Background and Purpose: In acute ischemic stroke caused by occlusion of the major arteries, there is uncertainty regarding the safety of administering intravenous thrombolysis (IVT) before mechanical thrombectomy (MT). We report the outcomes of MT alone for large vessel occlusion in patients with some concerns about hemorrhagic complication. Methods: Of the 126 patients who underwent MT during the two-year period of 2018–2019, the study subjects were 102 patients with arterial occlusion involving the major arteries of the cerebral anterior circulation. The patients were divided into two groups depending on with (MT+IVT) or without (MT-IVT) IVT before MT. A retrospective comparison of the outcomes of these two groups was performed. Results: No significant differences between the MT+IVT and MT-IVT groups were seen in characteristics of patients. No significant differences were seen in the overall rate of successful recanalization, rate of any intracranial hemorrhage (ICH), or rate of symptomatic ICH. Good functional outcome (mRS 0–2 at 90 days) was achieved in 64% of the MT+IVT group and 51% of the MT-IVT group, showing no significant difference. Conclusions: Our results of MT alone for anterior major vessel occlusion in patients with some concerns about hemorrhagic complication did not demonstrate inferiority compared with MT+IVTpatients. Successful reperfusion was related to good functional outcome even in MT-IVT patients.

Background and Purpose: The aim of this study was to clarify the relationship between the characteristics of aphasia and hematoma type in patients with left putaminal hemorrhage who were admitted to comprehensive inpatient rehabilitation wards. Methods: Age, gender period from onset to hospitalization, hematoma type and volume, neurological symptoms, and language functions were retrospectively investigated from the medical records of 92 patients. We examined the relationship between hematoma type and score of the Standard Language Test of Aphasia (SLTA) and its subitems of writing, speech, and comprehension. Results: Aphasia in patients with type I hematoma was mild and that in patients with types IV and V hematomas was severe. There was no difference in the severity of aphasia between types II and III hematomas. There was only a decrease in the writing score in type I hematoma. Writing and speech were impaired in type IV hematoma. Type V hematoma had lower scores for all modalities. Conclusion: The effect of hematoma volume on aphasia severity and all language modality by hematoma type was significant. We suggested that white matter damage caused by hematoma extension may be involved in aphasia severity.

Direct carotid-cavernous fistula (CCF) is a rare complication due to treatment of internal carotid artery (ICA) aneurysms with Pipeline Flex embolization device (PED) placement. We present the case where we were able to treat this condition via transvenous coil embolization. A 69-year-old woman was treated with PED placement for a left ICA aneurysm. Three weeks later, she suffered from severe tinnitus due to direct CCF because of delayed aneurysm rupture. Our initial treatment failed as we could not access the aneurysm through the fistula via venous rout and the patient suffered from left oculomotor nerve palsy one month later. We re-attempted the transvenous coil embolization by reducing the arterial flow from the ICA using a balloon catheter and determining the rupture point by evaluating multiplanar reconstruction (MPR) derived from three-dimensional rotational angiography (3DRA). The procedure enabled us to perform transvenous coil embolization, alleviating the patient’s symptoms. MPR of 3DRA and arterial flow reduction seemed to be a useful technique for transvenous coil embolization in CCF treatment.

We report cases of anterior cerebral artery aneurysm in identical twins. A 47-year-old man presented with subarachnoid hemorrhage (SAH). CT angiography revealed multiple aneurysms, including a ruptured anterior cerebral aneurysm, which had been treated by coiling. Moreover, his identical twin had multiple aneurysms, including an unruptured anterior cerebral artery aneurysm, for which he had undergone clipping. Twenty-four other cases of aneurysms in identical twins have been reported in the past. Reviewing these cases, the features of aneurysms in identical twins compared with spontaneous cases became clear. We found that female sex and younger age are predisposing factors for aneurysms in identical twins. In addition, the frequency of patients with multiple aneurysms is higher compared to spontaneous cases. Moreover, cerebral aneurysms in twins frequently rupture. Furthermore, it was only 3.75 years on average between one’s onset of SAH and his or her counterpart. Therefore, we recommend early screening of aneurysms in an identical twin when the counterpart already presents with the disease.

We report a case of bilateral cerebellar, left lateral medulla, and spinal cord infarction in a 69-year-old man with sudden headache. He reported speech disturbance and left motor weakness 11 hours after the onset of the headache. MRI showed acute bilateral cerebellar and left lateral medullary infarctions. On the 2^nd day of admission, right hemiparesis occurred and progressed to quadriplegia. Magnetic resonance imaging of the cervical spine showed a spinal cord infarction in the regions of C2 to C5. 1^st DSA revealed an almost complete occlusion from the origin of the left subclavian artery to the bifurcation of the left vertebral artery. No anterior spinal artery was recognized, even from the right vertebral artery. 2^nd DSA on the 30^th day of admission showed improvement of severe stenosis of the left subclavian artery. An ultrasound scan of the subclavian artery revealed a flap structure on the left side. We suspected that it was caused by arterial dissection due to the sequential morphological change and recanalization of the artery. We recommend to check the morphological changes in the vessels using several modalities, because severe stenosis of the subclavian artery is sometimes caused by arterial dissection. Ultrasound of the artery may help to identify the dissection.

A 28-year-old woman was admitted to our hospital with transient double vision. Head MRI and angiography revealed left thalamic infarction and fusiform dilatation of thalamic perforator originating from the right P1. It was difficult to diagnose it as AOP infarction, because AOP dissection should be really rare. Therefore, she started taking aspirin for prevention of recurrent ischemia, and was discharged with no symptom. Approximately one month later, she complained severe headache, and head CT revealed subarachnoid hemorrhage. Aspirin was suspected to exacerbate the AOP dissection and cause the hemorrhage. She stopped taking aspirin, and her blood pressure was kept low. Eventually, she was discharged with no neurological deficit, and the fusiform dilatation of AOP improved. The etiology was strongly suspected to be AOP dissection.

A 79-year-old woman with primary immune thrombocytopenia underwent carotid artery stenting (CAS) for a progressive, asymptomatic stenotic lesion in the right carotid artery. Preoperative carotid duplex ultrasound (CDU) and black-blood imaging with T1- and T2-weighted magnetic resonance imaging (MRI) of the plaque revealed a high echoic component and iso-intensity, respectively. We performed CAS successfully and observed no new neurological symptoms postoperatively. However, the following day, diffusion-weighted MRI (DW-MRI) showed ipsilateral multiple high intensities. CDU showed high echoic in-stent protrusion without stent strut fractures. Even after timely treatment with anticoagulant and double antiplatelet therapies, 3D-rotation angiography and intravascular ultrasonography (IVUS) revealed high echoic in-stent protrusion 7 days after CAS. The in-stent protrusion had the same size as in the week before. Thus, we identified it as the embolic source and performed further stenting in the stent. After deployment of two stents inside the first stent, IVUS showed dissipation of the high echoic in-stent protrusion. As highechoic plaques are hard components formed by calcification, high echoic in-stent protrusion without stent strut fractures is rare. The patient’s underlying primary immune thrombocytopenia could have explained the pathophysiological formation of a high echoic plaque, cerebral embolism, and high echoic in-stent protrusion after CAS.

A 79-year-old woman developed aphasia, left conjugate deviation, and right hemiplegia during postoperative management for acute aortic dissection. Two and a half hours before onset, the National Institutes of Health Stroke Scale score was 32, Alberta Stroke Program Early Computed Tomography Score was 10, and CTA revealed occlusion in the left middle cerebral artery proximal segment. Furthermore, thrombectomy was performed. Owing to the aortic dissection in the access route, access was judged as impossible; thus, direct puncture of the left common carotid artery under echography guidance was decided. Mechanical thrombectomy for the left middle cerebral artery occlusion was performed. After intubation and respiratory control using a ventilator, the sheath was removed. The patient recovered without complications and was extubated two days post operation. When the access route is difficult during thrombectomy, direct carotid artery puncture should also be considered, and echography-guided puncture is useful for patients with common carotid artery dissections. In addition, taking into consideration airway compression due to hematoma, intubation and ventilator management are recommended for hemostasis.

We report an autopsy case of 42-year-old man with Takayasu arteritis and subarachnoid hemorrhage due to ruptured anterior communicating artery aneurysm. Radiological imaging study revealed total occlusion of left common carotid artery and left subclavian artery. Renal hypertension was also pointed out. The patient was treated with longterm therapy of corticosteroids, and vasculitis had been controlled. Autopsy findings revealed severe subarachnoid hemorrhage due to ruptured saccular aneurysms at the anterior communicating artery. No vasculitis, atherosclerosis, or dissection was observed at the intracranial arteries and the aneurysmal walls. The histological findings of the largesized arteries were compatible with Takayasu arteritis. Although left common carotid artery was almost completely occluded, left internal carotid artery was patent. There were 22 case reports of subarachnoid hemorrhage due to ruptured aneurysm complicated with Takayasu arteritis. These papers reported that the aneurysms were more common in the posterior circulation and that one or more of the cervical arteries showed stenosis or occlusion in most cases. Aneurysmal formation due to hemodynamic mechanism is generally considered, but spread of inflammatory changes to the intracranial blood vessels has also been reported. The antiplatelet therapy for Takayasu arteritis is recommended to prevent thrombosis, and the condition of patients is often complicated with hypertension. Since aneurysmal formation at the cerebral arteries is not a rare complication and fatal subarachnoid hemorrhage may occur, periodic head imaging tests may be recommended and reconstructive vascular operation may be considered in certain cases.

A 76-year-old man presenting with symptomatic right carotid artery stenosis underwent carotid artery stenting (CAS). Based on ultrasonography images showing a progressing stenosis in the right carotid artery, percutaneous transluminal angioplasty (PTA) was repeatedly performed three times for 1.5 years. During follow-up, peak systolic velocity increased and revised CAS was performed with 4^th PTA. One hour post 2^nd CAS, restlessness and partial seizure were noted. Head CT did not reveal any cerebral hemorrhage, and the value of regional saturation of oxygen of right side was higher than that of left side, leading to a diagnosis of hyperperfusion syndrome. Under general anesthesia, the patient was administered antiepileptic drugs and the blood pressure was strictly controlled. After recovering from acute respiratory distress syndrome, the patient underwent extubation on day 14 and initiated rehabilitation. On day 88 post 2^nd CAS, the patient was discharged with no significant disability (mRS 1).

Objective: We report a rare case of lung cancer-associated tumor embolism that was diagnosed histopathologically with a thrombus collected via thrombectomy. Case: The patient was a 74-year-old man who was undergoing treatment of lung cancer at our hospital on an outpatient basis. The present illness was noted with sudden aphasia and right complete hemiplegia, for which he was transported to our hospital by an ambulance. MRI showed multiple small hyperintensities on DWI in regions including the left middle cerebral artery, bilateral cerebellum, and occipital lobes, and magnetic resonance angiography (MRA) revealed occlusion of the left MCA (M2). rt-PA was not used due to the risk for bleeding from the lung cancer lesion. Thrombectomy alone was performed, and recanalization of the thrombolysis in cerebral infarction (TICI) 2b was achieved with a stent retriever. The postoperative histopathological examination of the collected thrombus led to tumor emboli from squamous cell carcinoma of the lung. Neurological findings improved to NIHSS 1 one week after surgery; however, the patient died of progression of the primary disease on the 27th hospital day. Conclusion: Tumor embolism is a rare cause of cerebral embolism. Thrombi collected via thrombectomy from cancer patients with major artery occlusion should be evaluated histopathologically.

Objective: The safety of intravenous thrombolysis with rt-PA and mechanical thrombectomy during pregnancy is not well confirmed. We report a case of acute ischemic stroke during the first trimester of pregnancy that was treated with reperfusion therapy. Presentation: Aphasia and right hemiplegia developed suddenly in a 27-year-old pregnant woman. The left middle cerebral artery was occluded, and we performed reperfusion therapy by intravenous administration of rt-PA and mechanical thrombectomy. The patient's neurologic status improved immediately. Postoperative transesophageal echocardiography revealed patent foramen ovale; therefore, paradoxical embolism was diagnosed. Conclusion: Reperfusion therapy can be performed relatively safely in pregnant woman but its effects on the fetus must be considered.

A 36-year-old woman was presented with left hemiparesis. Her NIHSS was 13 points at the time of admission to our hospital. A brain MRI detected an occlusion of the right middle cerebral artery, and a heart echocardiogram identified vegetation on the mitral valve. She was diagnosed with middle cerebral artery occlusion due to infective endocarditis and underwent mechanical thrombectomy (MTB). Despite the occurrence of extravasation from the middle cerebral artery during the mechanical thrombectomy, thrombolysis in cerebral infarction Grade 3 (TICI3) was achieved. The whitish embolus material gotten during surgery was submitted for pathological examination. Following the operation, she developed acute heart failure due to severe mitral regurgitation, accompanied by cardiogenic and septic shock. On day 19 post admission, open heart surgery was performed, and she was later discharged from our hospital at her mRS0. We suggest that early diagnosis and treatment of IE, safe MTB, and cooperation with other departments are important factors for good patient outcomes.

A 35-year-old man presented with acute onset of right-sided facial paralysis, upper and lower limb paralysis, and dysarthria in April 2012. He indicated that he had experienced skin rashes on both thighs, sweating disorder, and pain in the extremities that were triggered by exercise and hot weather since childhood. A head magnetic resonance imaging scan revealed acute infarction that extended from the left lenticular nucleus to the corona radiata. The patient was diagnosed with Fabry disease (classical type) based on his childhood history, juvenile cerebral infarction, low alphagalactosidase activity, and deletion of two nucleotides in the alpha-galactosidase gene. We initiated treatment with agalsidase alfa. The pain in the extremities and sweating disorder improved after treatment, and the patient did not experience recurrence of cerebral infarction for 8.5 years. Few studies have reported the long-term follow-up of Japanese patients with Fabry disease. We believe this case is valuable because it suggests that early enzyme replacement therapy ensured that the patient remained free from the recurrence of cerebral infarction for a long period of approximately 8.5 years.