between the clinical, imaging, procedural factors, and poor outcome were evaluated. Using univariate analyses, there were significant differences in the preoperative National Institute of Health Stroke Scale (NIHSS) score (22.0 ± 9.0 vs. 30.5 ± 4.3, p <0.001), and infarct volume in brain stem (0.11 ± 0.19 cc vs. 2.55 ± 1.56 cc, p <0.001) between the control and very poor outcome groups. In receiver operating characteristic (ROC) curve analysis, the area under ROC curve of infarct volume in brain stem was 0.891 to predict very poor outcome. Preoperative infarct volume in brain stem is strong predictor for very poor outcome. The infarct volume in brain stem is useful for deciding treatment indications.

Effectiveness of Low-Dose Intravenous Tissue Plasminogen Activator before Stent Retriever or Aspiration Mechanical Thrombectomy.

PURPOSE: To determine whether thrombolysis with a lower dose of intravenous recombinant tissue plasminogen activator before mechanical thrombectomy is beneficial for functional outcomes compared with mechanical thrombectomy alone. MATERIALS AND METHODS: Data for 100 Japanese patients who underwent mechanical thrombectomy between July 2014 and November 2017 were retrospectively reviewed. These patients were divided into groups according to whether they received intravenous thrombolysis before mechanical thrombectomy, and outcomes were compared. Favorable outcome was defined as a modified Rankin scale score ≤ 2 at 3 months after treatment. RESULTS: Thirty-four patients for the thrombolysis group and 66 patients for the thrombectomy-only group were identified. The thrombolysis and nonthrombolysis groups did not differ significantly in baseline characteristics (mean age, 74.3 y vs 75.7 y [P = .485]; mean preoperative National Institute Health Stroke Scale score, 19.8 vs 19.6 [P = .825]). There were no significant differences in the times required for, or the rates of, successful recanalization. However, the thrombolysis group had a higher rate of complete recanalization (67.6% vs 43.9%; P = .041). Postoperative symptomatic intracranial hemorrhage was not significantly different between groups. Favorable outcomes were observed in 73.5% of patients in the thrombolysis group and 51.5% in the nonthrombolysis group (P = .028). CONCLUSIONS: This single-center retrospective study shows that lower-dose intravenous thrombolysis improves the outcomes of mechanical thrombectomy for Japanese patients with acute anterior-circulation stroke treated within 4.5 hours of onset.

Severe Vasospasm of the Middle Cerebral Artery after Mechanical Thrombectomy Due to Infective Endocarditis: An Autopsy Case.

Untreated infective endocarditis (IE) often produces infective emboli in major cerebral arteries. We describe a case of middle cerebral artery occlusion due to IE, which caused severe vasospasm and reocclusion after mechanical thrombectomy (MT). We present the pathologic findings of the occluded middle cerebral artery and investigate the precautions to be taken while performing MT due to IE. A 72-year-old man with atrial fibrillation treated with dabigatran presented with right hemiparesis and aphasia. A diffusion-weighted image showed a high-intensity area in the left temporoparietal junction, and magnetic resonance angiography revealed a left M2 occlusion. Because of an elevated activated partial thromboplastin time, the thrombolytic therapy was contraindicated; instead, MT was performed. Just after the withdrawal of a stent retriever, the left M2 segment showed severe vasospasm. The next day, the left M2 segment reoccluded. Transthoracic echocardiogram and blood culture findings revealed IE. On the ninth day, the patient died. According to the autopsy report, the cause of death was pulmonary embolism. Pathologic analysis of the occluded M2 segment revealed fibrin thrombi containing vast amounts of neutrophils and invasion of neutrophils into the internal elastic lamina. Severe vasospasm was thought to have occurred because the vascular injury caused by the stent retriever in the vessel had a marked inflammation background. Our findings suggest that devices that are less invasive to the vascular wall are required for performing MT due to IE. The Penumbra aspiration system is thought to be a suitable device.

Posterior pituitary bright spot in large adenomas: MR assessment of its disappearance or relocation along the stalk.

PURPOSE: To evaluate the disappearance or relocation patterns of posterior pituitary bright spot (PPBS) in the infundibuloneurohypophyseal (INH) system and endocrinologic implications in large pituitary adenomas. MATERIALS AND METHODS: Sixty-nine patients with adenoma and supradiaphragmatic extension were classified into PPBS-visible and PPBS-nonvisible groups on the basis of findings at preoperative T1-weighted magnetic resonance (MR) imaging. The adenoma shapes were classified into hourglass type with indentation and barrel type without indentation at the diaphragmatic level. RESULTS: The PPBS-visible group included 55 (80%) patients. PPBS most commonly occurred at the distal pituitary stalk immediately above the diaphragm in 48 patients with hourglass-type adenoma. In the remaining seven patients with barrel-type adenoma, PPBS occurred in the sella or in varying sites along the pituitary stalk. Postoperatively, two patients, whose PPBS became nonvisible, developed persistent diabetes insipidus. The PPBS-nonvisible group included 14 (20%) patients. Five had hourglass-type and nine had barrel-type adenoma. Occurrence of the barrel type was marked. In these patients, four developed postoperative permanent diabetes insipidus. CONCLUSION: The diaphragm, a probable major anatomic determinant of indentation, may serve as a transportation blockade and facilitate proximal accumulation of PPBS material, as evidenced in the hourglass-type adenoma. PPBS was more commonly nonnvisible in the barrel-type adenoma. The presence of PPBS in the INH system indicates its functional maintenance in large adenomas.