Background and Purpose: We retrospectively examined the efficacy of computed tomography perfusion imaging (CTP) for predicting the neurological deterioration of branch atheromatous disease (BAD). Methods: We treated 36 cases of BAD from October 2010 to September 2015. The patients were examined with both CTP and magnetic resonance imaging during the super acute stage. We divided the 36 cases into two groups; the lenticurostriate artery (LSA; n=28) and paramedian pontine artery (PPA; n=8) groups. In these two groups, we investigated the correlations between neurological deterioration and CTP finding or other factors. Results: Neurological deterioration occurred in 11 cases in the LSA group and 2 cases in the PPA group. In the LSA group, unilaterality was observed on CTP in 21 cases, whereas no such laterality was seen in the PPA group. There was no significant difference in the volume of the infarction between the deterioration-positive and -negative groups. All of the patients in the LSA group presented with unilateral neurological deterioration in mean transit time maps derived from CTP. Conclusions: Clinicians should carefully monitor the patients with BAD involving the LSA region who present with mild symptoms, but exhibit unilaterality on CTP.

Clipping of a cerebral aneurysm is known to have a long-term preventive effect on rebleeding. However, a few cases of recurrent cerebral aneurysm following incomplete clipping have been reported. The efficacy and safety of endovascular coiling for the treatment of recurrent cerebral aneurysms after surgical clipping are unclear. Here, we report six cases of aneurysm embolization for recurrent cerebral aneurysms after surgical clipping between 1998 and 2016 in our hospital. Complete obliteration without any complications was achieved in four of six cases. Our results suggest that time intervals from initial treatment to recurrence and rupture are approximately 5 years and 15 years, respectively. Endovascular coil embolization is a safe and effective treatment for recurrent cerebral aneurysms. Long-term follow-up is mandatory for patients who have undergone surgical clipping.

In order to not miss a mild aphasia that does not show obvious problems in everyday conversation, an alternative detection method using another neuropsychological tests was examined. The subjects were divided into mild aphasic group and non-aphasic group based on the presence or absence of aphasia in 33 stroke patients who had the Standard Language Test of Aphasia (SLTA) total score of 10 points. Several neuropsychological tests were carried out and the scores were compared between the two groups. As a result, mild aphasic group showed lower scores in frontal assessment battery and word fluency test than non-aphasic group. We suggested that the presence or absence of aphasia could be determined by the result of word fluency test by using the decision tree analysis.

A 67-year-old woman was admitted to our hospital, presenting with left hemiparesis. She had a history of old cerebral infarction and epilepsy. Brain magnetic resonance imaging (MRI) revealed acute infarction in the right frontal lobe. Cerebral angiography showed a mild stenotic lesion (NASCET 42%) in the origin of the right carotid artery. Ulceration was not obviously detected by angiographic image or ultrasonography. Despite antithrombotic treatment, cerebral infarction recurred in the right frontal lobe 81 days after the admission day of the first hospitalization. Contrast-enhanced ultrasonography revealed the plaque ulceration in the right carotid artery. A black-blood-MR T1-weighted image showed high-intensity signal in the right carotid artery, suggesting unstable plaque. Carotid endarterectomy was performed to prevent ischemic stroke recurrence. The patient had no perioperative complication or recurrent stroke. A carotid endarterectomy may be an effective therapeutic strategy for patients with symptomatic mild carotid artery stenosis who have carotid plaque ulceration and contrast-enhanced ultrasonography is useful to detect it.

We report the case of a 9-year-old boy with intracranial hemorrhage suspected to be due to renal vascular hypertension caused by fibromuscular dysplasia (FMD). The boy presented with abnormal hypertension, inarticulate speech, and right hemiparesis. The head CT revealed left putamen hemorrhage. Considering his age, we suspected vascular abnormality, such as AVM and Moyamoya disease, and performed enhanced 3D head CT. However, no vascular abnormality was confirmed. Although we performed an MRI and angiography soon after admission, we could not point out any vascular abnormality. The boy suffered from persistent severe hypertension. Although two antihypertensives, nicardipine and diltiazem, were given a full dose via continuous intravenous infusion, his blood pressure was beyond control. Follow up angiography revealed the existence of multiple intracranial microaneurysms. We suspected renal vascular hypertension and adrenal neoplasm, and performed abdominal ultrasound, abdominal MRI, renogram, and enhanced CT. We finally confirmed the existence of right renovascular stenosis by renovascular angiography, and reached to the clinical diagnosis, renovascular hypertension caused by FMD. Soon after percutaneous transluminal angioplasty (PTA) was performed, his blood pressure became under control without any medication.

A 79-year-old woman presented with left hemiparesis 180 minutes before admission. She had a score of 9 points on the National Institute of Health Stroke Scale (NIHSS). MRI revealed acute infarction at the right radiate crown, and the right middle cerebral artery (MCA) occlusion. We performed intravenous infusion of tissue plasminogen activator and mechanical thrombectomy with Penumbra system. The occluded MCA was recanalized in 345 minutes from the onset. Her NIHSS improved to 0 point, and postoperative MRI showed that the infarction was localized to the right radiate crown and the putamen. She discharged on the tenth postoperative day with modified Rankin Scale 1. However, she felt unmotivated after 2 months from the onset, and MRI revealed new white matter lesion on right MCA perfusion area. On magnetic resonance spectroscopy, the lesion showed an increased rate of choline (Cho)/creatine (Cr), and a decreased rate of N-acetylaspartate (NAA)/Cr, which suggested loss and destruction of the neuronal cells. We reported a case of delayed white matter lesion after mechanical thrombectomy for middle cerebral artery occlusion. The long follow-up should be required for the detection of delayed changes on rescued penumbra area.

We describe a case of a patient who developed an intracranial hemorrhage associated with direct oral anticoagulant (DOAC) after clipping for an unruptured aneurysm through craniotomy. A 65-year-old man with the administration of DOAC (Apixaban 10 mg/day) for embolic cerebral infarction underwent neck clipping for an unruptured left middle cerebral artery aneurysm. Three days before surgery, DOAC was stopped and heparin as 12,000 units/day was administrated intravenously. During surgery, a thin, pial artery bled slightly, and hemostasis was easily archived using cotton. Computed tomography (CT) immediately and 19 hours after surgery showed no evident intracranial hemorrhage. The patient received heparin as 12,000 units/day, and 10 hours later, heparin-DOAC bridge was started. Fourteen hours later, administration of heparin was stopped. Twenty-four hour later, he suffered sudden onset aphasia and CT showed a subdural hematoma and subarachnoid hemorrhage in the left Sylvian fissure. After discontinuance of DOAC, this symptom gradually resolved.

A 68-year-old man suffered from a severe headache 3 days after receiving a gastrectomy for early gastric cancer. Computed tomography demonstrated subarachnoid hemorrhage. Conventional angiography and magnetic resonance imaging (MRI) revealed bilateral vertebral artery dissections. Surgical management, such as trapping or proximal occlusion, should have been immediately performed, but the ruptured side in the vertebral arteries was unknown, and we were worried about brain ischemic complications after surgical intervention for the bilateral vertebral arteries. Therefore, the patient ultimately underwent conservative treatment. He had a good clinical course and was discharged from our institute 2 months after onset. An annual follow-up MRI showed no evidence of worsening dissection of the bilateral vertebral arteries over 5 years. Considering the difficulty involved in surgical treatments for ruptured vertebral artery dissections, we recommend conservative treatment.