Factors associated with the new appearance of cerebral microbleeds after endovascular treatment for unruptured intracranial aneurysms.

PURPOSE: Endovascular treatment of unruptured intracranial aneurysms may increase cerebral microbleeds (CMBs) in postprocedural T2*-weighted MRIs, which may be a risk for future intracerebral hemorrhage. This study examined the characteristics of postprocedural CMBs and the factors that cause their increase. METHODS: The patients who underwent endovascular treatment for unruptured intracranial aneurysms from April 2016 to February 2018 were retrospectively analyzed. Treatment techniques for endovascular treatment included simple coiling, balloon-assisted coiling, stent-assisted coiling, or flow diverter placement. To evaluate the increase in CMBs, a head MRI including diffusion-weighted imaging and T2*-weighted MRIs was performed on the preprocedural day; the first postprocedural day; and at 1, 3, and 6 months after the procedure. RESULTS: Among the 101 aneurysms that were analyzed, 38 (37.6%) showed the appearance of new CMBs. In the multivariate analysis examining the causes of the CMB increases, chronic kidney disease, a higher number of preprocedural CMBs, and a higher number of diffusion-weighted imaging-positive lesions on the first postprocedural day were independent risk factors. Furthermore, a greater portion of the increased CMBs was found in cortical and subcortical lesions of the treated vascular perfusion area within 1 month after the procedure. CONCLUSION: In endovascular treatment for unruptured intracranial aneurysms, CMBs tended to increase in patients with small vessel disease before the procedure, and it was also implicated in hemorrhagic changes after periprocedural microinfarction.

Sideway Aspiration Technique for Thrombus in a Sharply Bifurcated Branch of a Large Vessel.

Objective: Standard thrombectomy techniques, including stent retrieval and a direct aspiration first pass technique, are not effective when the occluded vessel is narrow and sharply bifurcated from the main trunk. Here, we present a new and alternative method for patients with such anatomical features and describe two cases treated by this method. Case Presentations: Case 1 was a 66-year-old woman who presented with consciousness disturbance and left hemiparesis. MRA suggested a right middle cerebral artery occlusion. Case 2 was an 86-year-old man who presented with sudden onset of consciousness disturbance; MRA indicated occlusion of the basilar artery. Both cases were successfully treated by our new method. First, we navigated a microcatheter, microguidewire, and aspiration catheter into the patent and visible branch adjacent to the occluded branch. The aspiration catheter was then carefully pulled back with continuous mechanical aspiration. When reverse blood flow from the aspiration catheter was suspended, we slightly advanced the catheter and caught the thrombus. Complete recanalization was attained in the two cases treated with this technique, which was named as sideway aspiration technique (SAT). Conclusion: Although it warrants further study, SAT may be a potentially safe and effective method for thrombectomy in cases with thrombus in a sharply bifurcated branch.

Symptomatic Cavernous Internal Carotid Artery Aneurysm Complicated by Simultaneous Rapid Growth of the Intra-aneurysmal and Parent Artery Thromboses.

Cavernous internal carotid artery (ICA) aneurysm complicated by simultaneous and spontaneous formation of thromboses in the aneurysm and the parent artery is a rare clinical condition. Although the majority of patients have good outcomes, some patients experience severe ischemic stroke. Here, we report a case of symptomatic large cavernous ICA aneurysm complicated by rapid growth of an intra-aneurysmal thrombosis with simultaneous parent artery thrombosis. A 68-year-old female presented with sudden-onset diplopia, right ptosis, right conjunctival hyperemia, and paresthesia of the right face. Magnetic resonance imaging (MRI) and digital subtract angiography (DSA) revealed the presence of a large partially thrombosed aneurysm in the cavernous portion of the right ICA. We planned endovascular embolization using a flow-diverting (FD) stent. Dual-antiplatelet therapy (DAPT) with aspirin and clopidogrel was started 2 weeks prior to treatment. Although the neurological state was stable, DSA conducted on the day of the endovascular treatment showed rapid growth of an intra-aneurysmal thrombosis and de novo thrombosis in the parent artery. Direct aspiration was performed via a distal support catheter with proximal blood flow arrest using a balloon-guide catheter, and the FD stent was successfully deployed. The patient's symptoms improved postoperatively and DSA obtained 12 months after the procedure confirmed complete occlusion of the aneurysm. Although the exact mechanism of simultaneous thrombosis formation of the aneurysm and its parent artery remains unclear, it is important to recognize that rapid growth of the thrombosis increases the risk of ischemic stroke.

Treatment of Aneurysms in Persistent Primitive Trigeminal Arteries with Stent-Assisted Coil Embolization.

Objective: Persistent primitive trigeminal artery (PPTA) is a rare condition in which a fetal carotid-basilar anastomosis persists into adulthood. PPTA aneurysms often necessitate endovascular treatment and adjunctive techniques, such as stent- or balloon-assisted techniques, are sometimes selected. This case report describes two women in their sixties with unruptured right PPTA aneurysms who underwent stent-assisted coil embolization procedures, with consideration of the anatomical features in each case. Case Presentations: One patient presented with an aneurysm at the bifurcation of the PPTA and the basilar artery (BA), which was classified as Saltzman type 1 with a hypoplastic vertebral artery (VA)-BA system. A stent was deployed from the BA to the PPTA to cover the neck of the aneurysm and coil embolization was performed. The second patient presented with an aneurysm at the bifurcation of the PPTA and the internal carotid artery (ICA), which was classified as Saltzman type 2 with a hypoplastic VA-BA system. A stent was deployed from the PPTA to the petrous segment of the ICA covering the neck of the aneurysm and coil embolization was performed. In both patients, the 1-year follow-up digital subtraction angiography (DSA) showed that the aneurysms had not recurred. Conclusion: The PPTA aneurysms were successfully treated with stent-assisted coil embolization. The treatment strategy should be devised in accordance with both the lesion site and the PPTA variant.

Clopidogrel response predicts thromboembolic events associated with coil embolization of unruptured intracranial aneurysms: A prospective cohort study.

OBJECTIVE: Periprocedural thromboembolic events are a serious complication associated with coil embolization of unruptured intracranial aneurysms. However, no established clinical rule for predicting thromboembolic events exists. This study aimed to clarify the significance of adding preoperative clopidogrel response value to clinical factors when predicting the occurrence of thromboembolic events during/after coil embolization and to develop a nomogram for thromboembolic event prediction. METHODS: In this prospective, single-center, cohort study, we included 345 patients undergoing elective coil embolization for unruptured intracranial aneurysm. Thromboembolic event was defined as the occurrence of intra-procedural thrombus formation and postprocedural symptomatic cerebral infarction within 7 days. We evaluated preoperative clopidogrel response and patients' clinical information. We developed a patient-clinical-information model for thromboembolic event using multivariate analysis and compared its efficiency with that of patient-clinical-information plus preoperative clopidogrel response model. The predictive performances of the two models were assessed using area under the receiver-operating characteristic curve (AUC-ROC) with bootstrap method and compared using net reclassification improvement (NRI) and integrated discrimination improvement (IDI). RESULTS: Twenty-eight patients experienced thromboembolic events. The clinical model included age, aneurysm location, aneurysm dome and neck size, and treatment technique. AUC-ROC for the clinical model improved from 0.707 to 0.779 after adding the clopidogrel response value. Significant intergroup differences were noted in NRI (0.617, 95% CI: 0.247-0.987, p < .001) and IDI (0.068, 95% CI: 0.021-0.116, p = .005). CONCLUSIONS: Evaluation of preoperative clopidogrel response in addition to clinical variables improves the prediction accuracy of thromboembolic event occurrence during/after coil embolization of unruptured intracranial aneurysm.

Late-onset ornithine transcarbamylase deficiency: a rare cause of recurrent abnormal behavior in adults.

BACKGROUND: Ornithine transcarbamylase is an enzyme of the urea cycle, which produces urea from ammonia. Although ornithine transcarbamylase deficiency mainly occurs as a severe neonatal-onset disease, a late-onset form that could become symptomatic from infancy to adulthood is also known. CASE PRESENTATION: A 34-year-old man presented with sudden onset of abnormal behavior, lethargy, and hyperammonemia (108 µmol/L). He had recently increased daily protein intake, which suggested urea cycle disorder. After initiation of protein-restricted diet and treatment with arginine and sodium phenylbutyrate, his symptoms resolved, along with a decrease in the ammonia level. An R40H(c.119G > A) mutation in the OTC gene was identified. CONCLUSION: Awareness of adult onset ornithine transcarbamylase deficiency in a patient with acute psychiatric symptoms due to hyperammonemia is important.

Intracranial Subdural Abscess Caused by Actinomyces meyeri Related to Dental Treatment: A Case Report.

Intracranial subdural abscess is a rare condition. Although brain abscess is often reported in relation to dental infection, reports of intracranial subdural abscess are few. Actinomyces spp. forms part of the normal flora of the oral, gastrointestinal, and genital tract, and is rarely the cause of intracranial infection; moreover, the pathogen Actinomyces meyeri is very rare. We report an exceptional case of intracranial subdural abscess caused by A. meyeri and related to dental treatment. A 57-year-old woman initially presented with a 5-day history of headache. Because left arm numbness and weakness became apparent, she was admitted to our department. She had a history of hypertension and dental problems requiring tooth extractions. Diffusion-weighted imaging (DWI) showed a 1-cm right convexity hyperintense mass above the postcentral gyrus. A post-gadolinium T1-weighted image showed a thin hypointense area with peripheral rim enhancement in the right subdural space that appeared to partially thicken in the same location as the DWI-positive mass. She underwent emergent navigation-guided drainage and 4 mL of pus was obtained. Postoperatively, left arm numbness and weakness disappeared. Cultures showed growth of A. meyeri and Fusobacterium nucleatum. She was started on intravenous penicillin G and metronidazole. After a 4-week course of the intravenous antibiotics, her headache gradually improved and the abscess in the subdural space subsided. To our best knowledge this is the first case report of intracranial subdural abscess caused by A. meyeri associated with dental treatment.

Long-term Outcomes After Intraprocedural Aneurysm Rupture During Coil Embolization of Unruptured Intracranial Aneurysms.

BACKGROUND: The long-term outcomes of patients with intraprocedural aneurysm rupture (IPR) during endovascular coiling of unruptured intracranial aneurysms (UIAs) remain unclear. We investigated the long-term outcomes and predictors of neurological outcomes in patients who sustained IPR during coil embolization of UIAs. METHODS: We retrospectively analyzed the medical record of 312 untreated UIAs in 284 patients who underwent endovascular coiling between April 2013 and July 2018. RESULTS: The mean follow-up period for the entire cohort was 25.6 months. Twelve patients (3.8%) experienced IPR. The mean aneurysm size in the IPR cohort was significantly smaller than that in the no-IPR cohort (P = 0.045). The IPR cohort had a higher percentage of earlier subarachnoid hemorrhage from another aneurysm (P = 0.019), anterior communicating artery (AComA) aneurysm (P < 0.001), and basilar artery (BA) aneurysm (P = 0.022) than the no-IPR cohort. Neurologic deterioration was observed in 3 patients. The morbidity and mortality rates of the IPR cohort were 25% and 8.3%, respectively. Patients with IPR during coil embolization for AComA aneurysm did not develop neurological deterioration. Two of the 3 patients (66.7%) with a BA aneurysm had neurological deterioration. The proportion of patients with an mRS score of 0-2 at the last follow-up did not differ between the 2 cohorts (P = 0.608). CONCLUSIONS: The proportion of functionally independent patients did not differ between patients with and without IPR. Patients with BA aneurysms who developed an IPR tended to exhibit more unfavorable clinical courses than patients with AcomA aneurysms.

A Case of Posterior Reversible Encephalopathy Syndrome After Surgical Clipping of Unruptured Cerebral Aneurysm.

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is characterized by reversible edematous lesions on imaging examinations, along with symptoms of altered consciousness disorder and seizures. Various factors associated with PRES have been reported. However, we encountered a very rare case that developed after clipping surgery for unruptured cerebral aneurysm. CASE DESCRIPTION: A 74-year-old man with a history of hypertension presented with an unruptured right middle cerebral artery aneurysm and underwent cranial clipping surgery. After surgery, he developed consciousness disorder and epilepsy after delayed awakening from general anesthesia. Radiological examinations revealed multiple edematous lesions, strongly suggesting PRES, and excluding asymmetry consistent with the area of craniotomy. With conservative treatment, symptoms and radiological findings almost disappeared. Symptoms and imaging findings remaining at the area of craniotomy were attributed to the severe difference in cerebral perfusion pressure due to craniotomy. CONCLUSIONS: Based on the literature, this case was considered to represent PRES caused by rapid blood pressure fluctuations accompanying general anesthesia for clipping surgery. Practitioners must keep PRES in mind as a rare complication after clipping for unruptured cerebral aneurysms. PRES developing after craniotomy shows unilaterality and may become severe in the craniotomy area and leave sequelae.

Thrombosis of Large Aneurysm Induced by Flow-Diverter Stent and Dissolved by Direct Factor Xa Inhibitor.

BACKGROUND: Antiplatelet agents are typically administered before and after treatment using flow-diverter stents (FDS) to prevent thrombotic complications, but the effects of anticoagulants are unclear. We present a patient with a giant aneurysm treated with an FDS. The thrombus within the aneurysm was dissolved when a direct factor Xa inhibitor was administered to treat lower limb venous thrombosis that occurred secondary to steroid use. CASE DESCRIPTION: A 60-year-old woman with a 30-mm giant thrombosed aneurysm in the cavernous segment of the right internal carotid artery presenting with headache and right abducens nerve palsy was treated by placing an FDS. Diplopia and increased pain in her right eye appeared on postoperative day 7, and both were alleviated by continuous oral administration of prednisolone. Angiography 3 months postoperatively revealed that the aneurysm thrombosis had progressed, and there were signs of healing. However, at the same time, lower limb venous thrombosis occurred, which was treated by continuous edoxaban. Six months after surgery, her headaches worsened and angiography showed that the aneurysm was again contrast enhanced and that the thrombus within the aneurysm had dissolved. After discontinuing edoxaban 9 months after surgery, the aneurysmal thrombosis had again rapidly progressed. CONCLUSIONS: Administration of a direct factor Xa inhibitor during healing after placing an FDS may cause dissolution of an existing thrombus; therefore factor Xa inhibitors must be used with caution.

Factors Associated with Postprocedural Diffusion-Weighted Imaging-Positive Lesions in Endovascular Treatment for Unruptured Cerebral Aneurysms.

BACKGROUND: In endovascular treatment for cerebral aneurysms, the appearance of asymptomatic thromboembolic lesions detected by postprocedural diffusion-weighted imaging (DWI) can be a surrogate marker for estimating the potential risk of symptomatic thromboembolism. The aim of this study was to clarify factors associated with postprocedural DWI-positive lesions in endovascular treatment for unruptured cerebral aneurysms. METHODS: Patients with untreated unruptured cerebral aneurysms undergoing endovascular treatment were consecutively enrolled. Treatment techniques were classified into simple coiling, balloon-assisted coiling, stent-assisted coiling, and flow-diverter placement. Head magnetic resonance imaging was performed within 3 months before and 24 hours after the procedure to assess the appearance of DWI-positive lesions. RESULTS: Among 376 aneurysms in 355 patients that were analyzed, 232 (61.7%) had postprocedural DWI-positive lesions. In univariate analyses, age (P = 0.001), dome size (P < 0.001), neck size (P < 0.001), treatment technique (P = 0.029), and total procedural time (P < 0.001) were significantly associated with postprocedural DWI-positive lesions. In the multiple logistic regression model, older age (odds ratio, 1.33; 95% confidence interval, 1.10-1.60; P = 0.003; per decade), flow-diverter placement (odds ratio, 4.93; 95% confidence interval, 1.33-20.92; P = 0.016; compared with simple coiling), and longer procedural time (odds ratio, 1.66; 95% confidence interval, 1.26-2.21; P < 0.001; per hour) were associated with postprocedural DWI-positive lesions. CONCLUSIONS: Older age, flow-diverter placement, and longer procedural time were associated with postprocedural DWI-positive lesions in endovascular treatment for unruptured cerebral aneurysms.

A Visual Task Management Application for Acute Ischemic Stroke Care.

Background: To maximize the effect of intravenous (IV) thrombolysis and/or endovascular therapy (EVT) for acute ischemic stroke (AIS), stroke centers need to establish a parallel workflow on the basis of a code stroke (CS) protocol. At Kokura Memorial Hospital (KMH), we implemented a CS system in January 2014; however, the process of information sharing within the team has occasionally been burdensome. Objective: To solve this problem using information communication technology (ICT), we developed a novel application for smart devices, named "Task Calc. Stroke" (TCS), and aimed to investigate the impact of TCS on AIS care. Methods: TCS can visualize the real-time progress of crucial tasks for AIS on a dashboard by changing color indicators. From August 2015 to March 2017, we installed TCS at KMH and recommended its use during normal business hours (NBH). We compared the door-to-computed tomography time, the door-to-complete blood count (door-to-CBC) time, the door-to-needle for IV thrombolysis time, and the door-to-puncture for EVT time among three treatment groups, one using TCS ("TCS-based CS"), one not using TCS ("phone-based CS"), and one not based on CS ("non-CS"). A questionnaire survey regarding communication problems was conducted among the CS teams at 3 months after the implementation of TCS. Results: During the study period, 74 patients with AIS were transported to KMH within 4.5 h from onset during NBH, and 53 were treated using a CS approach (phone-based CS: 26, TSC-based CS: 27). The door-to-CBC time was significantly reduced in the TCS-based CS group compared to the phone-based CS group, from 31 to 19 min (p = 0.043). Other processing times were also reduced, albeit not significantly. The rate of IV thrombosis was higher in the TCS-based CS group (78% vs. 46%, p = 0.037). The questionnaire was correctly filled in by 34/38 (89%) respondents, and 82% of the respondents felt a reduction in communication burden by using the TCS application. Conclusions: TCS is a novel approach that uses ICT to support information sharing in a parallel CS workflow in AIS care. It shortens the processing times of critical tasks and lessens the communication burden among team members.

Reversible cerebral vasoconstriction complicated with brain infarction immediately after carotid artery stenting.

Reversible cerebral vasoconstriction is a very rare complication after carotid artery stenting (CAS). It has been reported to occur more than several hours after CAS and to have a good clinical course. A 73-year-old man underwent CAS for a high-grade symptomatic stenosis of his left carotid artery. Immediately after CAS, he had consciousness disturbance and right hemiparesis. We first suspected hyperperfusion syndrome, but antihypertensive therapy exacerbated his symptoms. On repeated postoperative angiography, the middle cerebral artery (MCA) appeared to become progressively narrower. Perfusion computed tomography indicated hypoperfusion in the left MCA territory, so we diagnosed the patient with ischemic symptoms due to hypoperfusion associated with MCA vasoconstriction. Although these findings were temporary, right weakness and cognitive dysfunction lingered and caused severe disability. As vasoconstriction after CAS may result in a poor outcome, it must be promptly distinguished and treated accordingly.

Dural and Pial Arteriovenous Fistulas Connected to the Same Drainer in the Middle Cranial Fossa: A Case Report.

BACKGROUND: Dural arteriovenous fistulas (AVFs) in the middle cranial fossa are rare. Pial AVFs are similarly rare but differ from dural AVFs in that they derive their arterial supply from pial or cortical arterial vessels and do not lie within the intradural region. We report an extremely rare case of dural and pial AVF connected to the same drainer in the middle cranial fossa. CASE DESCRIPTION: In a 58-year-old man with a subcortical hemorrhage in the right temporal lobe, digital subtraction angiography showed a dural AVF in the middle cranial fossa fed by the middle meningeal artery (MMA) and draining into the sphenopetrosal vein. A combination with a small pial AVF connected to the same sphenopetrosal vein was suspected. Open surgery was performed to directly observe the shunt points. Transarterial indocyanine green (ICG) angiography using the MMA via the superficial temporal artery on a skin flap was performed to repeatedly and distinctly evaluate the dural shunt points and to prevent cerebral thromboembolism. Although the dural supply was completely disconnected, the sphenopetrosal vein remained arterialized. ICG angiography revealed pial AVF, which was fed by the cortical arteries draining into the same drainer. The pial supply was completely disconnected, and disappearance of the dural and pial AVF was confirmed. CONCLUSIONS: We report an extremely rare case of dural and pial AVF connected to the same drainer in the middle cranial fossa. To our knowledge, this is the first such case report described in the literature.