The recent research of carotid plaque has focused on evaluation of plaque component in addition to its stenosis and on how “vulnerable plaque” can be detected with some diagnostic modalities. On the other hand, in the natural history of atherosclerotic lesions, the healing process after plaque rupture is considered to be a very important pathology for elucidating the destabilization of plaque, but its recognition in the carotid artery is low. The healing process is a pathology that occurs within a certain period of time after plaque rupture and is in no way synonymous with plaque stabilization. If the healing process is effectively completed, a thick fibrous cap will be formed and the ischemic event may be the first attack only. On the other hand, if it becomes an incomplete healing process, the ischemia event will recur. Understanding the pathophysiology of healing process may be a very important issue in elucidating the natural history of atherosclerotic carotid plaque.

Purpose: We evaluated moderate or profound hyponatremia (serum sodium concentration ≤130 mEq/l) based on the European guideline in patients with cerebral infarction or cerebral hemorrhage to determine its clinical characteristics. Methods: We retrospectively analyzed the clinical characteristics of patients with central hyponatremia during hospitalization for acute cerebral infarction or cerebral hemorrhage. Results: Of 538 eligible patients (408 with cerebral infarction and 130 with cerebral hemorrhage), 13 patients (2.4%) developed hyponatremia due to cerebral infarction or cerebral hemorrhage after admission, including 10 patients with SIADH and 3 patients with CSWS. Hyponatremia was significantly more common in cerebral hemorrhage (p=0.004), and hospital stay was significantly longer in patients with hyponatremia (p=0.006). Conclusion: Hyponatremia was more frequent in patients with cerebral hemorrhage, and SIADH was the most common cause. The European guideline is useful for the diagnosis of hyponatremia in the clinical setting.

Background and Purpose: Although the proportion of good outcomes has increased with the development of acute reperfusion therapy in patients with ischemic stroke, not a few patients still have poor outcomes. The purpose of this study was to determine whether poor outcomes can be predicted in ischemic stroke patients by information available at the time of emergency arrival. Methods: Using a prospective, follow-up study of patients with ischemic stroke or transient ischemic attack who were admitted within 7 days of onset between April 2014 and December 2019 (n=2,144), age, sex, premorbid modified Rankin scale (mRS) score, and National Institutes of Health Stroke Scale (NIHSS) score on admission were assessed as predictors of a poor outcome (90-day mRS score 5 or 6). A factor or combination of factors that predicted a poor outcome in more than 80% was defined as a poor prognosis profile (PPP). Results: After excluding those with a premorbid mRS score of 5 and failure to complete follow-up, 2,106 patients (median 77 years, male 58%) were studied. A total of 289 (14%) patients had poor outcomes. On multivariate analysis, age (per 10-year increase, OR 1.8, 95% CI 1.5–2.1), premorbid mRS score (1.3, 1.2–1.5), and NIHSS score (per 5-point increase, 2.2, 2.0–2.4) were independently associated with a poor outcome. A combination of age 80 years or older and NIHSS score of 26 or more predicted a poor outcome in 84% of patients, corresponding to a PPP. Conclusion: Poor outcomes at 90 days can be predicted by age and the NIHSS score on admission.

Background and Purpose: The purpose of this study was to clarify the outcome of aspiration catheter (AC)-based mechanical thrombectomy (AC-MT) and the differences in techniques used for the first pass (FP). Methods: Consecutive patients with acute ischemic stroke who received AC-MT from April 2019 to September 2020 in our institution were enrolled. Their clinical outcomes were examined. They were categorized into the simple aspiration technique (SAT) group or the combined technique with stent retriever (CBT) group based on the FP technique. The clinical outcomes of the two groups were compared. Results: The subjects were 78 patients in which recanalization (modified thrombolysis in cerebral infarction 2b–3) was achieved in 29 (37%) patients and 73 (94%) patients at the FP and the endpoint of the procedure, respectively. Thirty-four (44%) patients had favorable outcomes (mRS 0–2 at 3 months). Thirty-five (45%) patients and 43(55%) patients were included in the SAT group and the CBT group, respectively. The number of recanalized cases was not different between the SAT group (94%) and the CBT group (93%). However, in the SAT group, compared to the CBT group, the median time from puncture to recanalization was shorter (33 minutes vs. 57 minutes) and the number of favorable outcomes was higher (57% vs. 33%). Conclusion: The recanalization rate of AC-MT was 37% at the FP. The procedure time was shorter and the number of cases of favorable outcomes was greater among patients treated with SAT as the FP than among patients treated with CBT.

The patient was a 28-year-old man who had a history of untreated atopic dermatitis (AD). He was hospitalized with Staphylococcus aureus (S. aureus) bacteremia and infective endocarditis (IE) during an acute flare-up of AD. He developed a ruptured infective cerebral aneurysm (ICA) and underwent decompressive craniectomy on the 9th hospital day. While dermatological skin care was provided, open heart surgery was performed 41 days after the rupture of ICA, and the ICA was cured with antibiotic therapy. There is skin colonization by S. aureus in patients with AD; therefore, scratching of the lesions may cause invasion of bacteria, subsequently promoting extracutaneous infections including IE and ICA, as well as postoperative infections. The decision of how best to manage ICA associated with AD should be evaluated with the aid of neurosurgery, cardiac surgery, and dermatology.

Delayed symptomatic vasospasm after carotid artery stenting (CAS) is extremely rare. We report a case of delayed vasospasm after CAS. A 73-year-old man with asymptomatic severe right carotid stenosis underwent CAS using a filter and open-cell stent under local anesthesia. No intraoperative complications occurred. He presented with disturbance of consciousness (Japan Coma Scale II-10), left hemispatial neglect and fever elevation 20 hours after CAS. ¹²³I-IMP single-photon emission computed tomography (¹²³I-IMP-SPECT) showed hypoperfusion in the right middle cerebral artery area. Angiography on the same day showed vasospasm in the right middle cerebral artery. Intravenous Edaravone 60 mg, intravenous Ozagrel sodium 80 mg and oral anticonvulsant drug (lacosamide) were administered. Additionally, we performed normotension therapy. His symptoms had resolved 3 days after CAS and cerebral blood flow was recovered on ¹²³I-IMP-SPECT 8 days after CAS.

We report two cases of diffuse vasospasm on the affected side after carotid artery stenting (CAS). Thromboembolism is the most common ischemic complication, but cerebral vasospasm has also been reported in rare cases. Both patients had symptomatic stenosis. Case 1 had a severe stenosis with a high probability of reduced cerebral vascular reserve. Case 2 had moderate stenosis with no loss of vascular reserve, and single-photon emission computed tomography immediately after CAS showed extensive hypoperfusion in the affected cerebral hemisphere. Cerebral vasospasm, along with hyperperfusion syndrome, is a condition that causes changes in cerebral blood flow and requires prompt diagnosis because the treatment is different. It is important to differentiate ischemic complications after CAS by considering not only thromboembolism but also this condition.

The patient was a 68-year-old male. He was taken to a hospital by ambulance with a chief complaint of difficulty moving. During his visit, he was found to be suffering from monoparesis of the left leg, with a cerebral infarction observed in the right anterior cerebral artery region on both CT and MRI. In addition, since he had fecal incontinence associated with a large amount of black stool and with a blood test indicating anemia of Hb 6.2 g/dl, gastrointestinal bleeding was suspected. Gastric ulcers were confirmed after performing upper gastrointestinal endoscopy. A thrombus was observed in the left internal carotid artery via a carotid duplex ultrasound, which was performed for the purpose of investigating the cause of the cerebral infarction, with a CTA indicating a large number of thrombi not only in the carotid artery but also in the abdominal aorta and pulmonary artery. Since we determined that the carotid thrombosis had a high risk of progressing to a cerebral infarction, daily ultrasound scans were performed as a follow-up. However, a new cerebral infarction occurred due to carotid thrombus dispersion. A cerebral infarction due to thrombosis throughout the entire body in association with anemia has only been rarely reported. We herein report the pathophysiology of this rate case with a review of the pertinent literature.

Objective: We report a case of recurrent hemorrhage of a perforating artery aneurysm associated with moyamoya disease in a patient who was successfully treated using endovascular parent artery occlusion. Case Presentation: A 31-year-old woman with a history of moyamoya disease and two episodes of intracerebral hemorrhage developed right hemiplegia and impaired consciousness. Computed tomography (CT) revealed intracerebral hemorrhage from the left cerebral peduncle extending to the thalamus, and the patient received conservative treatment. CT and CT angiography performed on the 9th day of admission revealed enlargement of the hemorrhagic area and an aneurysm involving the perforating branch of the left posterior cerebral artery. We scheduled diagnostic angiography; however, on the 11th day of admission, we observed deterioration in her consciousness level secondary to recurrent hemorrhage. Therefore, we performed diagnostic angiography and embolization under general anesthesia. Intraoperatively, we identified an aneurysm involving the distal portion of the short circumferential branch of the left posterior cerebral artery. Subsequent endovascular parent artery occlusion using N-butyl cyanoacrylate led to disappearance of the aneurysm. The patient had no perioperative complications and showed no recurrent hemorrhage 12 months post intervention. Conclusion: The location and vascular architecture of aneurysms associated with moyamoya disease tend to vary across patients; therefore, a careful and detailed angiography-documented anatomical evaluation is essential to determine indications for treatment of these aneurysms.

We report a case of possible contrast extravasation from a preexisting infected aneurysm distal to the occlusion after mechanical thrombectomy. In a 77-year-old woman with a history of infective endocarditis presenting with a cerebral infarction, a high-density area around a peripheral aneurysm distal to the occlusion was detected on head CT after mechanical thrombectomy. The patient underwent coil embolization for suspected hemorrhage from the aneurysm, which was eventually determined to be a contrast extravasation from a preexisting aneurysm associated with infective endocarditis into the surrounding tissues adhering to the aneurysm due to a past septic embolism. Contrast extravasation around the peripheral aneurysm after mechanical thrombectomy may be related to injection of contrast media through a microcatheter distal to the occlusion, cerebral ischemia, stagnation of contrast media in cerebral vessels, and aneurysm wall permeability to contrast media. Because the area around the peripheral aneurysm may appear as a high-density area on head CT due to the effect of using contrast media, the necessity of aneurysm embolization should be determined carefully on the basis of the clinical course, past images, and dual-energy CT findings.