Retrospective Observational Study of Patients With Subdural Hematoma Treated With Idarucizumab.

Use of anticoagulants is increasing with the aging of societies. The safe first-line drug is likely to be a direct oral anticoagulant (DOAC), but outcomes of treatment of traumatic brain injury (TBI) with anticoagulants are uncertain. Therefore, we examined the clinical effect of idarucizumab as reversal therapy in elderly patients with TBI who were treated with dabigatran. A retrospective multi-center observational study was performed in patients ≥65 years of age who developed acute traumatic subdural hematoma during treatment with dabigatran and underwent reversal therapy with idarucizumab. The items examined included patient background, neurological and imaging findings at arrival, course after admission, complications, and outcomes. A total of 23 patients were enrolled in the study. The patients had a mean age of 78.9 years. Cause of TBI was fall in 60.9% of the subjects. Mean Glasgow Coma Scale score at arrival was 8.7; anisocoria was present in 31.8% of cases. Exacerbation of consciousness was found in 30.4%, but only in 13.3% of subjects treated with idarucizumab before consciousness and imaging findings worsened. Dabigatran was discontinued in 81.8% of cases after hematoma development, with a mean withdrawal period of 12.1 days. The favorable outcome rate was 21.7%, and mortality was 39.1%. In multi-variate analysis, timing of idarucizumab administration was associated with a favorable outcome. There were ischemic complications in 3 cases (13.1%), and all three events occurred ≥7 days after administration of idarucizumab. These findings suggest that in cases that develop hematoma during treatment with dabigatran, it is important to administer idarucizumab early and restart dabigatran after conditions stabilize.

A Case of Bilateral Vertebral Artery Dissecting Aneurysm Treated With Multimodality Therapy Under Superficial Temporal Artery Assistance-Posterior Cerebral Artery Bypass.

A ruptured bilateral vertebral artery dissecting aneurysm (BVDA) is a challenging vascular disorder. Trapping surgery with bypass assistance could be a potential treatment; however, there is a risk of ischemic complications. Recently, endovascular treatment has been reported, but its long-term outcomes remain uncertain. The patient was a 57-year-old male who presented with subarachnoid hemorrhage. Digital subtraction angiography showed a dilated dominant left vertebral artery (VA) and a narrowed right VA, suggesting a BVDA. First, we performed a right superficial temporal artery-superior cerebellar artery (STA-SCA) insurance bypass. We then performed proximal clipping of the left vertebral VA. The pulsation of the STA-SCA bypass disappeared on day 6. Three-dimensional computed tomography angiography (3DCTA) showed the emergence of a fusiform aneurysm and proximal stenosis of the contralateral VA. On day 31, we performed a superficial temporal artery-posterior cerebral artery (STA-PCA) insurance bypass. Stent-assisted coil embolization was planned for two days after the STA-PCA bypass. However, preoperative angiography showed progression of right proximal VA stenosis, and stenting appeared impossible. There was no change in somatosensory evoked potential (SEP), and angiography showed sufficient retrograde blood flow to the posterior circulation during the right VA balloon occlusion test (BOT). Therefore, internal trapping of the right VA was performed. Postoperative angiography showed perfect patency of the left STA-PCA bypass and retrograde blood flow to the posterior circulation. There was no additional neurological deficit after endovascular treatment. Multimodality therapy could be a potential treatment for bilateral VA dissection.

A Case of Acute In-Stent Mobile Plaque after Carotid Artery Stenting Aspirated with a Distal Access Catheter.

Objective: Carotid artery stenting (CAS) is common procedure for carotid stenosis, but sometimes acute in-stent thrombosis or plaque protrusion after CAS leads to postoperative stroke. There are few reports of aspiration of in-stent plaque protrusion. This paper reports a case of acute in-stent mobile plaque aspirated with a distal access catheter. Case Presentation: A 74-year-old male underwent CAS for symptomatic internal carotid artery stenosis and postoperative course was thought to be good, but in-stent mobile plaque was detected by carotid duplex at postoperative day 6. As mobile plaque is a high risk for stroke, we performed plaque aspiration with a distal access catheter, without neurological deficit or a new cerebral lesion in magnetic resonance imaging. We present a case report, including a literature review, of acute thrombosis or in-stent plaque protrusion. Conclusion: Aspiration removal may be effective for in-stent mobile plaque, which is expected to be fragile, avoiding the disadvantages of increasing stents.

Case of a Pregnant Woman with Capillary Hemangioma of the Parasellar Region.

Here we report a rare case of capillary hemangioma (CH) in a 28-year-old woman suffering from gradual worsening diplopia at 28 weeks of pregnancy. Magnetic resonance imaging (MRI) showed a mass lesion (about 3 cm in diameter) in the right parasellar region. We decided to observe as she was pregnant, and had no symptoms other than right abducent nerve palsy. Fortunately, her symptoms did not worsen until delivery. Computed tomography, enhanced MRI, and angiography after delivery revealed that the lesion was highly calcified and vascularized. A dorsum sellae meningioma or highly calcified pituitary adenoma was suspected and the endoscopic transsphenoidal approach was used for tumor removal. The postoperative course was uneventful. The histological diagnosis was CH. Intracranial CHs or CHs of skull are rare vascular tumors. These tumors are reportedly more common in female patients and may change in size in adults according to menstrual cycle and pregnancy. Only six cases, including that of the present study, were diagnosed during the perinatal period. Some of them experienced rapid symptom progression and tumor growth in their course; thus, we should pay further attention to pregnant or peripartum patients with brain tumor, suspected hemangiomas.

Carotid Endarterectomy Requiring Removal of the Superior Horn of Thyroid Cartilage: Case Report and Literature Review.

Carotid endarterectomy (CEA) is an established surgical procedure for carotid stenosis. We present the case of a 74-year-old man who underwent CEA for symptomatic internal carotid artery (ICA) stenosis. During the operation, we found that the hyoid bone (HB) and the superior horn of the thyroid cartilage covered the carotid sheath, preventing adequate visualization. Since this was anticipated based on preoperative examinations, the superior horn of thyroid cartilage was removed with the help of an otorhinolaryngologist. The HB was preserved because it could be retracted, and thereafter we performed CEA. Although CEA is a common procedure, the HB and thyroid cartilage are rarely involved in the operation. We present a case report including literature review of acute cerebrovascular syndrome (ACVS) due to HB and thyroid cartilage obstruction.

Pediatric-Type Follicular Lymphoma in the Dura: A Case Report and Literature Review.

BACKGROUND: Primary central nervous system lymphoma (PCNSL) is a relatively common tumor of the central nervous system. Although PCNSLs generally arise from the parenchyma, lymphomas arising primarily from the dura are termed dural lymphomas (DLs). Mucosa-associated lymphoid tissue is the most unique histological feature of DLs. Because of its rarity, the clinical characteristics of and treatments for DL have not been fully elucidated to date. CASE DESCRIPTION: A 31-year-old man with no past medical history presented with numbness in his left upper limb. Magnetic resonance imaging revealed a dural-based tumoral lesion and cervical lymphadenopathies. The lesion was diagnosed radiologically as a meningioma, and tumor resection was planned. However, an intraoperative pathological diagnosis showed neoplastic lymphocytes, and the planned total tumor resection was halted. Histologically, the tumor was characterized by areas of poorly defined follicular architecture consisting of medium and large centroblasts. These tumor cells were immunohistologically positive for CD10 and CD20 and negative for B-cell lymphoma (BCL) 2 and BCL6. Fluorescence in situ hybridization did not show evidence of an Immunoglobulin H/BCL2 fusion. The lesion was subsequently diagnosed as a pediatric-type follicular lymphoma (PTFL). Six cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone) plus 2 cycles of rituximab were administered. The patient showed no evidence of relapse at 12 months after diagnosis, and follow-up was ongoing at the time of this report. CONCLUSIONS: This very rare case of DL was originally diagnosed as a PTFL. The tumor could be treated by immunochemotherapy alone.

[A case of transverse-sigmoid sinus dural arteriovenous fistula that became symptomatic after removal of coexisting sphenoid ridge meningioma].

Here, we describe a case with a transverse-sigmoid sinus(TSS)dural arteriovenous fistula(DAVF)with sinus occlusion at its proximal and distal ends;the TSS DAVF turned symptomatic after removal of a coexisting symptomatic sphenoid ridge meningioma. The patient was a 70-year-old man presenting with decreased daily activities and mentation due to dysphasia. Magnetic resonance imaging revealed a large, left sphenoid ridge meningioma. Angiography revealed a tumor stain and a coexisting left TSS DAVF with sinus occlusion at its proximal and distal ends. Cortical venous reflux(CVR)into the temporal veins was observed. After successful tumor removal, the superficial middle cerebral vein was arterialized intraoperatively. However, the patient showed worsened consciousness and dysphasia after the operation. Repeated angiography revealed CVR into the superficial middle cerebral vein through a sphenopetrosal sinus. Transvenous embolization was performed via the contralateral inferior petrosal and intercavernous sinus, which allowed access to the ipsilateral superior petrosal sinus(SPS);the procedure successfully eliminated CVR, while preserving the SPS. The patient demonstrated full recovery. This case exemplifies a coexisting TSS DAVF after tumor resection, and superficial middle cerebral vein decompression due to the sphenopetrosal sinus, an alternate drainage pathway for the superficial middle cerebral vein.

Transverse-sigmoid sinus dural arteriovenous fistula presenting with parkinsonism.

Dural arteriovenous fistula (DAVF) is rarely associated with parkinsonism. A 52-year-old woman presented with a rare case of DAVF manifesting as parkinsonism and subsequently akinetic mutism. She showed dramatic recovery after endovascular treatment. We also review 10 published reports of DAVF presenting with parkinsonism. The clinical features of these cases at presentation was more closely compatible with lower body parkinsonism or vascular parkinsonism rather than Parkinson's disease. Most lesions are located at the transverse-sigmoid sinus (TSS) with venous reflux into the straight sinus with probable venous congestion of the basal ganglia. Most importantly, parkinsonism due to TSS DAVF is reversible if embolization is achieved successfully.

Changes of neural activity correlate with the severity of cortical ischemia in patients with unilateral major cerebral artery occlusion.

BACKGROUND AND PURPOSE: In major cerebral arterial steno-occlusive diseases, there can be remarkably decreased hemodynamic reserve without marked neurological impairments. In such settings, it is not known whether the neural activity is well maintained or disturbed according to the severity of cerebral ischemia. The present study was therefore undertaken to examine the neural activity under mild cerebral ischemia resulting from major cerebral arterial occlusion. METHODS: Seven patients with minor neurological impairment as well as either unilateral internal carotid artery or middle cerebral artery occlusion were studied. The severity of the cortical ischemia was assessed by measuring regional cerebral blood flow (rCBF) with positron emission tomography. The change in neural activity in the ischemic brain was then evaluated by means of somatosensory evoked magnetic field with magnetoencephalography. RESULTS: The rCBF in the primary sensory area and the strength of the initial component of somatosensory evoked magnetic field (N20 m) were significantly reduced (P<0.01) and the second component (P30 m) was significantly augmented (P<0.05) in the lesioned cerebral hemisphere as compared with the nonlesioned hemisphere. The asymmetry indexes for N20 m were positively correlated (r=0.78) and those for P30 m were inversely correlated (r=-0.92) with asymmetry indexes for rCBF. CONCLUSIONS: In patients with either unilateral internal carotid artery or middle cerebral artery occlusion and minor neural impairments, there was a reduction of afferent signal and an augmentation of the secondary response of the neurons in the primary sensory area. This showed correlation with the severity of cortical ischemia.