Anti-thrombotic therapies including aspirin, or dual anti-platelet therapy (DAPT) comprising aspirin and clopidogrel, or intravenous infusion of ozagrel sodium or argatroban are currently available for patients with acute non-cardioembolic stroke. Based on the clinical condition of the patient with acute ischemic stroke, DAPT is highly recommended, but should be switched to single-agent anti-platelet therapy within a week, or chronically, up to one year from onset. In patients with acute cardioembolic stroke with non-valvular atrial fibrillation (NVAF), anti-coagulant therapy using warfarin or direct oral anticoagulants (DOACs) should be initiated within two weeks ; there is no evidence for clinical benefits from heparin infusion. From the perspective of reducing hemorrhagic complications in patients with NVAF, DOAC is preferentially recommended over warfarin. The latter is used in patients with mechanical valves, only because DOAC is not indicated for such patients.
Anti-coagulant therapy is recommended for patients with embolic stroke of undetermined source (ESUS), particularly in those with medium risk of heart disease, paradoxical cerebral embolism and venous thrombosis in the lower extremities. Anti-platelet therapy is recommended for patients with other ESUS, according to their individual clinical needs. Anti-thrombotic therapy requires patient blood pressure to preferably be under 130/80 mmHg. This is of significance in patients with cerebral microbleeds, previous cerebral hemorrhage, and lacunar infarction, where strict control of blood pressure prevents recurrent stroke and symptomatic cerebral hemorrhage. Peri-operative management of anti-thrombotic therapy is facilitated by team conferences with neurosurgeons, cardiologists, gastroenterologists, anesthesiologists and other medical staff. It is recommended for neurosurgeons to suspend and restart anti-thrombotic agents during the peri-operative period, after obtaining patient informed consent regarding the risks and benefits of anti-thrombotic therapy described in guidelines and according to consensus of the management team.
Between 2014 and 2015, five pivotal stroke trials (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME and REVASCAT) showed that stroke thrombectomy clearly improved functional outcome of patients with occlusion of the internal carotid artery or the M1 portion of the middle cerebral artery, with a baseline National Institutes of Health Stroke Scale score of ≥6, with a baseline Alberta Stroke Program Early Computed Tomography Score of ≥6, and who could receive thrombectomy within a 6-hour window of symptom onset. In 2018, the efficacy of stroke thrombectomy for patients with late-presenting stroke up to 16 to 24 hours of onset and who had clinical imaging mismatch or target mismatch based on RAPID analysis was also established by DAWN and DEFUSE 3 trials. “Brief imaging”-based patient selection, such as a combination of non-contrast computed tomography (CT) and CT angiography, and immediate treatment initiation are emphasized for patients within 6 hours of stroke onset. On the other hand, patient selection of a time window beyond six hours of onset necessitates “multimodal imaging” including RAPID analysis, which is unfamiliar in Japan. It will, therefore, be important how to extrapolate the evidence established on “multimodal imaging” in a real clinical setting in Japan. In addition, the establishment of precise preprocedural evaluation of occlusion site or occluded thrombi is warranted because inappropriate device selection for occlusion site, including pathological characteristics of vessel walls and thrombi, may reduce the efficacy of endovascular stroke reperfusion therapy.
The natural course of carotid artery stenosis is influenced by its symptomatology and stenosis ratio, both of which influence the choice of surgical interventions for moderate to severe stenotic lesions. The equivalence of carotid stenting and carotid endarterectomy rendered through refinement of therapeutic tools and practical technique ensured therapeutic efficacy with a concurrent reduction in morbidity and mortality. Recent advances in therapeutics and morphological assessment of plaques have resulted in the need for a revamp of surgical interventions for asymptomatic lesions. Moreover, clinical evidence related to optimal treatment for carotid artery stenosis should be updated to enable comparison of various treatment options.
Purpose : Clinical trials did not show the efficacy of endovascular therapy or open surgery for symptomatic intracranial artery stenosis (ICAS). However, the number of the patients resistant or contraindicated for medical therapy is not small, and there is no consensus how to treat such patients. In this report, clinical evidences regarding ICAS treatment were reviewed and treatment selection was discussed.
Background : ICAS accounts for 30% of total cerebral infarction approximately. The recurrence rate of stroke in patients having severe stenosis (>70%) was reported to be around 23% during aspirin treatment and around 12% during aggressive medical therapy including antiplatelets, blood pressure control, lipid lowering, and life style modification such as smoking cessation.
Treatments and clinical evidences : 1) Medical therapy : Randomized controlled trial (RCT) showed that aspirin was superior to warfarin. 2) Two RCTs failed to show the efficacy of endovascular therapy for symptomatic ICAS. Therefore, aggressive medical treatment is regarded as the first option. On the other hand, a new RCT in China is ongoing based on the previous studies. 3) Bypass surgery : There is no RCT aiming to show the efficacy of bypass surgery for ICAS. However, bypass is sometimes performed for the patients who are resistant or contraindicated for other therapies.
Conclusions : The standard treatment is medical therapy according to the clinical trials, however the efficacy of endovascular or other therapies for the medically-refractory patients will be tested in clinical trials.
Moyamoya disease (MMD) is a progressive cerebrovascular disease with unknown etiology, characterized by steno-occlusive changes at the terminal portion of the internal carotid artery and an abnormal vascular network formation at the base of the brain. The diagnostic criteria for MMD were updated in 2015 and included not only typical MMD patients with bilateral involvement but also patients with unilateral involvement and/or with atherosclerosis into definitive MMD. Surgical interventions including revascularization surgery comprising direct bypass has been known to prevent cerebral ischemic attack by improving cerebral blood flow and, as more recently shown, could reduce the potential risk of re-bleeding in MMD patients with posterior hemorrhage, who have regular and extremely high re-bleeding rate. Based on modern diagnostic criteria and increasing evidence for revascularization surgery, more MMD patients have lately undergone bypass surgery. We therefore aimed to review modern diagnostic criteria and indication of surgical revascularization for MMD.
Pituitary metastases of prostate cancer are rare. We report a case of prostate adenocarcinoma that metastasized to the anterior pituitary gland. A 54-year-old man presented with bitemporal hemianopsia, consciousness loss, and coxalgia. His serum sodium level was 116 mmol/l. Magnetic resonance imaging (MRI) revealed an intrasellar tumor that showed inhomogeneous enhancement, and was attached to the optic chiasm. Laboratory examination revealed free testosterone level to be 0.5 pg/ml (reference range, 6.1-25.0). His hyponatremia improved following cortisol replacement, and was diagnosed to be due to relative adrenal insufficiency. Additional diagnostic studies including pelvic MRI, bone scintigraphy, and prostate needle biopsy revealed the presence of prostate adenocarcinoma (Gleason score 4+3=7) with multiple metastases to the vertebrae and pelvis. While receiving combined androgen blockade (CAB) therapy using the gonadotropin-releasing hormone antagonist degarelix acetate plus the antiandrogen bicalutamide, he presented with progressive visual field deficits. Subsequently, he underwent transsphenoidal surgery. Pathological examination of the resected tumor revealed it to be a metastatic adenocarcinoma of the anterior pituitary gland, which originated from the primary prostate cancer. Postoperatively, his bitemporal hemianopsia showed marked improvement. After docetaxel therapy and stereotactic radiotherapy, MRI showed significant shrinkage of the pituitary metastasis.
In this case, hypogonadism caused by pituitary metastases might pose androgen resistance of the prostate cancer. Therefore, careful evaluation including hormone load test prior to the treatment is highly recommended.