Hyoid bone-related vasculopathy is underestimated, and the relation between carotid artery and hyoid bone is not familiar to us. So it is very important to make the pathophysiology well known. We evaluate the anatomical abnormal findings between carotid artery and hyoid bone with 3D-CTA, and we review the effect on the carotid artery and the pathology. The chronic contact and repeated compression to carotid artery by hyoid bone can give rise to stenosis, occlusion, dissection of carotid artery, or plaque formation, and result in ischemic events. The anatomical position of hyoid bone may vary more than expected and can be a risk factor for vasculopathy. We should pay attention that the morphological change and/or deviation of hyoid bone may easily inflict damage on the adjacent carotid artery, and it plays a central role within stylohyoid–thyroid chain. In the cases of twisted carotid bifurcation or embolic stroke of undetermined source, we should examine proactively the relationship between carotid artery and hyoid bone.

Background and Purpose: We aimed to clarify factors associated with a favorable outcome of patients receiving endovascular therapy (EVT) for internal carotid artery occlusion and patent middle cerebral artery (ICOPM). Methods: Subjects were consecutive patients with ICOPM who received EVT in our hospital between May 2014 and July 2021. We examined their baseline characteristics and time index, treatment contents, and clinical outcomes. Furthermore, we classified them into two groups, those with favorable outcomes who showed mRS 0–2 at 3 months (G group) and those with poor outcomes who showed mRS 3–6 at 3 months (P group), and compared each factor. Results: Thirty-six patients were included among the 511 who received EVT. The median age was 85 years, 23 were male, and the median NIHSS score was 17.5. The onset-to-door time was 200 minutes, and the puncture to recanalization time (P2R) was 84.5 minutes. Embolization to the distal territory was noted in 9 cases, and complete reperfusion (mTICI 2b–3) was observed in 32 patients. There were 13 patients in the G group. Compared with the P group, P2R was significantly shorter in the G group. Conclusion: Patients with ICOPM who received EVT numbered 36 (7%), among whom complete reperfusion and favorable outcomes were observed in 32 and 13 patients, respectively. These results indicate that EVT for ICOPM does not lead to a poor outcome. Compared with the P group, the G group showed a shorter P2R, but ICOPM involves a complex pathology, so a short P2R does not directly lead to an improved outcome.

Backgrounds and Purpose: Neurological worsening often occurs in patients with acute perforating artery infarction including branch atheromatous disease (BAD) against antithrombotic therapies, leading to poor functional outcomes. However, the effective antithrombotic therapy has not been established. The purpose of our study was to clarify acute treatment strategies for perforating artery infarction at primary stroke centers (PSCs) in Japan. Methods: We conducted a web survey at 500 PSCs. We provided clinical information and DWI images of different perforating artery infarction cases such as lacunar stroke and BAD and asked acute treatment strategies in each case. Results: The response rate from PSCs was 38%. In cases with NIHSS 3 and 6 hours after stroke onset, dual antiplatelet therapy (aspirin+clopidogrel) was selected only in about 10% as initial treatments in BAD cases, whereas a combination therapy of 2 or more antiplatelets plus anticoagulants (mainly argatroban) was selected in about 70% of BAD cases and in 25% of lacunar stroke cases. A further antithrombotic agent was added on neurological worsening in approximately half of PSCs, which selected 2 or more antiplatelets plus anticoagulants for BAD cases. In a BAD case with NIHSS 6 and 2 hours of stroke onset, intravenous tPA was selected in 87%. At early neurological worsening after thrombolysis, 35% of PSCs answered that they initiated antithrombotic agents within 24 hours after thrombolysis. Conclusion: At most of PSCs in Japan, more aggressive antithrombotic therapies beyond current stroke treatment guideline may be conducted, especially for BAD.

We report a case of a 60-year-old woman presenting with recurrent vascular events associated with pseudoxanthoma elasticum (PXE). The patient had a history of myocardial infarction that was treated with percutaneous coronary intervention for 10 years and had been treated with oral antiplatelet (clopidogrel) 3 years after a diagnosis of perforator infarction. She was transferred to our hospital after a sudden onset of left hemiparesis and dysarthria. MRI indicated acute perforator infarction at the right coronal radiation and multiple old infarctions at the bilateral basal ganglia. Major artery stenosis or occlusion was not observed on MR angiography (MRA). Biochemical examinations, such as those for d-dimer, proteinase 3 anti-neutrophil cytoplasmic antibody (PR3-ANCA), myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA), protein C/S, lupus anticoagulant, and anti-cardiolipin immunoglobulin, were normal. Physical examinations investigating the recurrent vascular events revealed yellowish papules at the posterior region of the neck and fundus hemorrhage. The diagnosis of PXE was made accordingly. Treatment with oral antiplatelet with acetylsalicylic acid replacing clopidogrel was continued. It is particularly important to keep in mind the identification of PXE in nonelderly patients with recurrent perforator infarction, for the management of concurrent disorders.

An 88-year-old woman was transported to our hospital two days prior because of unconsciousness and headache. She showed mild unconsciousness (Japan Coma Scale: 3) and hypertension (261/127 [172] mmHg), and head MRI revealed high-intensity area at the brain stem and bilateral posterior white matter. She was diagnosed with posterior reversible encephalopathy syndrome (PRES) and administered anti-hypertension therapy, which cured her unconsciousness on day 4. For treating renal failure, a diuretic drug was administered. On day 8, head MRI showed improvement of PRES; however, new cerebral infarction was also found at the bilateral hemisphere watershed area. We decreased the diuretic drug to increase the cerebral blood flow, and no new neurological deficits emerged. In cases of PRES induced by hypertension, the lowering of blood pressure is crucial, but the risk of hemodynamic infarction caused by too rapid lowering of blood pressure must be considered. We should explain the possibility of developing hemodynamic infarction to the elderly in advance.

We report a case of aneurysmal SAH in a young adult with hemiparesis. A-17-year-old woman was admitted to our hospital with sudden headache and right motor weakness. Head CT and 3D-CT-angiography revealed SAH due to ruptured saccular aneurysm of left internal carotid artery bifurcation. We performed surgical clipping and took measures to prevent cerebral vasospasm. The patient had a favorable outcome. Head MRI (7 days after the onset) showed infarction in the territory of left lenticulostriate artery with no angiographical spasm. Since the patient had no underlying disease that could cause cerebral infarction, we speculated that the pathology was due to subarachnoid hematoma, which caused physical damage to vulnerable perforating branch of the middle cerebral artery.

An 88-year-old female was admitted to our hospital because of aphasia and right hemiplegia (NIHSS=26). Brain MRI and MRA revealed acute ischemic lesion of the left hemisphere and occlusion of the left internal cerebral artery (ICA), respectively. We diagnosed acute ischemic stroke owing to occlusion of the left ICA caused by cardiogenic embolization (CE) (due to atrial fibrillation [AF]) or Trousseau’s syndrome (TrS) (due to multiple myeloma), and immediately performed intravenous administration of alteplase and mechanical thrombectomy, which resulted in incomplete recanalization of left MCA. The initial D-dimer was slightly raised (2.25 µg/ml). The retrieved thrombi was white and fresh clot. Cardiac ultrasound, whole-body CT, and another test were normal, but D-dimer increased to 8.83 µg/ml over time in admission. Although it was difficult for us to diagnose if this cerebral embolism originated from TrS or CE because she had AF and MM, we finally diagnosed that this event happened due to TrS considering histopathological findings of the thrombi and a rise in D-dimer. So we concluded that it is important to observe pathology of thrombi even though a patient has AF.

The first choice of treatment for pulmonary arteriovenous fistula (PAVF) is coil embolization, which requires continuation of antithrombotic drugs for a certain period. In this article, we present a probable case of hereditary hemorrhagic telangiectasia (HHT) associated with a cryptogenic stroke, which was treated surgically with PAVF allowing discontinuation of antithrombotic drugs. A 76-year-old woman was brought to the emergency room with right hemiplegia from waking up. Diffusion-weighted magnetic resonance imaging revealed acute infarction on the left side of the pons and the left cerebellum, and magnetic resonance angiography showed occlusion of the left posterior cerebral artery. Contrast-enhanced computed tomography revealed PAVF in the left upper lobe of the lung, but sonography revealed no deep venous thrombus. However, there were no other possible embolic sources, and we diagnosed the patient with cryptogenic stroke due to PAVF. She had a history of recurrent nosebleeds before the onset of stroke, which worsened after administration of antithrombotic agents. The PAVF was removed via thoracoscopic partial left pneumonectomy. After surgery, antithrombotic drugs were discontinued, but the patient did not experience any recurrence of ischemic stroke. HHT is complicated by easy bleeding, and prevention of recurrent cerebral infarction by antithrombotic drugs is risky. In this case, antithrombotic drugs could be discontinued through surgical eradication of PAVF.

Case 1 is a 55-year-old male. Five months after an embolism in the right cerebral hemisphere, he developed a recurrent embolism in the same vascular territory. Carotid web embolism was diagnosed by CT angiography of the carotid artery, which showed a shadow defect in the right internal carotid artery. Percutaneous stenting was performed 14 days after the recurrence. The patient was discharged home with mRS 0 on postoperative day 14. Case 2 is a 48-year-old woman. Three years and three months after the onset of embolism in the right cerebral hemisphere, consciousness disorder appeared. Mechanical thrombectomy was performed. The patient underwent percutaneous stenting 27 days after recurrence with a diagnosis of embolism caused by a carotid web. She was discharged home with mRS 0 on postoperative day 9. Carotid web has been reported to be a cause of cerebral infarction in young patients without risk factors for atherosclerosis. In the past, CEA was often performed to prevent recurrent embolism, but CAS has been increasingly reported in recent years. We review the past CAS cases including these two cases.

A 62-year-old man was urgently admitted to the hospital because of left incomplete paralysis, left upper limb paresthesia, and decreased level of consciousness. Head computed tomography revealed right thalamic hemorrhage with ventricular perforation, and another computed tomography scan 1 hour later showed acute hydrocephalus. The patient was diagnosed with stroke and underwent surgery to alleviate the hemorrhage. He was extubated the day after surgery, but reintubation was considered because of the high risk of saliva aspiration due to drooling. An in-hospital preparation of scopolamine ointment was applied to the mastoid process of the posterior auricle, which decreased the patient’s drooling and number of daily aspiration events. Although xerostomia was observed as a side effect, the patient continued oral care without oral contamination. No skin symptoms were observed at the site of the ointment application. The use of scopolamine ointment reduced the risk of choking and aspiration due to saliva, suggesting the possibility of respiratory management without the need for intubation, tracheotomy, or other invasive procedures.