Asymptomatic subarachnoid hemorrhage following carotid endarterectomy: illustrative case.

BACKGROUND: Carotid endarterectomy (CEA) and carotid artery stenting are common surgical interventions for internal carotid artery stenosis. Cerebral hyperperfusion syndrome (CHS) is a well-known complication of both procedures that can lead to intracranial hemorrhage and worsen clinical outcomes. Here, the authors report a rare case of non-aneurysmal subarachnoid hemorrhage (SAH) following CEA and review the relevant literature. OBSERVATIONS: A 70-year-old woman with hypertension and diabetes presented with progressive visual loss in the right eye and was diagnosed with ocular ischemic syndrome. Imaging revealed severe right cervical carotid artery stenosis. CEA was performed with no complications. Postoperatively, the patient's blood pressure was tightly controlled, with no evidence of CHS. However, an asymptomatic SAH was detected on postoperative day 7. Careful observation and blood pressure control were maintained. Since follow-up magnetic resonance imaging (MRI) showed no enlarging of the SAH and the patient was asymptomatic, she was discharged on postoperative day 15 with a modified Rankin scale score of 0. LESSONS: This case highlights the potential occurrence of non-aneurysmal SAH as a rare complication of CEA, even in asymptomatic patients. Repeated postoperative MRI is necessary to detect such complications. It is crucial to carefully control blood pressure after CEA regardless of symptoms.

Preoperative risk assessment for predicting the opening of mastoid air cells in lateral suboccipital craniotomy for microvascular decompression.

OBJECTIVE: Opening of mastoid air cells (MACs), a complication of lateral suboccipital craniotomy for microvascular decompression (MVD), might cause cerebrospinal fluid (CSF) leakage and meningitis. Only a few studies have investigated the association of degree of MAC development and actual opening of MACs. The present study focused on preoperative risk assessment for predicting the opening of MACs. PATIENTS AND METHODS: The study included 204 consecutive patients who underwent MVD at our hospital between January 2014 and December 2018. We retrospectively collected clinical and neuroimaging data from electronic medical charts and discharge summaries. MACs were classified into four types according to neuroimaging data. Postoperative computed tomography (CT) was used to assess patients with and without CSF leakage into MACs. RESULTS: No CSF leakage was observed into types 1 and 2 MACs, but it was noted in 14 of 46 patients (30 %) with type 3 and 44 of 58 patients (76 %) with type 4 MACs. Opening of MACs during surgery could not be recognized in 33 (57 %). CSF rhinorrhea was noted in 1 of the 58 patients with CSF leakage into MACs and meningitis was not noted. CONCLUSION: Patients with types 3 and 4 MACs have a high risk of CSF leakage. Complete prevention of mild symptoms, such as ear obstruction, is challenging even if opened MACs are sealed, but serious complications, such as CSF rhinorrhea and meningitis, can be avoided. For cases in which preoperative CT reveals a high risk of opening of MACs, preventive closure should be performed.

Subcutaneous Heparin Therapy for Patients with Cancer-Associated Stroke.

BACKGROUND: Anticoagulation therapy, particularly subcutaneous heparin therapy, is recommended for cancer-associated thrombosis. However, not starting or discontinuing anticoagulation was not rare. The aim of the present study was to examine the practical issues related to anticoagulation therapy and effects of subcutaneous heparin therapy for cancer-associated stroke. METHODS: Patients with cancer-associated stroke in our stroke center between October 2014 and August 2017 who were diagnosed as having acute ischemic stroke based on diffusion-weighted imaging were retrospectively enrolled. Baseline clinical characteristics, heparin injection, reasons for no subcutaneous heparin therapy, and clinical outcomes were collected. RESULTS: A total of 59 patients with cancer-associated stroke (75 ± 10 years old, male 42%) were enrolled. Lung cancer was the most frequently observed cancer (n = 17, 29%), followed by gastric cancer (n = 8, 14%) and pancreatic cancer (n = 8, 14%). Of the 19 patients (32%) who underwent subcutaneous heparin therapy, it was discontinued in 9 (47%), mainly because of patients' medical conditions (deterioration of cancer or hemorrhagic complication). Ten patients with long-term subcutaneous heparin therapy did not have stroke recurrence. In contrast, among nine patients who discontinued subcutaneous heparin therapy, three (33%) had recurrence of ischemic stroke. Of the 40 patients without subcutaneous heparin therapy, the main reasons for no subcutaneous heparin therapy were the patients' medical conditions (n = 22, 55%). CONCLUSIONS: Although subcutaneous heparin therapy was given to only one third of cancer-associated stroke patients, long-term subcutaneous heparin therapy might prevent recurrence of cancer-associated stroke.

Predictable Value of Functional Independence Measure Differs between Anterior and Posterior Circulation Ischemic Strokes.

BACKGROUND: The functional independence measure (FIM) is a standard tool to provide a detailed evaluation of ADL of patients with disabilities. This study aimed to show the differences in FIM scores as an outcome predictor between patients with anterior circulation (AC) and posterior circulation (PC) strokes. METHODS: Consecutive patients with acute ischemic stroke hospitalized within 7 days after onset were investigated. Baseline NIHSS scores, 1st-FIM (< 72 h after -admission to stroke unit), 2nd-FIM (< 72 h before discharge), and modified Rankin Scale (mRS) scores were collected. Logistic regression analyses were used to identify predictors of a favorable outcome (mRS 0-2) at 3-month after stroke. RESULTS: Three hundred eighty-five patients (median age, 78 years; male, 59%; median length of stroke unit stay, 20 days) were included. The median baseline NIHSS, 1st- and 2nd-FIM scores were 4 (interquartile range 2-9), 65 (33-91), and 98 (54-122) respectively. Baseline NIHSS (3 vs. 4, p = 0.01) and mRS score at 3-month (1 vs. 2, p = 0.01) were lower, and 1st-FIM (75 vs. 64, p < 0.01) and 2nd-FIM (113 vs. 95, p = 0.01) were higher in 82 patients with PC than 303 patients with AC strokes. On multivariate logistic regression analysis, 2nd-FIM score was an independent predictor of favorable outcomes in both PC (OR 1.18, 95% CI 1.04-1.48, p < 0.01) and AC (OR 1.12, 95% CI 1.06-1.20, p < 0.01) strokes. The optimal cutoff scores of 2nd-FIM for predicting favorable outcome were 104 for PC (sensitivity 0.82, specificity 0.88) and 93 for AC (0.88-0.90) strokes. CONCLUSIONS: The differences in outcome predictability by FIM score between AC and PC strokes should be considered, although FIM scores at discharge from stroke unit were useful to predict a favorable outcome.

Does Reducing the Duration from Symptom Onset to Recanalization Improve the Results of Intracranial Mechanical Thrombectomy in the Elderly?

Endovascular recanalization for acute major cerebral artery occlusion is effective within a short time after symptom onset. However, its efficacy in the elderly remains unknown. We assessed the efficacy of our comprehensive stroke center's reduction of this time in 28 consecutive patients for elderly patients (defined as patients aged ≥75 years) with acute major cerebral artery occlusion treated with intravenous injection of tissue plasminogen activator, followed by thrombus retrieval by endovascular therapy. The patients were divided into groups according to whether they were treated before implementation of the time reduction measure (from January 2012 to May 2014) or after (from June 2014 to May 2015). The onset-to-door, onset-to-needle, onset-to-recanalization (O2R), door-to-image (D2I), door-to-needle (D2N), door-to-puncture (D2P), door-to-recanalization (D2R), and puncture-to-recanalization time intervals were compared between the two groups. There were 14 patients (including 8 elderly patients ≥80 years) before and 14 patients (including 10 elderly patients ≥80 years) after the time reduction measure. The mean duration of each of the following time intervals was significantly reduced after the time reduction measure (P < 0.05). To reduce the O2R time, the D2P time is the first time interval that can be reduced. At our center, conferences were regularly held to raise awareness among staff and make specific changes in the workflow, and overall time reduction was achieved. Similar results were obtained in elderly patients.