Background and Purpose: For the atherothrombotic large vessel occlusion (AT-LVO) patients treated by the emergency neuroendovascular revascularization (ENER), the pros and cons of concomitant intravenous rt-PA (IV rt-PA) and additional antithrombotic agents within 24 hours remain controversial. We retrospectively evaluated the impact of IV rt-PA and additional antithrombotic agents within 24 hours in AT-LVO patients treated by ENER at our hospital. Methods: Of the 164 AT-LVO patients who underwent ENER over the past seven years, 60 patients who were treated in our hospital within 4.5 hours of onset were divided into two groups: 26 patients who received IV rt-PA (IV rt-PA(+)) and 34 patients who did not receive IV rt-PA for some reason (IV rt-PA(−)). The outcomes of these two groups were compared retrospectively and statistically. Results: No significant differences were observed in the background and characteristics of the patients. The rate of good functional outcome at 90 days was also not significantly different, although the rate of successful recanalization was significantly higher for IV rt-PA(−). The antithrombotic agents were loaded within 24 hours among 34% of IV rt-PA(+), and they were significantly restrained in IV rt-PA(+) compared with IV rt-PA(−). There was no significant difference in the rate of any intracranial hemorrhage. Conclusion: In patients with AT-LVO who underwent ENER, IV rt-PA and additional antithrombotic agents within 24 hours did not impact the hemorrhagic complication rate or outcome at 90 days.

Background and Purpose: In reperfusion therapy for patients with acute ischemic stroke (AIS), a shorter time to initiation of therapy is associated with a better prognosis. However, the intervention rate and the time until therapy initiation are still inadequate. In this study, we introduce a cell-phone-based system (stroke hotline [S-Hot]) in which the treating medical staff received information about potential stroke patients directly from the ambulance crew. This system was introduced as the next stage following the in-hospital maintenance system for the reperfusion therapy in AIS patients. We investigated the effect of S-Hot on improving the intervention rate and shortening the time until therapy initiation. Methods: We classified patients who received repurfusion therapy for stroke and were hospitalized from June 2021 to December 2022 into two groups – the S-Hot group and the non-S-Hot group – and investigated the effectiveness of S-Hot retrospectively. Results: The enforcement rate of reperfusion therapy was approximately 2 times higher in the S-Hot group compared to that in the non-S-Hot group. S-Hot shortened the intervals between the arrival at the emergency scene and the arrival at the hospital door (ADT), between the door and administration of IV t-PA (DNT), and between the door and the start of mechanical thrombectomy (DPT). However, only the ADT showed a significant difference. Conclusion: S-Hot was effective in shortening the time from the onset of AIS to therapy initiation. However, it is important to maintain an in-hospital system as well.

Background and Purpose: Although mechanical thrombectomy (MT) has been performed for the treatment of middle cerebral artery (MCA) M2 occlusion on a case-by-case basis, its efficacy and safety have not been established. We reviewed the results of the treatment of patients with M2 occlusion through MT to elucidate the efficacy and safety of MT. Methods: Patients with M1 or M2 occlusion and those treated with MT at our hospital between March 2014 and January 2022 were selected (M1: 93 patients, M2: 68 patients). The efficacy and safety of the treatment were examined. Results: The rate of successful recanalization (TICI≥2b) was higher in the M1 occlusion group (90.3% vs. 73.5%), and the rate of intracranial hemorrhage was high in the M2 occlusion group (14% vs. 38.2%). The incidence of subarachnoid hemorrhage was higher in the M2 occlusion group (38.2% vs. 6.5%), and the rate of developing subarachnoid hemorrhage was higher in patients with a large number of passes and in patients who underwent stent retriever alone even once. Conclusions: In the M2 occlusion group, MT appears to be effective as good recanalization increases the proportion of patients with good functional outcomes. However, given that intracranial hemorrhage is complicated in a high number of patients, counter measures are important.

A 77-year-old woman with rapidly worsening tinnitus, bilateral conjunctival hyperemia, and diplopia was admitted to our hospital for treatment. Cerebral angiography revealed a dural arteriovenous fistula (DAVF) of the left cavernous sinus, which mainly drained from the left external carotid artery into the bilateral posterior cranial fossa and bilateral superior ophthalmic veins. Contrast-enhanced magnetic resonance imaging revealed a tumor suspected of left-sided sphenoid ridge meningioma. However, we treated this tumor conservatively. Although transvenous embolization was performed for DAVF, left eye symptoms worsened 15 days after the operation. Repeated cerebral angiography showed slight residual shunt and outflow from the sphenoid ridge tumor flowing into the left superior ophthalmic vein. Transarterial embolization was performed for the remaining shunt and feeding vessels to the tumor, and the symptoms improved. Herein, we report a suggestive case in which perfusion by a distant tumor was involved in a DAVF and present speculated therapeutic considerations for cases with similar anatomic pathology.

An 89-year-old man suddenly developed left hemiplegia and was transported to our hospital about 40 minutes later. On admission, the level of consciousness was 2 on the JCS, and right conjugate deviation and severe left hemiplegia were observed. The NIHSS score was 21. A hyperdense MCA sign in the right M1 was observed on CT but no early cerebral ischemic changes. Electrocardiography revealed ST-segment elevation, and cardiogenic cerebral embolism associated with acute myocardial infarction was diagnosed. rt-PA intravenous therapy was skipped, and percutaneous coronary angioplasty for acute myocardial infarction was performed. Cerebral angiography was then performed, confirming occlusion of the right MCA M1 proximal region. Acute endovascular revascularization was performed, obtaining complete recanalization. The time from puncture to recanalization was 73 minutes. After treatment, the patient was able to lift the left upper and lower extremities and was transferred to another hospital with mRS 3. When both diseases are present, the order of treatment should be considered on a case-by-case basis. This case was judged to have highly severe acute myocardial infarction, which was therefore prioritized. Diagnosis by CT alone and skipping rt-PA intravenous therapy allowed treatment time to be minimized.

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder characterized by multisystem manifestations, including cutaneous findings, tumors, and vascular abnormalities. A 63-year-old woman developed headache and vertigo. After 5 days, she was admitted to our hospital due to seizures. A CT scan showed subcortical hemorrhage in the right temporal lobe and cerebral venous thrombosis (CVT) in the right transverse venous sinus. Laboratory tests revealed severe anemia, and a gastrointestinal stromal tumor (GIST) was diagnosed by small-intestinal double-balloon endoscopy. In addition, physical examination revealed multiple small soft masses on the skin all over the body, leading to a diagnosis of NF-1. Anemia is a risk factor for cerebral venous thrombosis, and close examination for gastrointestinal bleeding is important when thrombosis complicates NF-1.

A 54-year-old woman observed sudden difficulty in finding the correct words accompanied by weakness in her right hand 9 days after COVID-19. Head magnetic resonance imaging revealed acute cerebral infarction in the left middle cerebral artery (MCA) territory, and magnetic resonance angiography (MRA) revealed left MCA occlusion. She received recombinant tissue plasminogen activator (rt-PA) therapy and improved immediately thereafter. Head MRA performed 1 h later revealed recanalization of the left MCA. Transcranial ultrasonography (TCD) showed a right-to-left shunt, and lower extremity venous echocardiography revealed an isoluminous organized thrombus in the left soleus vein. Transesophageal echocardiography revealed Grade III patent foramen ovale and an atrial septal aneurysm. We diagnosed paradoxical cerebral embolism in the patient, and initiated apixaban therapy and performed foramen ovale closure. There are few reports of paradoxical embolism in COVID-19, and hence, we discuss the mechanism and treatment of paradoxical cerebral embolism involved in COVID-19.

An 81-year-old woman was brought unconscious to our hospital. She showed bilateral ptosis with loss of all extraocular movements and complete ophthalmoplegia (CO). Following the head MRI revealing bilateral paramedian midbrain–thalamic infarction, a disorder of the oculomotor nucleus and pseudo abducens palsy (PAP) were diagnosed. Rehabilitation was initiated by an anticoagulant therapy; however, she succumbed because of non-occlusive mesenteric ischemia and aspiration pneumonia on day 21. Midbrain infarction with CO is rare and is characterized by PAP, which is abducens palsy in the absence of an actual abducens lesion. This clinical pathology is induced by the interruption of inhibitory vergence pathways. Furthermore, cases of midbrain-thalamic infarction with CO reportedly with a tendency of high mortality necessitate early understanding of the underlying pathology by the physicians. Also, precise informed consent should be provided to the patient when these characteristic findings are confirmed.