Objective: The purpose of this study was to investigate the characteristics, time-line, and treatment results of in-hospital acute ischemic stroke due to large vessel occlusion (LVO) treated by mechanical thrombectomy.
Methods: The authors investigated 10 patients (six males and four females; mean age 78.6 years, range 65–92) with in-hospital LVO treated by thrombectomy between January 2016 and July 2018 in our institute. Patient characteristics, procedural results, clinical outcome, and time-line data of thrombectomy (last well known [LWK]/onset, recognition, arterial puncture, and recanalization) were retrospectively evaluated. Results obtained from in-hospital LVO were compared with those from 13 patients with community-onset LVO (eight males and five females; mean age 78.3 years, range 45–87).
Results: The initial admitting departments of in-hospital LVO were cardiology in six (60%) and hematology, otolaryngology, urology, and gastroenterology in one each (10%). The etiologies of ischemic stroke were cardioembolism in eight (80%), thrombosis in one (10%), and iatrogenic consequence in one (10%). The comorbid disease of in-hospital LVO included cardiac disease in eight (80%) and malignant tumor in four (40%) with overlapping. The factor contributing to in-hospital LVO was invasive procedure with withdrawal of antithrombotic agents in three (30%). The interval between LWK and recognition was a median of 60 minutes in in-hospital LVO, which was shorter than LWK-to-arrival time in community-onset LVO (medial 225 minutes). The interval between recognition and consultation to the neuroendovascular team was a median of 50 minutes. The recognition-to-puncture time was compared with arrival-to-puncture time in community-onset LVO. That presented no difference between them (median 130 vs 150 minutes). The LWK-to-recanalization time in in-hospital LVO was shorter than that in community-onset LVO (median 240 vs 495 minutes). The procedural results of thrombectomy demonstrated no differences between them. The rate of thrombolysis in cerebral infarction (TICI) 2b-3 was 70% in in-hospital vs 85% in community-onset LVO. The rate of favorable outcome (modified Rankin Scale [mRS] 0-2) at discharge was not different (30% vs 23%); however, higher rates of mortality and severe disability (mRS 5-6) were observed in patients with in-hospital LVO compared to those with community-onset LVO (40% vs 15%).
Conclusion: In this series, the procedural results of thrombectomy were not different between in-hospital and community-onset LVO. The recognition-to-puncture time in in-hospital LVO was similar to the arrival-to-puncture time in community-onset LVO, although the LWK-to-recognition/recanalization time in in-hospital LVO was shorter compared with the LWK-to-arrival/recanalization-time in community-onset LVO. The rate of clinical favorable outcome was similar, although a higher rate of poor outcome was observed in in-hospital LVO. Comorbid diseases may be associated with poor outcome in in-hospital ischemic stroke due to LVO.
Objective: We report a 73-year-old male in whom a traumatic pseudoaneurysm of the middle meningeal artery (PMMA) increased during conservative treatment for traumatic subarachnoid hemorrhage, an acute subdural hematoma, and brain contusion, leading to intracerebral hemorrhage related to its rupture.
Case Presentation: During decommissioning operations, he fell down from the bed of a truck, and was brought to our hospital by ambulance. Head CT revealed traumatic subarachnoid hemorrhage, left acute subdural hematoma, and brain contusion. Conservative treatment was performed. Left temporal lobe hemorrhage related to the rupture of a traumatic pseudoaneurysm of the left middle meningeal artery (MMA) was observed 20 days after onset. Emergency endovascular treatment and hematoma removal under craniotomy were conducted.
Conclusion: In cases of subarachnoid hemorrhage after head trauma, serial changes should be assessed using CTA and DSA, considering the possibility of a traumatic PMMA.
Objective: We encountered the case of re-occlusion occurred within a short time after thrombectomy to the patient with acute cerebral embolism complicated by protein C deficiency. We have reported this case as its clinical presentation is rare and important for considering a treatment strategy for young adult-onset cerebral embolism in the future.
Case Presentation: A 34-year-old male developed dysarthria, aphasia, and right hemiparesis and was diagnosed with cerebral infarction caused by left M1 occlusion. Mechanical thrombectomy was performed and achieved recanalization, but the same region was re-occluded after 7 hours and thrombectomy was repeated. The patient was diagnosed with protein C deficiency based on the blood test findings. Re-occlusion was considered due to epithelial damage by a stent retriever and a hypercoagulable state induced by protein C deficiency.
Conclusion: Since young adult-onset cerebral embolism may be complicated by underlying disease, such as coagulopathy like this patient, the possibility of re-obstruction induced by epithelial damage should be considered.
Objective: Transarterial embolization (TAE) for dural arteriovenous fistula (dAVF) is sometimes risky because of dangerous anastomosis. We successfully treated orbital apex dAVF by blocking back-flow to the internal carotid artery and ophthalmic artery with coil and balloon.
Case Presentation: A 51-year-old man had red right eye and exophthalmos, and was diagnosed with right orbital apex dAVF. TAE using n-butyl-2-cyanoacrylate (NBCA)/lipiodol mixture via the artery of the superior orbital fissure was performed under flow control of the internal carotid artery and ophthalmic artery with balloon microcatheter and temporary placing of detachable coil. After the treatment, the shunt disappeared and the symptoms were improved.
Conclusion: A proper understanding of dangerous anastomosis is important for safe and effective use of TAE for dAVF.
Objective: The authors report a rare case of symptomatic unruptured fusiform vertebral artery (VA) aneurysm causing hemifacial spasm, which was successfully treated by endovascular parent artery occlusion (PAO).
Case Presentation: A 56-year-old man presented with left hemifacial spasm, and the symptom progressed rapidly over 3–4 weeks including difficulty of eye opening. Brain MRI showed a left fusiform VA aneurysm with a maximum diameter of approximately 10 mm, which compressed the root exit zone (REZ) of the left facial nerve. Endovascular PAO of the left VA was performed with coils. The hemifacial spasm disappeared immediately after PAO. The size of the aneurysm was markedly reduced on MRI on the next day. No recurrence of the hemifacial spasm and aneurysm was observed after half a year after PAO.
Conclusion: This rare case suggested that endovascular PAO may be an effective treatment for hemifacial spasm caused by a relatively large aneurysm.
Objective: Antiplatelet drugs are frequently used to prevent ischemic complications of endovascular therapy, but patients who showed poor responses to these drugs have been reported. We have adjusted antiplatelet drugs based on platelet aggregation activity before endovascular therapy. The objective of this study was to investigate the association between platelet aggregation test-based modification of antiplatelet drugs and perioperative complications.
Methods: In this study, we enrolled 146 patients who received elective endovascular therapy between October 2015 and December 2016. All patients received administration of aspirin 100 mg and clopidogrel 75 mg from 2 weeks before endovascular therapy and platelet aggregation activity was measured 1–2 days before the procedure. Cilostazol was additionally administered to patients who poorly responded to aspirin, or the drug was switched to prasugrel in patients who poorly responded to clopidogrel. Thereafter, platelet aggregation activity was re-tested on the following morning.
Results: On the initial test, 52 (35.6%) and 57 (39.0%) patients showed poor responses to aspirin and clopidogrel, respectively, and these rates were higher than those previously reported. After antiplatelet drug modification, 31 (21.2%) and 20 (13.7%) patients showed poor responses to aspirin and clopidogrel, respectively, showing significant decreases (p = 0.012 and <0.0001, respectively). Perioperative ischemic complication developed in five patients (3.4%), being lower than that (4.6%) previously reported.
Conclusion: The rate of patients with poor responses to antiplatelet drugs on the platelet aggregation test was higher than those previously reported, but their responses were improved by drug modification. Platelet aggregation test-based drug modification may be effective to prevent perioperative complications and further investigation is necessary.
Objective: The clinical course of extracranial internal carotid artery dissection (eICAD) treated with medical therapy alone is usually benign, but late embolism may cause intracranial large artery occlusion (iLAO). We report a new procedure to treat iLAO caused by eICAD.
Case Presentation: A 47-year-old man patient presented with two episodes of transient right hemiparesis and mild neck pain. An emergent MRI detected a left internal carotid artery (ICA) occlusion but no new infarction. Because it was strongly suspected that eICAD was the cause, medical therapy was started, and the patient’s neurological condition was frequently checked to ensure prompt response if a late embolism developed. One day after onset, a follow-up MRI revealed recanalization of the ICA occlusion and eICAD without a new infarction. Unfortunately, a late embolism of the left middle cerebral artery occurred 2 days after onset. We started intravenous tissue plasminogen activator administration immediately after a CT scan. We performed a mechanical thrombectomy (MT), resulting in thrombolysis in cerebral infarction (TICI) score of 3. Subsequently, we performed carotid artery stenting (CAS) for eICAD. Ten days after the stroke, the patient’s National Institutes of Health Stroke Scale (NIHSS) score was 2.
Conclusion: When treating iLAO due to eICAD by MT and CAS, further vascular injury and intracranial embolism must be prevented. We used proximal and distal protection in combination, employing an aspiration catheter to withdraw the stent retriever and deliver a distal embolic protection device before CAS. As a result, the patient’s condition improved.
Objective: A rare case of enlargement of asymptomatic dissecting aneurysm after its initial treatment with stent-assisted coiling with parent artery occlusion for the ruptured contra lateral side is reported.
Case Presentation: A 52-year-old male patient presented with a subarachnoid hemorrhage resulting from a bilateral vertebral artery dissecting aneurysms. The patient was treated within 24 hours of the hemorrhage to prevent re-rupture by parent artery occlusion of the right vertebral artery and stent-assisted coiling of the left side. A 6-month follow-up showed an enlargement of the left side dissecting aneurysm. A second treatment was done to the left side also using stent-assisted coiling. The patient was discharged with no neurological deficit.
Conclusion: To our knowledge, parent artery occlusion for ruptured vertebral artery dissecting aneurysms (VADA) may cause contra lateral VADA enlargement even after its initial treatment by stent-assisted coil embolization in the same setting.
Objective: We report a case of ruptured large thrombosed true posterior communicating artery (PCoA) aneurysm and consider its treatment.
Case Presentation: A 71-year-old male patient had a left ruptured large thrombosed true PCoA aneurysm (maximum diameter 23 mm) with a small neck. Intra-aneurysmal coil embolization via the internal carotid artery was performed to preserve the premammillary artery (PMA). The adjunctive technique could not be used because the diameter of the PCoA was 1.5 mm. The result was a neck remnant and the aneurysm was recanalized. After 14 months, similar treatment was performed, and the aneurysm was recanalized again. The acute and twisted angle of the PCoA origin and the thinness of the PCoA were considered as factors for incomplete embolization. Because the distance between the origin of the PMA and aneurysmal neck was 5 mm, short-segment internal trapping of the aneurysm was performed 13 months after the second embolization. As a result, the PMA was no longer visualized on DSA; however, he had no neurologic deficit. The aneurysm remained obliterated after 7 months.
Conclusion: Making a tight intra-aneurysmal coil embolization of a large thrombosed true PCoA aneurysm is difficult. If there is a certain distance between the PMA and the aneurysm neck, short-segment internal trapping might be useful to treat it.
Objective: Thin-walled regions of cerebral aneurysms are areas of risk for rupture, particularly during surgical procedures. Prediction of thin-walled regions before surgery can lead to safer treatment, avoiding interactions with thin-walled regions. It is considered that blood flow influences aneurysm wall thickness reduction. The objective of this study was to establish a parameter to accurately identify thin-walled regions using computational fluid dynamics (CFD) analysis.
Methods: The surgical field was photographed during craniotomy in 50 patients with unruptured middle cerebral artery aneurysms and red regions of the aneurysm wall were compared with the color of the parent vessel and defined as a thin-walled region. CFD analysis was performed and the distribution map of wall shear stress divergence (WSSD*) was compared to the surgical image of the cerebral aneurysms.
Results: The WSSDmax region and thin-walled region were coinciding in 41 (82.0%) of the 50 patients. There was a significant difference (P = 0.00022) between the patients with and without coincidence between the WSSDmax and thin-walled regions, and the threshold, sensitivity, specificity, and area under the curve (AUC) on receiver operating characteristic (ROC) analysis of WSSDmax were 0.230, 0.900, 0.875, and 0.883, respectively.
Conclusion: High-WSSD regions tended to be coinciding with thin-walled regions, suggesting that WSSDmax is useful to identify thin-walled regions of cerebral aneurysms.
Objective: For patients with tandem occlusion (TO), it is controversial whether an antegrade approach or retrograde approach should be undertaken. Here, we report our strategy for treating patients with TO by simultaneous approach. First, a microcatheter was advanced to the distal occlusion site along with a microwire. Second, a stent retriever (SR) was deployed as an anchor at the distal lesion, and percutaneous transluminal angioplasty (PTA) was performed at the proximal lesion using push wire of SR. After that, the microwire was removed and PTA balloon as well as the guiding catheter (GC) was advanced along the wire of SR. Finally, the SR was withdrawn with clot.
Case Presentations: Cases 1 and 2, who were confirmed as TO, were treated by the method described above. We could re-perfuse successfully. These two cases had favorable outcomes, indicating a modified Rankin scale 2 at the time of discharge.
Conclusion: Our therapeutic strategy for TO might be useful for early reperfusion of a distal occlusion site and associated with favorable outcome.
Objective: We report a first case of stent-assisted coiling for the left vertebral artery aneurysm via the left distal radial approach.
Case Presentation: The patient was a 47-year-old male with unruptured left vertebral artery aneurysm. Transfemoral approach was infeasible because of the history of thoracoabdominal aortic dissection, the left distal radial approach was selected. Distal radial artery in the left anatomical snuffbox was punctured and a 4 Fr guiding sheath was introduced to the left vertebral artery, followed by successful coil embolization with stent.
Conclusion: The left distal radial approach via the anatomical snuffbox is a feasible method for left vertebral artery lesions.