We report a case in which acute revascularization was performed for acute middle cerebral artery occlusion associated with neurofibromatosis type 1 (NF1). A 74‒year‒old Japanese woman with NF1 was found collapsed at her home by her family and brought to our hospital by ambulance. On arrival, her symptoms were Japan Coma Scale I‒3, complete paralysis of the right upper and lower limbs, aphasia, and left conjugate deviation; her National Institutes of Health Scale score was 28 points. Magnetic resonance imaging showed scattered cerebral infarctions in the left cerebral hemisphere and occlusion in the proximal left middle cerebral artery. We performed emergency percutaneous revascularization. Left internal carotid artery angiography showed M1 occlusion and a fusiform aneurysm in the C1‒C2 portion. A REACT^TM 71 catheter was guided to the proximal M1, and a Solitaire 4×40 stent retriever was deployed to M1 after lesion crossing with a Phenom^TM 17 catheter. The Solitaire was completely drawn into the REACT17 catheter and retrieved, and recanalization was observed after one pass, but severe stenosis was observed in M1. Aspirin 200 mg and clopidogrel 300 mg were administered, but reocclusion occurred over time. Next, angioplasty using a Solitaire stent retriever was performed, resulting in temporary recanalization, but reocclusion occurred. Additional prasugrel 20mg was administered, and we performed percutaneous transluminal angioplasty using a Gateway 2.0×12‒mm balloon catheter which recanalized the artery. Since there was no reocclusion thereafter, the procedure was terminated. The patient’s symptoms tended to improve after the surgery.

  To determine whether reversing the use of direct oral anticoagulants (DOACs) improved patient outcomes, we retrospectively analyzed the cases of 22 patients (14 males, 8 females, median age 77 years) with acute intracranial hemorrhage admitted to our department and taking a DOAC. The patients (n=11) whose DOAC idarucizumab (n=1) or andexanet alfa (n=10) was reversed (reversal group) was compared with the same number of consecutive cases before the introduction of reversal agents, i.e., a non‒reversal group (n=11). The primary outcome was a poor outcome defined as a decrease in the patient’s baseline Glasgow Coma Scale (GCS) score at discharge or death. The safety outcome was the occurrence of embolic disease. No patient‒background variables differed significantly between the reversal and non‒reversal groups; the groups’ poor‒outcome rates were 9.1% and 54.5% respectively, with an adjusted odds ratio of 0.027 (95%CI: 0.001‒0.92, p=0.045). The safety outcome did not differ significantly between the groups. The introduction of anticoagulant reversal agents improved outcomes, with a 97% reduction in poor outcomes defined by a decrease in the GCS score at discharge or death.

  We present the case of a 63‒year‒old Japanese man with a giant thrombosed aneurysm located in the left anterior cerebral artery (ACA), which was successfully treated using endovascular therapy. The patient was observed sitting in front of his house late at night, exhibiting signs of disorientation and difficulty walking. He was transferred to a nearby hospital, where a physician suspected an intracranial lesion and referred him to our neurosurgery department. When he arrived at our hospital, he exhibited a Japanese Coma Scale (JCS) score of 3 and had difficulty walking. The CT and MRI examinations at the initial hospital revealed a 26‒mm mass lesion extending from the suprasellar region to the left caudate nucleus which was causing obstructive hydrocephalus. We performed three‒dimensional CT angiography (3D CTA), gadolinium‒enhanced MRI, and cerebral angiography, which led to the diagnosis of a partially thrombosed giant aneurysm located at the distal segment of the left ACA. Given the size and location of the aneurysm, a surgery would be complicated. Right internal carotid angiography revealed that the ACA was right A1‒dominant, and the anterior communicating artery (AcomA) was well‒developed, allowing visibility of the left A2. Given that most of the aneurysm was thrombosed and the left A1 appeared narrow and wavy, we speculated that stent‒assisted coil embolization would be challenging and therefore opted to perform internal trapping on both the distal and proximal sides of the left A1, in addition to coil embolization. Since the perforator originated from the proximal side of the left A1, we made sure to preserve it during the embolization process. Following the treatment, no new ischemic symptoms or signs of cerebral infarction were observed. The post‒operative angiography revealed that the aneurysm was completely occluded, with good blood flow from the right A1 to the left A2 through the AcomA. The symptoms of hydrocephalus also showed improvement, and the patient was transferred to a rehabilitation hospital with a modified Rankin Scale (mRS) score of 2 on post‒operative day 15. Six months after the treatment, MRI indicated that the aneurysm had shrunk and the mass effect had improved, resulting in an mRS score of 0. We believe that both coil embolization and internal trapping of the parent artery contributed to the patient’s positive outcome.

  We report two cases of ruptured vertebral artery dissecting aneurysm (VADA) with contralateral vertebral artery (VA) hypoplasia successfully treated with stent‒assisted coil embolization (SAC) in the subacute phase. Patient 1, a 54‒year‒old female with right VA hypoplasia, presented with subarachnoid hemorrhage (SAH) from a ruptured left posterior inferior cerebellar artery (PICA)‒involved VADA and underwent SAC on SAH Day 20. Patient 2, a 59‒year‒old male with a right VA terminating at the PICA, presented with SAH from a ruptured left VADA that subsequently re‒ruptured within a few hours of admission. Following external ventricular drainage to manage the acute phase, SAC was performed on SAH Day 18. Both patients achieved favorable outcomes without procedure‒related symptomatic complications. In patients with contralateral VA hypoplasia, limited collateral circulation may increase the risk of ischemic complications after SAC for a ruptured VADA. Therefore, in selected mild cases, delaying SAC until the subacute phase may be a useful option to mitigate the risk.

  Vertebral artery dissecting aneurysm (VADA) is an important stroke etiology in young individuals, presenting with diverse manifestations, including asymptomatic cases, ischemia, and hemorrhage. We describe a left VADA followed by the formation of a right VADA at the early stage. We observed the morphological changes of both VADAs, including repair and enlargement, over an 8‒month course. Ultimately, endovascular surgery was performed on the right VADA to prevent rupture. The patient was a 51‒year‒old Japanese woman presenting with headache and nausea. Magnetic resonance imaging revealed left and right VADAs. The left VADA gradually underwent occlusion and remodeling, resulting in improvement; the right VADA tended to reduce in size but eventually enlarged over approx. 3 months, culminating in occlusion and the development of a cerebral infarction. Within a few days post‒infarction, the distal posterior inferior cerebellar artery (PICA) bulge rapidly enlarged. Considering the high rupture risk, surgical intervention was deemed necessary. The right VADA involved the PICA. The bulge distal to the right PICA was treated with coil embolization, and a flow diverter (FD) was deployed to cover the dissection cavity from the proximal VA to the right PICA. The patient’s postoperative course was favorable and she was discharged with a modified Rankin scale score of 0, indicating independent ambulation. Follow‒up imaging 4 months post‒treatment showed complete occlusion of the dissection cavity with no new cerebral infarctions. This case highlights the importance of both long‒term and careful imaging follow‒up in unruptured VADAs and the appropriate timing for surgical intervention.

  Spinal cord infarction (SCI) is a less frequent disease compared to ischemic cerebral infarction. We retrospectively reviewed the clinical courses, radiographical findings, and prognosis of five spontaneous spinal cord infarction cases in our single institution. We included four males and one female with a median age of 65.2 years old. Impaired spinal levels ranged from the upper thoracic to the upper lumbar spine. Only one case had a history of cardiovascular events. Their clinical symptoms were as follows: anterior spinal artery syndrome in three, posterior spinal syndrome in one, and Brown‒Séquard syndrome in one case. The mean time from onset to definitive diagnosis was 5.71 days. Among four patients who were treated by steroid pulse therapies with methylprednisolone, two patients showed neurological improvement after the treatment, while the other two patients remained unchanged. The functional outcomes were grade B in one case and grade D in four cases when evaluated by American Spinal Injury Association Impairment Scale classification. All patients were taken aspirin medication to prevent recurrence. In clinical practice, SCI is a rare but sometimes encountered disease. We report the clinical courses of five cases with a literature review.

  In 2018, one of Japan’s 47 prefectures, i.e., Saitama Prefecture launched the Saitama Stroke Network (SSN), a transportation service for acute stroke patients. We investigated the effect of arriving during ‘off‒hours’ (outside of regular hospital hours) on the outcomes of acute ischemic stroke patients who underwent a mechanical thrombectomy (MT) after using the SSN transportation system to get to a hospital. We analyzed the cases of the 211 patients who underwent an MT for acute vessel occlusion in their anterior circulation between April 2019 and September 2023. We divided the patients into those who used the SSN and arrived at a hospital during on‒hour times (n＝103) and those who used the SSN and arrived during a hospital’s off‒hour times (n＝108). The two patient groups’ backgrounds, time from onset to reperfusion, and treatment outcomes were compared. No significant between‒group differences in patient demographics were identified. The door‒to‒puncture time was significantly longer in the off‒hour group (by 8 min) compared to the on‒hour group (61 vs. 53 min, p＜0.001). Particularly, the imaging‒to‒puncture time was significantly increased (by 4 min) in the off‒hour group (40 vs. 36 min, p＜0.001). The two groups’ Modified Rankin scale scores at discharge were similar. Together our findings indicate that the transportation service provided by the SSN and the in‒hospital workflow for acute stroke patients might have reduced the delay in the performance of MTs during hospital off‒hours.

  Intracranial infections caused by Salmonella spp. are not uncommon in pediatric patients, among whom Salmonella typhi (S. typhi) is the predominant pathogen. We report the rare case of an adult intracranial infection caused by Salmonella Thompson (S. Thompson). The patient was a 70‒year‒old Japanese man who was scheduled to be hospitalized for the evaluation of possible malignant lymphoma and presented with fever, headache, and altered consciousness. Brain computed tomography (CT) revealed a subdural lesion with midline shift. He underwent urgent burr hole drainage with a preoperative diagnosis of subdural empyema. When the dural incision was performed, white pus was observed and evacuated, confirming the diagnosis of a subdural empyema. A bacterial culture of the pus identified S. Thompson as the pathogen. The patient’s symptoms gradually improved with a 6‒week ceftriaxone regimen, and follow‒up brain CT revealed resolution of the empyema. Whole‒body CT for a systemic evaluation revealed intra‒abdominal lymphadenopathy. The biopsy of the lymph nodes led to a diagnosis of mantle cell lymphoma. The patient was transferred to the hematology department for chemotherapy and achieved remission of the lymphoma. Although the route of infection remained unidentified, he was subsequently discharged home. This appears to be the first reported case of an adult subdural empyema caused by S. Thompson. Clinicians should be aware that Salmonella spp. can be the cause of intracranial infections in patients with immunosuppressive conditions or latent systemic diseases.