Background and Purpose: We evaluated the present situation of the prognosis and the rate of home return in patients with aneurysmal subarachnoid hemorrhage (SAH) in our hospital. Methods: The 183 out of 253 SAH patients who underwent surgical treatments in our hospital from January 2010 to December 2013 were included in this study. Clinical data of the patients were collected from the Database of Referral System for Stroke in Kumamoto. Results: The median age of the patients was 64 years and 70% of them were women. On admission, 72.7% patients were present under grade III in World Federation of Neurosurgical Surgeons (WFNS) grading and there were 86.3% in CT Fisher group 3. A part of patients suffered from symptomatic vasospasm (19.9%), cerebral infarction (16.6%), and hydrocephalus (16%) with surgical treatments. The patients with good recovery and moderate disability at discharge from our hospital were 73.2%, and 73.1% of SAH patients could return to their home. Over the age of 80, WFNS grading, symptomatic vasospasm, cerebral infarction, and hydrocephalus were independent factors regarding the determinant factor for the home return. Conclusion: Although the prognosis of SAH is thought to be poor, our patients showed relatively good course at discharge. We suggest that it is important to carry out a multidisciplinary therapy against cerebral vasospasm, cerebral infarction, and hydrocephalus, all of which were determinant factors for the prognosis of our patients. In addition, it is also important to establish a seamless rehabilitation in recovery phase of the patients.
Objectives: We evaluated carotid artery lesions in patients with acute ischemic stroke at the hospitals participating in the registration of stroke patients of the Yamagata Society in Treatment for Cerebral Stroke (YSTCS). Methods: From June 2005 to December 2006, 510 consecutive patients who underwent evaluation of carotid artery lesions by carotid ultrasonography and 3D-CT angiography within 2 weeks of the onset were enrolled in this study. Results: Forty-eight of 510 (9.4%) patients presented with a stenosis of 50% or more and 32/510 (6.3%) presented with a stenosis of 70% or more, of the neck internal carotid artery. The common carotid artery (CCA) mean intima-media thickness (IMT) in each stroke subtypes was 1.09 ± 0.51 mm in atherothrombotic infarction, 1.06 ± 0.42 mm in cardioembolic infarction, and 1.03 ± 0.39 mm in lacunar infarction, respectively. Multivariable logistic regression analysis demonstrated that age (odds ratio: 1.029) and total cholesterol/HDL value ratio (odds ratio: 1.450) were significantly associated with a CCA mean-IMT of 1.1 mm or more. Conclusions: We reveal the feature of carotid artery lesions in patients with acute ischemic stroke. The CCA mean-IMT tends to be raised significantly in atherothrombotic infarction.
We report three consecutive cases of subcortical hemorrhage in the right parietal lobe which needed surgical removal due to rapid growth of the liquefied focus without re-bleeding in the acute phase. The cases were admitted to our hospital from January 2009 to December 2011; the age ranged from 61 years to 78 years with the mean age of 70 years and there were 1 male and 2 females. At the first visit, all cases were JCS grade I and diagnosed as subcortical hemorrhage in the right temporal or parietal lobe without intraventricular casting by computed tomography. In all cases, their condition had deteriorated due to growth of the liquefied focus in the acute phase, and all cases underwent surgical removal with craniotomy. No case was demonstrated vascular anomalies by evaluation. The location of hematoma may have some relationship with rapid growth of the liquefied focus because hematoma was close to ventricular space in all cases. Therefore, in case of subcortical hematoma attached to lateral ventricle, we should keep it in mind that the liquefied focus might grow rapidly in the acute phase.
Cerebral air embolism is uncommon but usually causes lethal condition. We report an extremely rare case of a massive cerebral air embolism with retrograde venous air embolism from pneumomediastinum. An 80-year-old male was found in comatose state with right dilated pupil, and admitted to our hospital. The CT scan revealed massive intracranial air. The air mostly existed in the right transverse sinus, sagittal sinus, temporal and bilateral front-parietal lobes. Because of severe brain swelling, he suffered from brain herniation. His condition was very hard to save, so we treated him conservatively. He died in a short time, and an autopsy was performed. The brain specimen revealed that the endovascular space of cerebral veins were filled with air, but the lumen of cerebral arteries were filled with red blood cells. Therefore, it was confirmed that the air was retrograded to cerebral veins. And pneumomediastinum was also confirmed by the autopsy. So we thought this massive air embolism was caused by pneumomediastinum. We should share the information of spontaneous air embolism by such mechanism in this rare case.
An 80-year-old man, a smoker, was admitted to our hospital complaining mild weakness of the right limb. Diffusion-weighted magnetic resonance imaging (MRI) disclosed multiple small high signal intensities at bilateral cerebral hemispheres. Thus he was diagnosed as having cerebral embolism, and anticoagulation therapy using heparin was started. Four days after admission, contrast enhanced computed tomography (CT) showed complex atheromatous plaque 15 mm in diameter at ascending aorta. We diagnosed him as having aortogenic cerebral embolism. Dual antiplatelet therapy using aspirin and clopidogrel, in combination with atorvastatin, was added 5 days after admission. At 20 days after admission, anticoagulation was switched from heparin to warfarin, when his international normalized ratio of prothrombin time (PT-INR) reached the target level between 1.6 and 2.6. Enhancement CT 20 days after admission, however, showed no improvement of aortic atheroma. In addition, a new embolic lesion was detected on brain MRI 22 days after admission. Therefore, ascending aorta replacement was carried out at 24 days after admission. We restarted clopidogrel, atorvastatin, and warfarin after the operation. The patient was discharged at 43 days after admission without any deficit. We considered that the decision of surgical indication for aortogenic cerebral embolism should be made after temporal evaluation of the aortic lesion under medical treatment. A new embolic lesion detected on each brain MRI 23 days and 6 months after operation detected one silent embolic lesion, but we did not change medical therapy. No more new lesion occurred on brain MRI 7 months and 11 months after operation. We considered that the decision of surgical indication for aortogenic embolism should be made after medical treatment and evaluation of the aortic lesion for 2 weeks.
A 73-year-old woman underwent a left upper lobectomy for lung cancer. On postoperative day 3, she developed cerebral infarction. She was transferred to our stroke center because consciousness disturbance occurred on the 4th day from onset. Computed tomography scans suggested the presence of an embolic stroke mechanism. When evaluating the embolic source, contrast-enhanced chest computed tomography revealed thrombus formation in the stump of the left superior pulmonary vein. We predicted that this left pulmonary vein stump thrombus had caused the cerebral embolism. Thrombus in the stump of the pulmonary vein is a rarely described complication after lung lobe resection. However, it has recently been reported that the occurrence of left pulmonary vein stump thrombi is not as rare as first thought. In addition, the time of onset of such embolic events and of thrombus detection is not only during the perioperative period but also the late postoperative period. Therefore, when there is a medical history of left upper lobe resection, the possibility of cerebral embolism caused by pulmonary vein stump thrombus should be considered.
A 75-year-old woman presented with right hemifacial and right upper extremity swelling 12 days after rib and clavicular fracture caused by traffic injury. Contrast computed tomography (CT) revealed acute right subclavian, innominate, and internal jugular vein thrombosis. The patient was started with intravenous heparin immediately, and followed by oral anticoagulant edoxaban 30 mg. The symptom improved after 3 weeks and thrombus disappeared after 3 months. For the treatment of upper torso venous thromboembolism, edoxaban is an effective and a safe treatment.
A 25-year-old woman with a right neck swelling visited her local hospital, where paravertebral arteriovenous fistula (PAVF) was diagnosed. The PAVF was fed mainly by the ascending cervical artery and also by the subcutaneous cervical, external cervical, and vertebral arteries, and it drained via multiple fistulas and a varix into the paravertebral venous plexus. Ligation of the main feeding artery and transarterial embolization were performed, but the PAVF recurred, so the patient was referred to our hospital, where angiography revealed multiple high-flow feeding arteries, fistulas, and draining veins. We adopted a bidirectional treatment strategy, combining transarterial and transvenous catheterization and coil embolization. The fistulas were obliterated, and 1-year follow-up angiography showed no signs of recurrence. PAVF is a rare condition involving spinal vascular malformations and for which there is no established treatment strategy. Simultaneous transarterial and transvenous embolization should be considered for PAVF with a complex angioarchitecture.
We experienced a case with left ventricular systolic dysfunction persisting for at least 1 year after the onset of Takotsubo cardiomyopathy, which had manifested 7 days after surgery for subarachnoid hemorrhage. A 67-year-old woman, who had developed a subarachnoid hemorrhage due to a ruptured anterior communicating artery aneurysm, underwent aneurysm-clipping surgery on the day of the hemorrhage. Seven days post-operatively, she complained of sudden chest discomfort and developed acute heart failure. The patient was diagnosed with Takotsubo cardiomyopathy based on electrocardiography, transthoracic echocardiography, and coronary angiography, and was considered to concomitantly have experienced an acute myocardial infarction due to coronary spasm based on high levels of cardiac enzymes and a positive hyperventilation test. The subarachnoid hemorrhage resolved uneventfully, but the findings of Takotsubo cardiomyopathy remained unchanged for at least 1 year without any improvement of either the impaired left ventricular wall motion or cardiac function. The reason for impaired left ventricular wall motion and cardiac dysfunction persisting for at least 1 year in this patient with Takotsubo cardiomyopathy was considered to be the concomitant acute myocardial infarction due to coronary spasm.