To meaningfully define cognitive changes before and after CEA, in each patient postoperative cognitive improvement or decline was determined based on subjective cognitive assessment by a neurosurgeon and the patient’s next of kin and changes in neuropsychological test scores. As a result, the prevalence of postoperative cognitive improvement and decline was 11% and 11%, respectively. Studies using SPECT, PET, and MRI showed that CEA improves cerebral blood flow and metabolism, neurotransmitter receptor function, and white matter microarchitecture, leading to postoperative cognitive improvement. Pre-existing cerebral white matter hyperintensities on magnetic resonance imaging adversely affect cognitive improvement after CEA. These studies also demonstrated that cerebral hyperperfusion following CEA impaired cerebral metabolism, neurotransmitter receptor function, and white matter microarchitecture, resulting in postoperative cognitive decline. Cerebral microbleeds as toxic substances may leak through the blood-brain barrier that is disrupted by cerebral hyperperfusion and injure neural tissue, resulting in postoperative cognitive decline.

Background and purpose: Since the financial health of developed countries is tight, not only medical relevance but also efficiency and economic rationality are important for maintaining medical care. Using data that reflected facilities throughout Japan, we conducted an exploratory study of factors associated with the length of hospital stay in patients with acute cerebral infarction who were treated with rt-PA. Methods: The rt-PA-administered patients included in the sampling data of National Database of Health Insurance Claims of Japan (NDB) obtained from the Ministry of Health, Labor and Welfare were divided into two groups: patients with a mean hospitalization period or longer and patients with a mean hospitalization period or shorter, and the factors related to the length of hospitalization were analyzed. Results: The factors associated with a long hospital stay were a 2-digit code of Japan Coma Scale at admission, enteral feeding, infection and laxative/enema prescription. Infections, which can be intervened after the onset of stroke, were estimated to affect an extended hospital stay of 3.8 days. Conclusions: Nationwide data analysis revealed the importance of infection control in shortening the hospitalization period for acute stroke. Promotion of infection prevention is important in terms of patient benefits and proper allocation of medical expenses.

Objective and methods: This study, involving patients with nonvalvular atrial fibrillation (NVAF) associated with renal dysfunction (estimated glomerular filtration rate, <60 ml/min/1.73 m²), retrospectively compared the incidence of adverse clinical events between those treated with warfarin (Wa; n = 166; age, 79 ± 8 years) and those treated with direct oral anticoagulants (DOACs; n = 196; age, 80 ± 10 years). Results: The incidence rates of ischemic stroke or systemic embolism were 3.41 and 1.75 cases per 100 person-years and those of major bleeding were 3.70 and 1.09 cases per 100 person-years in the Wa and DOAC groups, respectively. The all-cause mortality rates in the Wa and DOAC groups were 7.39 and 5.02 cases per 100 person-years, respectively. In multivariate analysis, the incidence of ischemic stroke/systemic embolism and major bleeding in the DOAC groups was significantly lower than that in the warfarin group, but no differences were noted in the all-cause mortality rate between the two groups. Conclusion: In patients with NVAF associated with renal dysfunction, the incidence of adverse clinical events in DOAC-treated patients was lower than or similar to that in warfarin-treated patients in daily clinical practice.

Background and Purpose: Treatment strategy using endovascular thrombectomy (EVT) for atherosclerotic internal carotid artery (ICA) occlusion at the original segment has not been established. We hypothesized that carotid ultrasound may detect the portion where guidewire can penetrate the atherosclerotic ICA origin occlusion. Methods: From our EVT registry, data on patients with atherosclerotic ICA origin occlusion who were examined using carotid ultrasound and successfully treated using EVT between April 2015 and May 2019 were retrospectively analyzed. Only patients in whom carotid ultrasound was able to detect the portion where guidewire penetrated were analyzed. Results: 6 patients were analyzed. Carotid ultrasound demonstrated the portion as hypoechogenic lesion, distinguished from surrounding hyperechogenic and isoechogenic lesions. Color Doppler clearly showed the blood flow signal entering to the hypoechogenic lesion in 3 patients. The lesion where guidewire penetrated was located at the frontal side of the ICA near the external carotid artery. Conclusion: Ultrasound examinations may detect the occlusive portion where the guidewire can penetrate.

We report the case of a 34-year-old woman with paradoxical embolism due to the combination of patent foramen ovale and pulmonary arterial hypertension. She took norethisterone with ethinylestradiol for endometriosis. She visited our hospital with sudden dizziness and vomiting. Only gaze evoked nystagmus when looking left was observed, and National Institutes of Health Stroke Scale (NIHSS) was 0. Magnetic resonance imaging (MRI) of the head showed acute brain infarction in the left temporal lobe and left cerebellar hemisphere, and MR angiography (MRA) of the head and neck showed no stenosis or occlusion in the main arteries. Transthoracic echocardiography showed a suspicion of pulmonary hypertension, and contrast transesophageal echocardiography revealed right-to-left shunt via patent foramen ovale. Deep venous thrombosis was not detected. She was diagnosed with pulmonary arterial hypertension at the Department of Cardiology, and it is considered that paradoxical embolism was caused by the combination of patent foramen ovale and pulmonary arterial hypertension. She was treated with rivaroxaban for paradoxical embolism. In paradoxical embolism with patent foramen ovale, the possibility of pulmonary hypertension should be considered.

Fenestration of the middle cerebral artery (MCA) is rare but can be a pitfall for mechanical thrombectomy. We experienced a case of complete recanalization using ADAPT in a case of occluded MCA fenestration. A 71-year-old man with left hemiparesis and dysarthria was transported to our hospital. National Institutes of Health Stroke Scale (NIHSS) was 7 on admission. Diffusion-weighted imaging showed some high-intensity spots in the right MCA region, and magnetic resonance angiography (MRA) showed the right M1 near occlusion. On angiography, we found a linear contrasting loss part in M1 and we diagnosed occlusion of the M1 fenestration. We performed mechanical thrombectomy using ADAPT. We achieved complete recanalization (modified thrombolysis in cerebral infarction grade 3); the left hemiparesis improved postoperatively. Postoperative MRA showed fenestration in the right M1. He was treated with antiplatelet therapy and discharged with modified Rankin Scale (mRS) 1 on postoperative day 12. From this study we conclude that when we find a linear contrasting loss part in M1, we should suspect M1 fenestration. The superior limb should be recanalized as priority.

Objective: Cerebral embolism is known as a complication of percutaneous coronary intervention (PCI) but is rare. We present a case of mechanical thrombectomy for acute middle cerebral artery occlusion during PCI for acute myocardial infarction. Case: A 72-year-old male was transferred to our hospital because of acute myocardial infarction. Emergent PCI was performed. During PCI, he suddenly developed conscious disturbance, right hemiplegia, and aphasia. Cerebral angiography was done immediately after PCI, and left middle cerebral artery (MCA) occlusion was confirmed. Mechanical thrombectomy was performed, and MCA was successfully recanalized. Yellowish plaque containing cholesterin crystal was captured with a stent retriever. After thrombectomy, his motor function was fully recovered; however, total aphasia remained. He was transferred to the rehabilitation hospital with modified Rankin scale 3. After rehabilitation, sensory aphasia was significantly recovered. Conclusion: Cerebral embolism associated with PCI is rare but might cause severe neurological deficits. It is important to establish prompt cooperation between cardiologists and neuro-interventionists.

Thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) or mechanical thrombectomy (MT) is well-established and effective for acute cerebral infarction, but evidence of safety is inadequate. We treated two patients with cardioembolic infarction who were receiving anticoagulant dabigatran with administration of idarucizumab, a specific reversal agent for dabigatran, before rt-PA therapy and MT. Case 1: A 74-year-old man with a history of atrial fibrillation (Af) treated with dabigatran was admitted after sudden onset of aphasia. The National Institutes of Health Stroke Scale (NIHSS) was 6 points. Diffusion-weighted imaging showed high-intensity areas from the insula to the parietal lobe. Magnetic resonance angiography showed arterial deficits in the left inferior trunk (M2) of the middle cerebral artery. He was treated with rt-PA and MT after idarucizumab administration, resulting in thrombolysis in cerebral infarction (TICI) grade 2b. Postoperative computed tomography (CT) showed small hemorrhage in the infarction area, but follow-up CT identified no hemorrhage growth. His symptoms improved gradually, and the NIHSS was 1 point. Case 2: An 89-year-old woman with a history of Af treated with dabigatran suffered from sudden onset of right hemiparesis. A pacemaker was implanted to resolve bradycardia. CT showed a hyperdense area in the right M2. She was treated with rt-PA and MT after idarucizumab administration, resulting in TICI grade 3. Postoperative CT showed no intracerebral hemorrhage. Consciousness disturbance and left hemiparesis improved gradually. Intravenous rt-PA and MT can be safely performed after idarucizumab administration even in patients with acute ischemic stroke taking dabigatran.

We report the case of a patient with in-stent thrombosis who was effectively treated by administration of prasugrel. Although a 70-year-old man with symptomatic ICA stenosis was treated with CEA one year ago, restenosis was seen. He did not have clopidogrel resistance; hence, he underwent CAS with clopidogrel 75 mg/day and aspirin 100 mg/day. On the fifth day after the stent placement, the patient showed sudden onset of right hemiparesis and aphasia. Emergency angiography showed in-stent thrombosis. An additional stent was placed. Aspirin was changed to cilostazol 200 mg/day. Heparin and argatroban were administered. However, on the fifth day after the CAS retreatment, the patient showed sudden onset of recurrence of right hemiparesis. Emergency angiography showed in-stent thrombosis. We administered prasugrel 20 mg orally. The thrombus started disappearing after 10 minutes and had disappeared after 2 days. Prasugrel may be one of the treatment options for in-stent thrombosis.

Objective: A case of an internal carotid-infraoptic (IC-IOA) course of an anterior cerebral artery aneurysm with multiple cerebrovascular variations is reported. Case Presentation: A 37-year-old woman who presented with headache was referred by a local doctor to our institution. Magnetic resonance imaging (MRI) showed a paraclinoid internal carotid artery aneurysm on the right side. The angiography, however, showed small bilateral infraoptic arteries (IOAs) and the right IC-IOA aneurysm with a maximum diameter of 6.7 mm. Several arterial variations also coexisted, such as a plexiform anterior communicating artery complex leading to a bihemispheric anterior cerebral artery (ACA), bilateral ophthalmic arteries exclusively supplied by the external carotid arteries, atypical courses of bilateral vertebral arteries, and the left occipital artery arising from the IC artery. Moreover, her corpus callosum appeared mildly dysplastic on MRI. Stent-assisted coil embolization for the aneurysm with preservation of the vessel was successfully performed. Conclusion: Since this relatively rare aneurysm tends to have many variations, detailed reading of images might be of great importance, particularly prior to treatment.

The present paper reports a case of a 41-year-old female. The patient developed left middle cerebral artery occlusion 10 years prior and had been aware of dysarthria and weakness in the right upper and lower limbs on several occasions. The patient again developed left middle cerebral artery occlusion, and we predicted carotid web during thrombectomy. Subsequently, carotid stenting was performed to prevent stroke recurrence. It is essential to differentiate carotid webs during cerebral infarction without risk factors, especially in young patients.

Progressive stroke has generally a poor prognosis and is sometimes difficult to treat. In cases of resistance to best medical treatment, surgical treatments such as carotid artery stenting (CAS) have been considered. Emergent CAS is associated with a risk of hemorrhage due to hyperperfusion. When the symptom is gradually worsening, percutaneous transluminal angioplasty is performed at first, followed by CAS after approximately 24 hours. In this study, hyperperfusion was not observed in both cases, indicating that this treatment strategy improves neurological outcomes.