Effects of clinical outcomes by modification of patient selection protocol based on premorbid independence for mechanical thrombectomy in older adult patients.

OBJECTIVES: Since the beneficial effect attained by mechanical thrombectomy (MT) seems to be worse in older than in the younger population, the establishment of an ideal and distinctive patient selection protocol in older is warranted. Herein, we modified our patient selection protocol based on age and premorbid independence in older adult patients. MATERIALS AND METHODS: We retrospectively reviewed 141 consecutive patients with acute ischemic stroke who were treated with MT between 2015 and 2020. We started to restrict the indication of MT in very old patients (≥85-year-old) with severe premorbid functional independence (≥modified Rankin Scale [mRS] 3) in 2018. Clinical outcomes before the modification of protocol (period 1) were compared to after (period 2). RESULTS: Although there were no significant differences in median mRS at 90 days and the rates of favorable outcomes (mRS 0-2) between both periods, rates of poor outcomes (mRS 5, 6) significantly decreased (37.3% vs. 19.7%, P = 0.021) during period 2 compared with period 1. For older adults (≥80-year-old), median mRS was significantly better (P = 0.012) during period 2 than period 1. During period 1, rates of favorable outcomes were significantly lower (P = 0.004) in older than in younger. However, this significant difference was diminished (P = 0.28) during period 2. CONCLUSION: Our modified patient selection protocol in older adults, not only limited by age but also premorbid function, improved the therapeutic outcome of MT. In rapidly aging society, further investigations facilitating a better understanding are necessary to establish an optimal patient selection protocol.

A case of catastrophic epistaxis from the internal carotid artery due to multiple surgeries and irradiations for pituitary tumor: Rescued utilizing high-flow bypass and simultaneous skull base reconstruction.

Revascularization for internal carotid artery rupture should be considered immediately under the situation where endovascular treatment is not indicated. Revascularization can prevent the risk of hemorrhage during skull base reconstruction.

ADAPT First-Line Strategy for MCA Mainstem Occlusion; Analysis for Optimal Salvage Therapy and its Related Factor.

OBJECTIVES: A direct first-pass aspiration technique (ADAPT) is an attractive interventional technique for mechanical thrombectomy (MT), which could achieve recanalization quickly and safely at a small amount of material resources. To clarify its usefulness, our ADAPT first-line strategy for middle cerebral artery (MCA)-mainstem occlusion was retrospectively analyzed. MATERIALS AND METHODS: We reviewed 54 consecutive patients who underwent MT for MCA-mainstem occlusion using ADAPT first-line strategy. A salvage procedure was concurrently conducted in cases that failed to achieve successful recanalization by ADAPT attempt alone. Procedural and clinical outcome were assessed in both ADAPT alone and Salvage groups. Further investigation was performed in cases that required salvage procedure to determine the reason, risk factors, and optimal procedure. RESULTS: Forty-one patients (75.9%) were able to achieve successful recanalization with ADAPT technique alone. In salvage group, the procedural time was longer, and rates of successful recanalization were lower than in ADAPT-alone group. No significant difference in the rates of favorable outcomes was observed. Among 13 patients who required salvage therapy, the major reason (eight cases) was intra-procedural "thrombus distal migration". Failure of recanalization was seen in two cases due to "inaccessibility". In patients who had "thrombus distal migration", occlusion in the proximal portion was more frequently observed than in patients who did not (p = 0.032, 63.6% vs. 23.3%). CONCLUSIONS: Our ADAPT first-line strategy for MCA-mainstem occlusion demonstrated favorable procedural and clinical outcomes, even in cases that required additional procedures. Further investigation and better understanding are required to refine this promising procedure.

A Direct Aspiration First Pass Technique for Vertebra-Basilar Occlusion: A Retrospective Comparison to Stent Retriever.

OBJECTIVES: This study aimed to assess the clinical usefulness of a direct aspiration first pass technique as a first-line strategy for mechanical thrombectomy in posterior circulation. MATERIALS AND METHODS: We examined 34 consecutive patients treated with mechanical thrombectomy for acute vertebrobasilar artery occlusion. Procedural and clinical outcomes were assessed and compared between patients treated with a direct aspiration first pass technique first-line strategy (ADAPT group) and stent retriever system first-line strategy (stent retriever group). RESULTS: Overall, successful reperfusion, complete reperfusion, and first-pass effects were achieved in 94.1%, 61.8%, and 50% of patients with acute ischemic stroke in vertebra-basilar artery occlusion treated with mechanical thrombectomy, respectively. The ADAPT group required a significantly shorter procedural time (p=.015) and fewer attempts (p=.0498) to achieve successful recanalization than the stent retriever group. The ADAPT group also tended to show better recanalization rates and first-pass effects than the stent retriever group. The rates of favorable outcomes seemed to be better, although insignificant, in the ADAPT group than in the stent retriever group (52.2% vs. 27.3%, p=.217). However, a significant correlation between the time required for reperfusion and clinical outcome was detected, and this will serve as the rationale for encouraging a direct aspiration first pass technique as a first-line strategy in the acute vertebra-basilar artery. CONCLUSIONS: The a direct aspiration first pass technique first-line strategy for mechanical thrombectomy in posterior circulation may achieve successful recanalization with fewer attempts and shorter durations than the stent retriever first-line strategy.

Intracranial plasmacytoma arising from dura mater secondary to multiple myeloma and presenting with sudden lethal intracerebral hemorrhage: A case report and literature review.

BACKGROUND: Intracranial and central nervous system's involvement with multiple myeloma (MM) is a clinically rare manifestation. Furthermore, the development of intracranial plasmacytoma without bone involvement is much rarer. Herein, we report the case of massive intracerebral hemorrhage form intracranial plasmacytoma that arose from the dura mater without bone involvement. CASE DESCRIPTION: A 71-year-old woman, who had been diagnosed as MM and treated 2 years prior, developed sudden lethal intracerebral hemorrhage from the intracranial plasmacytoma. Massive hemorrhage was observed after a rapid tumor growth in the middle fossa. Immediate hematoma evacuation and tumor resection allowed the patient to avoid severe neurological deficits and lethal conditions. CONCLUSION: A close follow-up by neuroimaging studies is essential in cases of intracranial plasmacytoma in MM patients and early intervention with surgical resection or radiotherapy should be considered.

A Case Series of Double Bypass Technique Used for the Treatment of Internal Carotid Blood Blister-like Aneurysms in Patients in Poor Initial Neurological Condition at the Early Stage of Subarachnoid Hemorrhage.

BACKGROUND: Optimal surgical treatment of blood-blister aneurysms (BBA) remains controversial. Some surgeons prefer clipping reconstruction while others favor primary bypass with trapping. OBJECTIVE: To analyze of benefit of double bypass technique to surgical outcomes in patients with ruptured BBA in poor initial neurological condition (PINC). METHODS: Retrospective analysis of clinical, radiological, and surgical data in 9 patients treated between January 2009 and December 2015. Intraoperative middle cerebral artery blood pressure (MCABP) measurement was used for selection of bypass procedure. RESULTS: Seven patients presented with World Federation of Neurosurgical Societies (WFNS) subarachnoid hemorrhage (SAH) score 4 or 5. No pulse pressure in the MCA after internal carotid artery (ICA) clamping was found in 3 patients, although their ACoA or PCoA were well visualized on preoperative angiograms. By contrast, only a minimal drop in MCABP following ICA clamping was detected in two cases, although their collaterals were slim/nonvisualized on imaging. Although angiographic vasospasms were not observed in our patients, two of them experienced cerebral infarction, attributable more to the mass effect and postoperative ICA thrombosis than to SAH-induced vasospasm. There were 2 premature intraoperative ruptures, but no perioperative mortality, aneurysm recurrence, or rebleeding. Five patients with WFNS SAH score 4 or 5 achieved favorable outcomes. CONCLUSION: Early double bypass technique guided by MCABP measurement and combined with trapping (or rarely clipping) seems to be a safe method with excellent long-term outcomes in patients in PINC. This study may thus contribute to the debate on the optimal treatment strategy for BBA.

Management strategy for bilateral complex vertebral artery aneurysms.

Bilateral complex vertebral artery aneurysms (BCoVAAns) have no established strategy of management. We retrospectively reviewed five consecutive patients with unruptured BCoVAAns between January 2006 and December 2012. Considering surgical risks of lower cranial nerve (LCN) injuries and eventual growth of an opposite side lesion after unilateral vertebral artery (VA) occlusion, we proposed a strategy of combined open and interventional treatment using revascularization. We applied the following several specific techniques: (1) proximal clipping and occipital artery-posterior inferior cerebellar artery (OA-PICA) and/or superficial temporary artery (STA)-superior cerebellar artery (SCA) bypasses; (2) Distal blood pressure, motor evoked potentials (MEPs), and somatosensory evoked potentials (SEPs) monitoring after parent artery temporary occlusion for safe permanent occlusion of the proximal portions of VA and PICA; (3) V3 to V4 bypass using radial artery (RA) graft with proximal clipping or trapping, two of them combined with OA-PICA bypass; (4) VA fenestration as an opportunity to preserve the flow of the parent artery. Two patients were treated bilaterally and 3 unilaterally, with modified Rankin scale assessed at 39 months postoperatively in average 0 in 2, 1 in 2, and 2 in 1, respectively, and the untreated opposite side lesions without regrowth or bleeding. Two patients with patent V3-RA-V4 bypass complained of dysphagia due to LCN palsies. One of them however suffered a cerebellar infarction due to occlusion of the OA-PICA bypass. When BCoVAAns require surgical treatment, revascularization or preservation of the VA should be considered at the first operation. By doing so, the opposite aneurysm can be effectively occluded by coil embolization, even with VA sacrifice if required.

Usefulness of V3-radial artery graft-V4 bypass in bilateral fusiform aneurysms of vertebral artery: case report.

A 55-year-old woman with bilateral vertebral artery (VA) aneurysms was transferred to our hospital. She suffered from a minor stroke. Magnetic resonance imaging (MRI) for the stroke incidentally revealed bilateral VA aneurysms. Due to its size, more observation was recommended, and the patient was found eager to be treated. Both side surgeries were found inappropriate because of severe lower cranial nerve disturbances. The right aneurysm involved the posterior inferior cerebellar artery (PICA) and the V4 segment was deviated to the right side. Therefore, the smaller right aneurysm was treated first with an occipital artery (OA)-PICA bypass and a V3-radial artery graft (RAG)-V4 bypass followed by proximal clipping of the PICA and the right VA. The right VA was successfully remade by RAG and the right aneurysm was not revealed on postoperative examination. By doing so, the opposite aneurysm was able to be eliminated by the parent artery occlusion even by using an interventional radiology (IVR). The V3-RAG-V4 bypass is a useful method for treating bilateral VA aneurysms. This is a new bypass which has not been reported so far to the best of our knowledge.

The significance of intraoperative monitoring of muscle motor evoked potentials during unruptured large and giant cerebral aneurysm surgery.

The goal of this study was to characterize the utility of muscle motor evoked potentials (MMEPs) elicited by direct cortical stimulation as a means of monitoring during unruptured large and giant cerebral aneurysm surgery. This analysis focused on intraoperative changes in MMEPs and their relationship to postoperative motor function. The study population consisted of 50 patients who underwent surgery for large (n = 31) or giant (n = 19) cerebral aneurysms. Intraoperative MMEPs were continuously and successfully obtained in muscles belonging to the vascular territory of interest. There was no postoperative motor paresis in 31 (62%) patients in whom intraoperative MMEPs remained unchanged. Transient MMEP change occurred in 15 (30%) of the 50 patients, but 9 of those patients had no postoperative motor deficits, 5 had transient motor deficits, and 1 suffered permanent motor deficits resulting from postoperative delayed blood flow insufficiency due to arteriosclerosis of the parent artery. Permanent MMEP loss occurred in 4 (8%) of 50 patients, all of whom developed severe and permanent postoperative motor deficits. MMEP is a useful monitoring modality in patients undergoing surgery for large or giant cerebral aneurysms. This strategy can help predict functional prognosis or guide the neurosurgeon intraoperatively in an effort to promote better outcomes.

Anti-convulsant effect of electrical stimulation and lesioning of the anterior thalamic nucleus on kainic acid-induced focal limbic seizure in rats.

PURPOSE: We examined the effect of electrical stimulation and lesioning of the anterior nucleus of the thalamus (ANT) on focal limbic seizures induced by intraamygdaloid kainic acid (KA) injection in a rat model. To address the mechanism underlying these anti-convulsant actions, cerebral glucose metabolism following ANT electrical stimulation and lesioning was also assessed. METHODS: Wistar rats were divided into five major groups: control, unilateral and bilateral ANT electrical stimulation, and unilateral and bilateral ANT lesioning. After KA injection, average clinical-seizure frequencies in each group were measured. Local cerebral glucose utilization (LCGU) was also measured using [(14)C] 2-deoxyglucose autoradiography in three groups: control, ANT electrical stimulation and ANT lesioning. RESULTS: Animals subjected to ANT electrical stimulation and lesioning exhibited significantly decreased mean seizure frequency and secondary generalized seizure frequency, compared with control-animals. In control-group, LCGU was markedly increased at both the limbic and corticothalamic circuits sites. While in ANT stimulation or lesioning-group, there was significant reduction in LCGU at the corticothalamic circuit sites, but not so considerable decrease at the limbic structures. CONCLUSION: ANT electrical stimulation and lesioning in the focal limbic seizure model were effective on convulsive seizures and secondary generalization, specifically with respect to the severity of these seizures.

The effect of electrical stimulation and lesioning of the anterior thalamic nucleus on kainic acid-induced focal cortical seizure status in rats.

PURPOSE: The present study aimed to clarify the effect of electrical stimulation and lesioning of the anterior nucleus of the thalamus (ANT) on kainic acid (KA)-induced focal cortical seizures in a rat model. To address the mechanism underlying these anticonvulsant actions, cerebral glucose metabolism after ANT electrical stimulation and lesioning was also examined. METHODS: Wistar rats were divided into five major groups: control (n = 9), unilateral (n = 9), and bilateral (n = 9) ANT electrical stimulation, and unilateral (n = 9) and bilateral (n = 9) ANT lesioning. After KA injection, average clinical-seizure frequencies in each group were measured. Electrical stimulation of ANT was introduced after induction of seizure status epilepticus. Stimulation was on for 30 min and off for 30 min per 60-min cycle. Local cerebral glucose utilization (LCGU) was also measured by using [(14)C] 2-deoxyglucose autoradiography in three groups of rats: control (n = 7), bilateral ANT stimulation (n = 7), and bilateral ANT lesioning (n = 7). RESULTS: Unilateral ANT electrical stimulation and lesioning significantly reduced clinical seizure frequency, compared with control animals. Strikingly, no animals treated with bilateral ANT procedures demonstrated any clinical seizure. LCGU was markedly increased in the sensorimotor cortex, striatum, thalamus, mammillary body, and midbrain tegmentum of control group rats after KA injection, but no increase in LCGU was noted in rats treated with bilateral ANT lesioning or stimulation. CONCLUSIONS: The electrical stimulation and lesioning of ANT suppressed focal cortical clinical seizures induced by KA injection. Additionally, an analysis of cerebral metabolic changes indicated that these procedures might suppress the function as amplifier and synchronizer of seizure activity.

[A case of coexistence with cavernous angioma and focal cortical dysplasia].

There have recently been a number of new pathological findings of specimens from epileptic foci that have become widespread of surgical treatment. We reported a case with seizures resulting from brain lesions which pathologically demonstrated a coexistence with a cavernous angioma and a focal cortical dysplasia. A 24-year-old man was admitted to our hospital because of generalized convulsion from 1 year ago. Brain MRI revealed an enhanced mass lesion, in diameter 1.5 cm, with hemosiderin rim in the left temporal tip. Ictal EEG showed the initiation of the spike from the lateral side of the left temporal lobe. Because the epileptogenic focus was thought to be the lateral side in the left temporal lobe, anterolateral temporal resection was performed and subsequently total removal of the tumor was performed. He had no seizure after surgery. A light microscopic examination was performed on specimens stained with hematoxilin and eosin. We verified to be pathologically coexistent with a cavernous angioma and a focal cortical dysplasia. We also found unusual neurons that were accompanied by perineuronal glial satellitosis in the subcortical white matter, those were occasionally observed in epileptic foci and were thought to be a form of neuronal migration disorders.