Stroke outcomes of Japanese patients with major cerebral artery occlusion in the post-alteplase, pre-MERCI era.

This study examined outcomes of patients with acute ischemic stroke (AIS) with major cerebral artery occlusion after the approval of intravenous recombinant tissue-type plasminogen activator (IV rt-PA) but before approval of the MERCI retriever. We retrospectively enrolled 1170 consecutive patients with AIS and major cerebral artery occlusion (496 women; mean age, 73.9 ± 12.3 years) who were admitted within 24 hours after the onset of symptoms to 12 Japanese stroke centers between October 2005 and June 2009. Cardioembolism was a leading cause of AIS in this group (68.2%). The occlusion sites of the major cerebral arteries included the common carotid artery and internal carotid artery (ICA; 29.6%), middle cerebral artery (52.2%), and basilar artery (7.6%). Recanalization therapy (RT) was performed in 32.0% of patients (IV rt-PA, 20.0%; neuroendovascular therapy, 9.4%; combined, 2.5%). Symptomatic intracerebral hemorrhage within 36 hours with a ≥ 1-point increase in the National Institutes of Health Stroke Scale score occurred in 5.3% of the patients. At 3 months (or at hospital discharge), 29.3% of the patients had a favorable outcome (based on a modified Rankin scale score of 0-2), 23.8% were bedridden, and 15.6% died. After multivariate adjustment, RT was positively associated with a favorable outcome and negatively associated with death, whereas age, baseline National Institutes of Health Stroke Scale score, and ICA occlusion were negatively associated with a favorable outcome and positively associated with death. One-third of the patients with AIS and major cerebral artery occlusion were treated with RT, which was independently associated with favorable outcomes and death. However, 40% of the patients became bedridden or died during the post-alteplase, pre-MERCI era in Japan.

Describing and Quantifying Wrong-Patient Medication Errors Through a Study of Incident Reports.

Purpose: Our aim was to inform a new definition of wrong-patient errors, obtained through an analysis of incident reports related to medication errors. Methods: We investigated wrong-patient medication errors in incident reports voluntarily reported by medical staff using a web-based incident reporting system from 2015 to 2016 at a university hospital in Japan. Incident report content was separately evaluated by four evaluators using investigational methods for clinical incidents from the Clinical Risk Unit and the Association of Litigation and Risk Management. They investigated whether it was the patient or drug that was incorrectly chosen during wrong-patient errors in drug administration in incident reports and assessed contributory factors which affected the error occurrence. The evaluators integrated the results and interpreted them together. Results: Out of a total 4337 IRs, only 30 cases (2%) contained wrong-patient errors in medication administration. The cases where the intended drugs were administered to incorrect patients occurred less frequently than cases where the wrong drugs were administered to the intended patients through the investigation of wrong targets. After a discussion, the evaluators concluded that the patient - drug/CPOE screen mismatch, caused by choosing the wrong patient, drug, or CPOE screen (mix-ups), occurred in the wrong-patient medication errors. These errors were caused by three conditions: (1) where two patients/drugs were listed next to one another, (2) where two patients' last names/drugs' names were the same, and (3) where the patient/drug/CPOE screen in front of the staff involved was believed to be the correct one. Additionally, these errors also involved insufficient confirmation, which led to failure to detect and correct the mismatch occurrences. Conclusion: Based on our study, we propose a new definition of wrong-patient medication errors: they consisted of choosing a wrong target and insufficient confirmation. We will investigate other types of wrong-patient errors to apply this definition.

Uncommon course for a vertebral artery dissection: rupture, occlusion and recanalization.

Intracranial arterial dissections of the vertebrobasilar system are recognized as a cause of stroke. Although the pathogenic mechanism underlying this phenomenon is unknown, in some cases the stroke originates from subarachnoid hemorrhage, while in others ischemia is the cause. In cases where hemorrhage occurs, occlusion of the lesion is effective in reducing the risk of re-bleeding. However, deciding on treatment is difficult in uncommon cases in which occlusion occurs immediately after hemorrhage. Intracranial arterial dissections of the vertebrobasilar system often present as subarachnoid hemorrhage, and the most appropriate surgical treatment remains controversial. In this report, we describe a rare case of vertebral artery dissection in which occlusion occurred immediately after subarachnoid hemorrhage. Serial angiography revealed spontaneous recanalization of the right vertebral artery dissection, as well as enlargement. The progressive angiographic changes of the ruptured vertebral artery dissection and the endovascular treatment of such arterial dissections are discussed.

Change in Cerebral Blood Flow after Palliative Percutaneous Angioplasty and Timing of Second Stage Carotid Artery Stenting in Staged Angioplasty.

The purpose of this study is to elucidate the hemodynamic changes after palliative angioplasty and the timing of second stage carotid artery stenting (CAS) in staged angioplasty for patients with severe hemodynamically compromised carotid artery stenosis. Among consecutive 111 patients with carotid artery stenosis, chronological changes in the cerebral blood flow of all 11 hemodynamically compromised patients treated with CAS were evaluated with single photon emission computed tomogram (SPECT) in each stage of the treatment. Ten of these 11 patients underwent staged angioplasty and one was treated with single-stage CAS. All the 10 patients who underwent staged angioplasty showed improved cerebral vascular reactivity (CVR) on SPECT after the first stage palliative angioplasty. Only one patient treated with staged angioplasty with 4-week interval before the CAS showed restenosis of the lesion. Cerebral hyperperfusion syndrome (CHS) was not observed in nine of 10 patients with staged angioplasty. One patient of staged angioplasty (who presented restenosis at the time of elective CAS) and another patient in whom we could not apply staged angioplasty (for his renal dysfunction) showed CHS after CAS. In conclusion, restoration of CVR could be achieved within a few days following palliative angioplasty, and 1-2-week interval is enough for staged angioplasty.

Subtle computed tomography abnormalities in cerebral deep sinus thrombosis.

A patient with cerebral deep sinus thrombosis, which was not diagnosed on the first examination, is reported. A 46-year-old woman presented with headache and vomiting. Neurological examination and a brain computed tomography (CT) scan showed no obvious abnormal findings. The patient suffered disturbed consciousness on the day after the examination, and was admitted to our emergency centre. A CT scan and magnetic resonance imaging revealed an ischaemic lesion in the left basal ganglia, suggesting deep sinus occlusion. Anticoagulant therapy was administered. One day after admission, a CT scan showed a haematoma and severe brain swelling in the same region. Cerebral angiography demonstrated a straight sinus occlusion. Intracranial pressure was not controlled with hypothermia, and the patient died 25 days after admission. Review of the initial CT scan revealed subtle, early findings of deep venous thrombosis that were missed on first examination.

Trend of Malpractice Litigation against Neurosurgeons in Japan: An Analysis of Disclosed Database by Courts in Japan from 2001 through 2015.

Following the modern raising of public awareness, the numbers of malpractice litigation are increasing in the health care delivery system in Japan despite the extensive efforts of physicians. Authors reviewed the issues of litigation and the reasons for court decision from the healthcare-related negligence lawsuits in the past 15 years in Japan and investigated the cautionary points for reducing potential litigation. Healthcare-related negligence lawsuits between January 2001 and December 2015 were retrieved and sorted in each clinical field from the database in Courts in Japan and investigated on the proportional factors of the claims and court decisions in the neurosurgical field. During the period, 446 of healthcare-related court decisions including 41 against neurosurgeons (9.2%) were retrieved. Three of 41 decisions retrieved were decisions to retries for lower court decisions. In 38 claims against the neurosurgeons, 26 identified the negligence and 12 dismissed. In 26 decisions in favor of the plaintiffs, identified negligence in diagnosis in 4, clinical judgment in 3, technical skills in 5, clinical management in 7 and process of informed consent in 7. Five out of 18 decisions after 2006 were identified as negligence in an informed consent process, and additional one, who was mainly identified in inadequate technical skills also identified existing an inadequate informed consent process as a fundamental cause of litigation. Neurosurgeons are a higher risk group for malpractice litigation in Japan and adequate informed consent is important to reduce the risk of litigation.

Middle cerebral artery occlusion associated with acute myocardial infarction in the perioperative period--case report.

A 68-year-old woman with no history of cardiac events suffered acute myocardial infarction after surgery for middle cerebral artery (MCA) occlusion manifesting as transient left motor weakness. Diffusion-weighted magnetic resonance imaging revealed multiple infarctions in the right cerebral hemisphere. Magnetic resonance angiography and cerebral angiography demonstrated an occlusion at the horizontal segment of the right MCA and no collateral circulation. Cerebral blood flow study 6 weeks after the initial presentation indicated decreased blood flow in the right cerebral hemisphere. Superficial temporal artery-MCA anastomosis was conducted to prevent recurrent cerebral infarction. Two hours after surgery, her systolic blood pressure fell to 60 mmHg and her consciousness worsened. Emergency coronary angiography indicated occlusion of the right coronary artery. Percutaneous coronary intervention was successfully performed and the subsequent course was uneventful. Preoperative evaluation of the coronary artery may be necessary before surgery for cerebral ischemic disease in both the intracranial and extracranial arteries.

A saccular-like dissecting aneurysm of the anterior cerebral artery that developed 2 years after an ischemic event.

BACKGROUND: A rare case of a growing dissecting aneurysm, which was located at the horizontal (A1) segment of the anterior cerebral artery (ACA), is reported. CASE DESCRIPTION: A 53-year-old woman experienced left hemiparesis and alien hand syndrome. A computerized tomography scan showed an infarction in the right frontal lobe, and cerebral angiography revealed a false lumen and intimal flap at the A1 segment of the ACA. Magnetic resonance angiography demonstrated that the stenosis progressed 6 months later and improved 1 year later. Cerebral angiography showed a saccular-like aneurysm 2 years later. The surgery was planned for prevention of aneurysmal rupture. The aneurysm, which was cocoon shaped, was exposed surgically and was resected. Histological examination of the aneurysm showed arterial dissection. The postoperative course was uneventful without additional neurological deficits. CONCLUSION: This is the first case report of A1 dissecting aneurysm presenting with an ischemic event in the literature. The sequential change of the configuration was curious to develop aneurysmal dilatation in 2 years. Long-term follow-up is necessary even after disappearance of the arterial dissection.

Microvascular pathological features of immediate perinidal parenchyma in cerebral arteriovenous malformations: giant bed capillaries.

OBJECT: The behavior of brain tissue in cases of arteriovenous malformations (AVMs) is a matter of debate. The authors believe that the local microvascular environment in the AVM bed shares the hemodynamic changes influencing that behavior in one way or another. The purpose of this study was to investigate the microvascular pathological features in the immediate perinidal brain tissue. METHODS: This retrospective study was conducted using excised AVM specimens obtained in 35 patients, from which the authors selected 20 specimens that fulfilled the criteria for sufficient brain tissue around the excised nidus. Specimens were stained with hematoxylin and eosin, and the immediate perinidal microvascular environment was examined using light microscopy. CONCLUSIONS: Eighty-five percent of the AVMs studied showed the presence of huge, dilated capillaries, and 65% showed severe congestion of these capillaries. The authors have named these capillaries "giant bed capillaries." In this study capillary bleeding was shown in AVMs, and a pericapillary space was seen around some vessels. The brain parenchyma containing AVMs with these findings proved to be significantly ischemic.

Compartments in arteriovenous malformation nidi demonstrated with rotational three-dimensional digital subtraction angiography by using selective microcatheterization. Report of three cases.

Although in several histological studies of arteriovenous malformation (AVM) nidi the presence of compartments has been documented, no clinical study has been published. The present study was conducted to determine the presence of nidus compartments in clinical cases by using a new radiographic method. Two patients with unruptured and one with a ruptured AVM (all Spetzler-Martin Grade III) were studied. A microcatheter was superselectively introduced into each of two or three feeding arteries of the AVMs under three-dimensional (3D) angiographic guidance to obtain 3D images of the nidus by using rotational digital subtraction angiography. On 3D images the different feeding arteries were found to be independent from one another, which allowed the authors to confirm the presence of compartments. On the other hand, separate feeding arteries often had a common draining vessel. Compartments in AVM nidi were demonstrated by a novel rotational 3D angiographic procedure by using superselective microcatheterization, which should be useful for designing treatment strategies for large and complex AVMs.

Radiometric analysis of paraclinoid carotid artery aneurysms.

OBJECT: Classification of paraclinoid carotid artery (CA) aneurysms based on their associated branching arteries has been confusing because superior hypophyseal arteries (SHAs) are too fine to appear opacified on cerebral angiograms. The authors performed a retrospective radiometric analysis of surgically treated paraclinoid aneurysms to elucidate their angiographic and anatomical characteristics. METHODS: A retrospective analysis was made of 85 intradural paraclinoid aneurysms in which the presence or absence of branching arteries had been determined at the time of surgical clipping. The lesions were classified as supraclinoid, clinoid, and infraclinoid aneurysms based on their relation to the anterior clinoid process on lateral angiograms of the CA. The direction of the aneurysms were measured according to angles formed between the medial portion of the horizontal line crossing the aneurysm sac and the center of the aneurysm neck on anteroposterior angiograms. Branching arteries were associated with 68 aneurysms, of which 28 were ophthalmic artery (OphA) lesions (32.9%) and 40 were SHA ones (47.1%); associated branching arteries were absent in 17 aneurysms (20%). Twenty-five aneurysms (29.4%) were located at the supraclinoidal level, 46 (54.1%) at the clinoidal, and 14 (16.5%) at the infraclinoidal. The majority of aneurysms identified at the supraclinoidal level were OphA lesions (44%) or those unassociated with branching arteries (48%), with mean directions of 57 degrees or 67 degrees, respectively. At the clinoidal level, the mean directions of aneurysms were 76 degrees in six lesions unassociated with branching arteries (13%), 43 degrees in 16 OphA lesions (35%), and -11 degrees in 24 SHA ones (52%). All aneurysms at the infraclinoidal level arose at the origin of the SHAs, with a mean direction of -29 degrees, and most of these were embedded in the carotid cave. CONCLUSIONS: Aneurysms arising from the SHA can be distinguished from those not located at an arterial division by cerebral angiography, because SHA lesions are usually located at the medial or inferomedial wall of the internal carotid artery at the clinoidal or infraclinoidal level. Their distribution correlates well with the reported distribution of SHA origins. The carotid cave aneurysm is a kind of SHA lesion that originates at the most proximal intradural CA.

Endovascular therapy versus surgical clipping for basilar artery bifurcation aneurysm: retrospective analysis of 117 cases.

OBJECTIVE: The purpose of this study was to retrospectively evaluate and compare the feasibility, indication and limitations of two treatment options, clipping and coil embolization, for basilar artery (BA) bifurcation aneurysms. MATERIALS AND METHODS: During the last 13 years, 117 patients with 117 BA bifurcation aneurysms were treated exclusively with direct surgery until February 1997, and with either direct surgery or coil embolization therapy since March 1997. Of them, 76 (65%) aneurysms were treated with direct clipping and 41 (35%) were treated with Guglielmi detachable coils (GDCs) embolization. The 76 surgically clipped aneurysms were analyzed on the basis of the pre-operative angiograms as to whether coil embolization would be feasible or not if each case had been attempted. The 41 embolized aneurysms, on the other hand, were analyzed as to whether clipping surgery would be feasible or not if it had been attempted. RESULTS: In the total 117 aneurysms, complete coil obliteration was judged to be possible and simple in 61 (52%) aneurysms, possible with complex techniques (difficult) in 29 (25%) and impossible in 27 (23%). Whereas, complete obliteration with direct clipping was judged to be simple in 66 (57%) aneurysms, difficult in 38 (32%) and impossible in the remaining 13 (11%). Linear correlation as to the technical difficulty was found in 61 (52%) aneurysms, but 14 (12%) had marked discrepancy between the two methods. Of the 76 patients treated with clipping surgery, 17 (22%) were left with some post-operative neurological deficits, and in six out of the 17 aneurysms, embolization might have been simple. There were complications in two patients; one procedure-related and the other with late re-bleeding due to aneurysmal re-growth, in the embolization, group. CONCLUSIONS: Endovascular therapy is an effective alternative for treating BA bifurcation aneurysms, although a quarter of the cases cannot be obliterated completely. It is important to select a suitable treatment option in each case depending on the patient's condition and the angiographical features of each aneurysm as well as the characteristics of the two methods.

Gross total surgical removal of malignant glioma from the medulla oblongata: report of two adult cases with reference to surgical anatomy.

Surgery was performed on the medulla oblongata of two adult patients with malignant glioma. Gross total resection of the tumors, located laterally or medially in the upper half of the medulla respectively, was achieved. The patient with the medially located tumor experienced significant postoperative neurological deterioration including sleep apnea. The other patient with the laterally located tumor showed symptomatic improvement without respiratory complications. The patient with an anaplastic astrocytoma survived approximately 4 years and the patient with a glioblastoma multiforme approximately 2 years. Although the upper half of the medulla is more critical than the lower half, a lateral approach to the upper half of the medulla appears to be relatively safer than a medial approach. Some cases of focal malignant gliomas in the medulla may be amenable to gross total resection in order to achieve improved outcome. Surgery can be undertaken when a tumor is unilateral and its margin appears relatively clear on magnetic resonance images.

Carotid artery stenting for atherosclerotic stenosis associated with non-bifurcating cervical carotid artery.

A 68-year-old man presented with right cervical carotid artery stenosis manifesting as ipsilateral amaurosis fugax. Angiography showed non-bifurcating cervical carotid artery with atherosclerotic stenosis near the branching of the superior thyroid artery. Carotid artery stenting (CAS) was carried out using two balloons for embolic protection of the internal carotid artery and middle meningeal artery because the ophthalmic artery was supplied by the middle meningeal artery. No procedure-related complications or restenosis occurred after stenting. Non-bifurcating cervical carotid artery is a very rare anomaly, in which the branches of the external carotid artery directly arise from the common trunk of the carotid artery without forming a bifurcation. The present patient was successfully treated with CAS for atherosclerotic stenosis associated with non-bifurcating cervical carotid artery.

Suboccipital approach for primitive trigeminal artery obliteration associated with cavernous aneurysm.

OBJECTIVE: A 63-year-old woman presented with diplopia resulting from abducens paralysis. Examination revealed a giant cavernous aneurysm supplied by the internal carotid artery (ICA) and primitive trigeminal artery (PTA) via the vertebrobasilar system. METHODS: After evaluation of balloon test occlusion (BTO) at the distal side of the PTA origin, the aneurysm was treated with PTA obliteration through the suboccipital route in the lateral position followed by cervical carotid ligation with superficial temporal artery-to-middle cerebral artery anastomosis in the supine position. RESULTS: The aneurysm showed marked shrinkage after the surgery. CONCLUSION: PTA obliteration through the retrosigmoid opening is a therapeutic surgical option in a patient with a cavernous aneurysm supplied by the PTA.

Massive hemorrhage and pseudo-obstruction of the small intestine caused by primary AL amyloidosis associated with gastric cancer: report of a case.

We report a case of AL amyloidosis in a patient diagnosed with early gastric cancer after presenting with massive gastrointestinal hemorrhage and pseudo-obstruction of the small intestine. Primary systemic amyloidosis accounts for 7% of nonhematological malignancies, but very few cases of gastric carcinoma in patients with primary amyloidosis have been described. We performed distal gastrectomy with biopsy of the small intestine in the absence of a diagnosis of systemic amyloidosis associated with early gastric cancer; however, the patient suffered severe postoperative complications secondary to the amyloidosis. Although acute pseudo-obstruction is an uncommon clinical manifestation of AL amyloidosis, the coexistence of both gastrointestinal hemorrhage and pseudo-obstruction of the small intestine should alert the clinician to a diagnosis of gastrointestinal amyloidosis. We discuss the clinical manifestations of primary amyloidosis occurring in association with gastric cancer.