Irreversible postoperative cognitive impairment after unruptured intracranial aneurysm treatment in the elderly.

PURPOSE: Postoperative cognitive dysfunction and recovery remain unclear in older patients undergoing interventional therapies for unruptured intracranial aneurysms (UIAs). This study aimed to compare changes in postoperative cognitive function between younger and older patients and to detect factors associated with non-recovery from postoperative cognitive dysfunction. METHODS: This study reviewed 59 consecutive patients with UIAs who underwent interventional therapies, including microsurgical clipping or endovascular treatment, from 2021 to 2022. All patients were divided into the older (aged ≥ 70 years) and younger (aged < 70 years) groups. Mini-Mental State Examination (MMSE) and Frontal Assessment Battery (FAB) were performed within 2 months before interventions, at 1 week postoperatively (POW1), and 3-6 months postoperatively (POM3-6). RESULTS: MMSE and FAB scores decreased more frequently in the older group than in the younger group at POW1 (older vs. younger: MMSE: 48% vs. 21%, p < 0.05; FAB: 56% vs. 18%, p < 0.01). In the older group, the FAB Z-score decreased in POW1 and recovered by POM3-6 (p < 0.01), while the MMSE Z-score continued to decrease (p = 0.04). Age and the preoperative MSME Z-score were significantly associated with non-recovery from decreased MMSE score at POM3-6 (recovery vs. non-recovery, age: 62 years old vs. 72 years old, p = 0.03, preoperative MMSE Z-score: 0.16 vs. - 0.90, p < 0.01). CONCLUSIONS: This retrospective study found that older patients were more likely to have a postoperative cognitive decline after UIA treatment and implicated that global cognitive function tended to decline more than executive function in the long term. In addition, this study demonstrated that lower preoperative cognitive function was associated with inadequate postoperative cognitive recovery. The findings potentially contribute to the establishment of indications for treating UIAs in older patients.

Multiple large vessel occlusions resulting in vessel perforation in single pass of mechanical thrombectomy with stent retriever.

Mechanical thrombectomy (MT) is a highly effective treatment for acute ischemic stroke, and hemorrhagic complications caused by vessel injury are rare. However, there is no evidence regarding the efficacy of MT for multiple large vessel occlusion or its procedural strategy. Herein, we report a case of MT with a stent retriever for multiple large vessel occlusion in the internal carotid artery and middle cerebral artery M1 distal, which resulted in vessel perforation in a single pass. A 79-year-old woman underwent MT for internal carotid artery occlusion, and multiple large vessel occlusion was observed on digital subtraction angiography. A longer and larger stent retriever was selected for thrombus retrieval in a single pass. Immediately after retrieval, digital subtraction angiography revealed internal carotid artery recanalization. Then, extravasation was observed from the M1 distal occlusion. Treatment was interrupted after hemostasis was confirmed. Nevertheless, rebleeding occurred after 4 hours. Emergency trapping was performed, and vessel perforation of >1 mm was observed. When retrieving a thrombus in a single pass with a stent retriever for multiple large vessel occlusion, vessel perforation may occur if the device is selected according to the diameter of the proximal occluded vessel. Based on the type of device, even a single pass may result in vessel perforation. Although aggressive MT intervention should be performed for multiple large vessel occlusion, a device that is appropriate for the pathological condition must be selected.

High-Flow Bypass for Ruptured Aneurysms at Non-branching Sites of the Middle Cerebral Artery: A Case Report.

Small cerebral aneurysms that occur at non-branching sites are generally considered to have extremely weak aneurysm walls or a pseudoaneurysm formed by a thrombus. Since conventional clipping and coil embolization are difficult and high-risk, trapping with bypass has been considered the preferred treatment method. The aim of this study is to investigate a case of trapping with high-flow bypass for a ruptured aneurysm at non-branching sites of the middle cerebral artery (MCA). In this study, the CT results indicated subarachnoid hemorrhage, while the CT angiography (CTA) results showed a small aneurysm at the non-branching site of the MCA M1 segment. Moreover, the intraoperative digital subtraction angiography (DSA) results strongly suggested a pseudoaneurysm. The aneurysm was judged to be a pseudoaneurysm over the rupture site of the true aneurysm sac. Coil embolization was performed, but the treatment was interrupted as the aneurysm completely disappeared during the procedure. However, based on the magnetic resonance angiography findings, the aneurysm reappeared on day five and became enlarged. Thus, trapping with high-flow bypass was performed on day 15 and the patient was cured. Owing to the unusual and noteworthy course of this case, trapping with high-flow bypass was considered to be the safest and most reliable first-choice treatment procedure for pseudoaneurysm at non-branching sites of the MCA.

Two Cases of Rare Intratumoral Hemorrhage Following COVID-19 Vaccination.

The increase in the rate of mRNA vaccination against coronavirus disease 2019 (COVID-19) worldwide has been accompanied by reports of an increase in the side effects of the vaccine. In the field of neurosurgery, several cases of venous thrombosis have been reported as possible complications after COVID-19 vaccination. However, no such side effects have been reported in patients with brain tumors, and COVID-19 vaccination is considered safe for this patient population. In this report, we present the cases of two patients with brain tumors who experienced intratumoral hemorrhage as a possible side effect of the COVID-19 vaccine. In the first case, a 54-year-old man who had received CyberKnife treatment for a vestibular schwannoma eight years prior presented with tongue discomfort, right-side facial numbness, and dizziness since the day after his COVID-19 vaccination. MRI revealed intratumoral hemorrhage of the vestibular schwannoma. The second patient was a 60-year-old woman who presented with a sudden-onset headache and vomiting that had started three days after her COVID-19 vaccination. CT revealed a meningioma with intratumoral hemorrhage. Both patients had undergone surgery prior to this presentation, and their symptoms had improved. They had no risk factors for intratumoral hemorrhage, suggesting that it may be a side effect of the mRNA vaccine against COVID-19. Although the causal relationship is unclear, acute inflammation with predominantly lymphocytic infiltration and thrombogenicity after COVID-19 vaccination may damage the fragile microcirculation of the tumor.

Preprocedural Prediction of Underlying Atherosclerotic Lesions in Cerebral Large-Vessel Occlusions: Clinical Backgrounds, Radiological Findings, and Treatment Outcomes.

AIMS: Mechanical thrombectomy using a standard device has been effective for acute cerebral large-vessel occlusions, particularly those due to cardiogenic embolism. However, evidence for those with underlying atherosclerotic lesions is lacking. In this study, we evaluated the predictive factors, treatment details, and outcomes of acute cerebral large-vessel occlusions with underlying atherosclerotic lesions in patients who underwent mechanical thrombectomy. METHODS: We retrospectively analyzed consecutive patients with acute large-vessel occlusions who underwent mechanical thrombectomy at our institution between August 2014 and May 2021. Predictive factors of underlying atherosclerotic lesions were evaluated using univariate and multivariate analyses. In addition, treatment details and outcomes were evaluated and compared with those of other etiologies. RESULTS: Among 322 included patients, 202 (62.7%) were males and 65 (20.2%) had underlying atherosclerotic lesions. Multivariate analysis identified dyslipidemia, lack of arterial fibrillation documented on admission, smoking, internal carotid artery lesions, and stenosis ≥ 25% in non-occluded large vessels as predictive factors of underlying atherosclerotic lesions. Regarding treatment for underlying atherosclerotic lesions, the need for percutaneous transluminal angioplasty, stent placement, medical therapy, and longer procedure time were observed, while successful reperfusion rates, favorable outcomes, and mortality rates showed no significant differences with those of other etiologies. CONCLUSION: Coexisting diseases and radiological findings were useful for predicting underlying atherosclerotic lesions. Further understanding these characteristics may lead to the early detection of underlying atherosclerotic lesions, optimal treatment strategies, and better outcomes.

Thrombectomy for acute large vessel occlusion in posterior and anterior circulation: a single institutional retrospective observational study.

PURPOSE: Thrombectomy has been the gold standard therapy for anterior circulation occlusion; however, studies regarding thrombectomy in posterior circulation are lacking. In this study, we compared the efficiency of thrombectomy for acute large vessel occlusion between the posterior and anterior circulation at a single institution. METHODS: We retrospectively analyzed consecutive patients who underwent thrombectomy for acute large vessel occlusion at our institution between August 2014 and April 2021. Differences in the clinical background, time course, and treatment technique and outcomes were evaluated between anterior and posterior circulation occlusions. RESULTS: Overall, 353 patients (225 men and 128 women) were included: 314 patients had anterior circulation occlusion and 39 patients had posterior circulation occlusion. Between the patients with anterior and posterior circulation occlusions, the National Institutes of Health Stroke Scale (NIHSS) score (16 [12-21] vs. 29 [19-34], respectively, p < 0.001), door-to-puncture time (65 [45-99] vs. 99 [51-121] min, respectively, p = 0.018), and mortality (22 [7%] vs. 8 [20.5%] patients, respectively, p = 0.010) were significantly different; however, favorable outcome was not significantly different. CONCLUSION: Higher NIHSS score, delayed treatment, and higher mortality were observed in posterior circulation occlusion than in anterior circulation occlusion; successful reperfusion and favorable outcomes were similar between them. Similar favorable outcomes and reperfusion ratio to the anterior circulation might be achieved also in the posterior circulation; however, delayed treatment and the optimal first-pass strategy might need further improvement.