Clinical Outcomes in Elderly Patients with Chronic Subdural Hematoma: Validation of Irrigation Assignment Based on Hematoma Characteristics.

The number of elderly patients with chronic subdural hematomas (CSDH) is increasing worldwide; however, there is limited data regarding the clinical outcomes in this population. Our therapeutic method using burr hole evacuation for CSDH is based on the hematoma characteristics, using simple drainage for single-layer lesions and drainage with irrigation for multiple-layer lesions. This study aimed to compare the postoperative outcomes of elderly and younger patients, identify the predictors of outcomes in elderly patients, and verify the validity of our therapeutic methods. In total, we included 214 patients who underwent burr hole evacuation between April 2018 and March 2022. Baseline characteristics, hematoma characteristics, recurrence, and clinical outcomes were compared between the elderly and younger patients. Overall, 96 elderly patients (44.9%) were included in the study, and more elderly patients underwent antithrombotic therapy than younger patients (33.3% vs. 19.5%, p = 0.027). Moreover, elderly patients had significantly fewer favorable outcomes than younger patients (70.8% vs. 91.5%; p < 0.001); however, this was not significant after adjusting for the baseline modified Rankin Scale (mRS). Similarly, elderly patients had higher recurrence rates than younger patients (10.4% vs. 2.5%; p = 0.021). However, the baseline mRS score was the only predictor of unfavorable outcomes. In conclusion, although the clinical outcomes of elderly patients were comparable to those of younger patients, the higher rate of preoperative antithrombotic therapy in elderly patients may result in a higher rate of recurrence requiring a long-term follow-up.

Intraarterial urokinase for thrombus migration after mechanical thrombectomy for large vessel ischemic stroke.

BACKGROUND: Achieving rapid and complete reperfusion is the ultimate purpose for ischemic stroke with large vessel occlusion (LVO). Although mechanical thrombectomy (MT) had been a proverbially important procedure, medium vessel occlusion (MeVO) with thrombus migration can sporadically occur after MT. Moreover, the safe and effective approach for such had been unknown. We reported thrombolysis with intraarterial urokinase for MeVO with thrombus migration after MT. METHODS: We included 122 patients who were treated by MT with LVO stroke at our institution between April 2019 and March 2021. Of 26 patients (21.3%) who developed MeVO with thrombus migration after MT, 11 (9.0%) underwent additional MT (MT group) and 15 (12.3%) received intraarterial urokinase (UK group). The procedure time; angiographically modified Treatment in Cerebral Ischemia Scale (mTICI); functional independence, which was defined as modified Rankin Scale 0-2, on day 30 or upon discharge; and symptomatic and asymptomatic intracerebral hemorrhage (ICH) were compared between the UK and MT groups. RESULTS: The procedure time, mTICI, and asymptomatic ICH did not significantly differ between the groups. In the UK group, 8 of 15 (53.3%) patients obtained functional independence, and the functional independence rate was significantly higher in the UK group than in the MT group (p < 0.05). Symptomatic ICH did not occur in the UK group, and its incidence was significantly smaller than that in the MT group (p < 0.05). CONCLUSION: The results of this study suggest that intraarterial urokinase for MeVO with thrombus migration after MT may safely improve angiographic reperfusion.

Early Enteral Nutrition with High-Protein Whey Peptide Digestive Nutrients May Improve Prognosis in Subarachnoid Hemorrhage Patients.

Background and Objectives: Nutritional management in patients with subarachnoid hemorrhage (SAH) during the acute phase is important; however, there is no proper evidence or recommendations on the appropriate nutrients for early enteral nutrition. This study compared the influence the two different tube-feeding liquid diets for early enteral nutrition might have on the prognosis of patients with SAH. Materials and Methods: In a seven-year period, this single-center retrospective study included 245 patients with aneurysmal SAH who underwent craniotomy and aneurysm neck clipping and received enteral nutrition. The patients were divided into two groups according to the nutrient received: (1) high-protein whey peptide oligomeric formula diet (oligomeric group, 109 patients); and (2) high eicosapentaenoic acid-containing polymeric formula diet (polymeric group, 136 patients). The modified Rankin Scale (mRS) score at discharge was evaluated as the primary outcome. The presence or absence of diarrhea (watery stool and mushy stool) during the period from initiation of enteral nutrition to discharge from the stroke unit was also evaluated. Results: There were no significant differences in patient characteristics between groups. The time until initiation of enteral feeding in the oligomeric and polymeric groups was 2.8 ± 2.3 and 2.9 ± 2.2 days, respectively. The proportion of patients with mRS scores of 0-1 was significantly higher in the oligomeric group (25.7%) than in the polymeric group (14.7%) (p = 0.036), while the incidence of watery stool was significantly lower in the oligomeric group (15.8% to 34.3% in the polymeric group) (p = 0.003). Multivariate analyses confirmed that the oligomeric diet and the presence or absence of diarrhea significantly affected the mRS scores. Conclusions: The adoption of early enteral nutrition with high-protein whey peptide digestive nutrients might be associated with superior mRS scores at discharge and decreased diarrhea in patients with SA, indicating that the choice of nutrients might affect the outcome and prognosis.

Management of Wide-Necked Basilar tip Aneurysms.

While the frequency of direct surgery for basilar tip aneurysms is decreasing, the need for safe and effective surgical treatments for difficult-to-treat aneurysms, including large or wide-necked aneurysms, is likely to continue. In this chapter, our surgical approach for large wide-necked basilar tip aneurysms using the orbitozygomatic approach, the anterior temporal approach, and hybrid surgery are described.

Familiarization with Contact Aspiration using Non-Penetrating of the Thrombus (CANP) Technique as the Initial Procedure for Acute Ischemic Stroke.

OBJECTIVES: This study aimed to prove the safety and efficacy of the contact aspiration using non-penetrating of thrombus (CANP) technique for the initial procedure for acute ischemic stroke and to increase operator familiarization with the technical aspects of the CANP technique. MATERIALS AND METHODS: A total of 103 patients with large-vessel stroke who were treated using thrombectomy alone at our institution between April 2019 and March 2021 were included in this study. CANP technique was performed using a large lumen catheter (inner diameter, ≥0.060 in.) without penetrating a thrombus. Results of the CANP technique, including the procedure time; first-pass effect (FPE); angiographical recanalization; functional independence; thrombus migration; and intracerebral hemorrhage (ICH) were compared with combined technique. RESULTS: A total of 77 patients (74.8%) were scheduled to undergo the CANP technique for initial procedure, and 50 (64.9%) attempted the CANP technique. Of 50 patients with CANP technique, 33 (66.0%) achieved angiographically good recanalization using CANP technique alone. FPE was achieved in 31 patients (62.0%) in CANP technique group; the rate of FPE was significantly higher (p = 0.008). Asymptomatic ICH were significantly smaller in the CANP technique group (p = 0.008). The median interval of only the CANP technique was 20 (IQR, 16-29.5) min for groin puncture to final recanalization, and was significantly faster (p < 0.001). CONCLUSIONS: CANP technique was safe with low risk of hemorrhagic complication and effective for the initial procedure of acute ischemic stroke.

Clinical and Morphological Characteristics of Ruptured Small (<5 mm) Posterior Communicating Artery Aneurysms.

CONTEXT: Small intracranial aneurysms (IAs) are considered to have a low risk of rupture; however, in clinical practice, we often encounter patients with subarachnoid hemorrhage (SAH) due to rupture of small IAs. AIMS: This study aims to clarify the clinical and morphological characteristics of ruptured small IA, focusing on posterior communicating artery (PCoA) aneurysms as a prone site. SETTINGS AND DESIGN: We retrospectively reviewed 102 consecutive patients with SAH due to ruptured PCoA aneurysm who underwent microsurgical or endovascular aneurysm repair between April 2013 and March 2018. SUBJECTS AND METHODS: All PCoA aneurysms were diagnosed using three-dimensional rotation angiography or three-dimensional computed tomography angiography. Information regarding the following clinical characteristics was collected: age, sex, past medical history, current smoking, antithrombotic therapy, multiplicity, hydrocephalus, intracerebral hemorrhage, intraventricular hemorrhage, and World Federation of Neurosurgical Societies (WFNS) Grade on admission. STATISTICAL ANALYSIS USED: We analyzed factors of ruptured small IA, focusing on PCoA aneurysms using univariate and multivariate regression analyses. RESULTS: Univariate and multivariate analyses revealed that low aspect ratio (AR) (odds ratio [OR] = 0.33, P = 0.01) and nonfetal type of PCoA (OR = 0.31, P = 0.02) might be independent characteristics of ruptured small PCoA aneurysms. However, age, sex, past medical history, WFNS grade, and treatment outcome were not different between the small and nonsmall PCoA aneurysms. The aneurysm size was not associated to the selection of treatment, proportion of complications, and treatment outcome. CONCLUSIONS: In cases of ruptured PCoA aneurysms, low AR and nonfetal type of PCoA might be associated with rupture of small aneurysms.

Current treatment options and prognostic factors for ruptured distal anterior cerebral artery aneurysms.

BACKGROUND: Distal anterior cerebral artery (ACA) aneurysms are rare, representing 1-9% of all intracranial aneurysms. The best treatment strategy for these aneurysms continues to be debated. We clarified the clinical features and treatment outcomes of patients with ruptured distal ACA aneurysms according to the treatment options at our institute. METHODS: Thirty-seven consecutive patients (26 women; mean age, 65.2 years) with ruptured distal ACA aneurysms who underwent surgical clipping or coil embolization between 2012 and 2018 were included in the study. Clinical presentations, radiographic findings, and outcomes were retrospectively reviewed and compared between patients who underwent either surgical clipping or coil embolization. Risk factors associated with poor outcomes (modified Rankin Scale 4-6) were analyzed using multiple regression analysis. RESULTS: Nineteen patients (51.4%) had World Federation Neurological Surgeons (WFNS) Grade IV-V, 18 (48.7%) had frontal lobe hematomas, and 13 (35.1%) had multiple aneurysms. Surgical clipping and endovascular coiling were performed in 28 (75.7%) and nine (24.3%) patients, respectively. Aneurysms located at the A4-5 portions were mainly treated by surgical clipping (P = 0.04). There were no significant between-group differences in procedure-related morbidity and mortality; however, the complete occlusion rate was higher in the surgical group (P < 0.01). Overall, a favorable neurological outcome at discharge (mRS 0-3) was obtained in 23 patients (62.5%). Multiple regression analysis revealed that WFNS Grade IV-V and frontal lobe hematomas were risk factors for poor outcomes (mRS 4-6). CONCLUSION: Acceptable outcomes were obtained in 62.5% of cases, and there were no significant between-group differences in treatment results between clipping and coiling. A poor WFNS grade and intracerebral hematomas were risk factors for a poor prognosis.

Real-world treatment results for ruptured blood-blister aneurysm of the internal carotid artery: analysis of a Japanese nationwide multicenter study.

Ruptured blood-blister aneurysm (BBA) of the internal carotid artery (ICA) remains a challenging lesion, even in the age of modern neurosurgery and endovascular treatment. This retrospective multicenter study aimed to investigate the real-world treatment choice and treatment results. We included 182 ruptured BBAs of the ICA treated at 51 neurosurgical centers in Japan between 2013 and 2017. The baseline patient characteristics, radiological features of the aneurysm, treatment modality, details of treatment, complications of treatment, and treatment results were retrospectively collected. The treatment strategy was divided into deconstructive and reconstructive procedures. Primary clinical outcomes were evaluated using the modified Rankin scale (mRS) at final follow-up. Direct surgery was performed in 144 (79%) cases, and the remaining 38 (21%) cases received endovascular treatment. The majority of treatment selections were deconstructive and reconstructive procedures in the direct surgery group and endovascular treatment group, respectively. Overall, favorable clinical outcomes (mRS 0 to 2) were achieved in 66% of cases, and the mortality rate was 15% at the final follow-up (mean 23 months). There was no significant difference in clinical outcome between direct and endovascular treatment groups. Our large nationwide study compared the real-world treatment options for ruptured BBAs and their results. Our findings may offer beneficial information for treatment decision and for future studies investigating ruptured BBAs.

Clinical Characteristics of Ruptured Intracranial Aneurysm in Patients with Multiple Intracranial Aneurysms.

OBJECTIVE: It is difficult to correctly identify the ruptured aneurysm in patients with multiple intracranial aneurysms. Here, we investigated the clinical characteristics of ruptured intracranial aneurysms in such patients. METHODS: We retrospectively analyzed 361 patients who underwent microsurgical clipping of ruptured intracranial aneurysms at our institution from 2012 to 2018. Patients' age, sex, Fisher group, World Federation of Neurosurgical Societies grade, size (neck width, depth, maximum diameter), location, and shape of intracranial aneurysm, and hemorrhage pattern on admission were reviewed. RESULTS: In total, 266 patients (74%) had single intracranial aneurysms and 95 (26%) had multiple intracranial aneurysms. Eighty-nine of the 95 multiple intracranial aneurysms (94%) had irregular shape (P < 0.01). The median aspect ratios of ruptured and unruptured intracranial aneurysms were 2.2 ± 1.1 and 1.0 ± 0.4, respectively (P < 0.01). Twelve of 95 patients (13%) had ruptured intracranial aneurysms that were smaller than unruptured intracranial aneurysms. Among the 12 patients, the aspect ratios of ruptured intracranial aneurysms were greater than those of unruptured intracranial aneurysms (P < 0.01). Regarding morphologic characteristics, aspect ratio, maximum size, and irregular shape could be the useful predictive factors, but the greatest aspect ratio among patients with multiple aneurysms was the most predictive of an intracranial aneurysm rupture, after adjustment for aneurysmal size (adjusted odds ratio 217.82; 95% confidence interval 56.41-841.08). CONCLUSIONS: The results of this study indicate that the aspect ratio is the most predictive factor of a ruptured intracranial aneurysm in patients with multiple intracranial aneurysms.

Use of flexible endoscopic aspiration for an intraventricular small floating clot with hemorrhage: a technical note.

BACKGROUND: Although flexible endoscopy is effective for intraventricular lesions, it is less frequently used for hemorrhagic cases. In some hemorrhagic strokes, blood clots may plunge into the cerebral aqueduct and cause acute obstructive hydrocephalus. A flexible endoscope can aspirate clots and prevent acute hydrocephalus. METHODS: Here, we report four cases of hemorrhage: one of intracerebral hemorrhage and three of subarachnoid hemorrhages. RESULTS: In all cases, acute hydrocephalus was not apparent upon admission. Sudden comatose occurred; computed tomography revealed acute obstructive hydrocephalus with a strangulated clot in the cerebral aqueduct. We performed aspiration of the strangulated clot using a flexible endoscope. Consciousness improved in all cases, and acute hydrocephalus was prevented in all cases. CONCLUSION: The use of simple flexible endoscopic aspiration for clots might be a beneficial and less-invasive procedure for acute obstructive hydrocephalus caused by a small clot with hemorrhagic stroke.

Identification of Prognostic Factors in Surgically Treated Patients with Acute Epidural Hematoma.

CONTEXT: Only few comprehensive studies have investigated acute epidural hematoma (AEDH), and a low incidence of the lesion has been observed in comparison with other types of traumatic brain injuries such as subdural hematoma, traumatic subarachnoid hemorrhage, and contusion. AIM: This study aims to identify the prognostic factors of surgically treated AEDH. SETTINGS AND DESIGN: The medical records of 58 consecutive patients with surgically treated AEDH between September 2011 and 2018 were retrospectively reviewed. SUBJECTS AND METHODS: All patients were diagnosed with AEDHs using 5-mm-slice computed tomography (CT). Information regarding the following demographic and clinical characteristics was collected: age, sex, antithrombotic drug use, mechanisms of injury, time from onset to operation, neurological examination, vital signs, blood examination, and CT findings. STATISTICAL ANALYSIS USED: We analyzed prognostic factors in patients with AEDH using univariate and multivariate regression analyses. RESULTS: Univariate and multivariate regression analyses revealed that age (P < 0.01) and the Glasgow Coma Scale (GCS; P < 0.01) were independent predictive factors for good prognosis. In addition, receiver operating characteristics (ROC) analysis showed that an age of <55 years and a GCS score of >12 were optimal cutoff values for predicting good prognoses, with the areas under the ROC curve of 0.827 and 0.810, respectively. CONCLUSIONS: Age and GCS are useful predictors of prognosis in patients with surgically treated AEDH. These findings are appropriate prognostic indicators for urgent surgery performed to treat AEDH and intended to help clinicians make a prompt diagnosis.

Long-Term Outcomes of Elderly Patients with Poor-Grade Aneurysmal Subarachnoid Hemorrhage.

OBJECTIVE: Long-term outcomes after surgical treatment and intensive care have not been investigated in elderly patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to analyze 12-month outcomes and prognostic factors of patients with poor-grade aSAH who were at least age 70 years. METHODS: We performed a single-center, retrospective study including poor-grade (World Federation of Neurological Societies [WFNS] grades IV and V) aSAH patients who were at least age 70 years, were admitted to our stroke center, and received aneurysmal treatment between April 2012 and September 2018. The clinical outcomes were evaluated at months 3 and 12. Univariate/multivariate analyses were performed to identify the independent prognostic factors of good neurologic outcomes (modified Rankin Scale score 0-3). These factors included sex, age, WFNS grade, Fisher group, delayed cerebral ischemia, aneurysm treatment, aneurysm size, aneurysm location, and blood examination data in the 14 days post subarachnoid hemorrhage. RESULTS: The proportion of patients with good outcomes (modified Rankin Scale score 0-3) was increased at 12 months compared with that at 3 months. No intracerebral hemorrhage was a significant predictor of good neurologic outcomes at 3 months (P = 0.03). The absence of delayed cerebral ischemia and small fluctuations in the average absolute daily difference from normal sodium levels were significant predictors of good neurologic outcomes at months 3 and 12 (P = 0.04 and P = 0.03, respectively). CONCLUSIONS: The absence of delayed cerebral ischemia and small fluctuations in the average absolute daily difference from the normal sodium levels were independently associated with good neurologic outcomes at 12 months in elderly patients. Intracerebral hemorrhage did not appear to affect long-term outcomes. These findings suggest that elderly patients with severe subarachnoid hemorrhage should not be excluded from receiving surgical treatment on the basis of their age alone.

Trans-lamina terminalis approach assisted by endovascular temporary basilar artery occlusion for high-positioned, recurrent, basilar tip aneurysm: A technical case report.

BACKGROUND: Coil embolization is increasingly becoming the surgical intervention of choice for cerebral aneurysms, particularly for those in the posterior circulation. However, in cases where it is difficult to perform coil embolization, microsurgical clipping is still required. CASE DESCRIPTION: We present a case of a high-positioned, ruptured, recurrent basilar tip aneurysm treated with a combination of microsurgical clipping through the trans-lamina terminalis approach and endovascular procedure. The technical considerations of this approach are discussed. CONCLUSION: Microsurgical clipping through the trans-lamina terminalis approach combined with an endovascular technique can be effective for basilar tip aneurysms. This approach is particularly useful for high-positioned, small, anterior projective aneurysms and cases with dilation of the third ventricle due to hydrocephalus or clot.

Incidence and predictors of calcified cerebral emboli detected in patients who underwent endovascular procedures.

OBJECTIVES: There are very few reports on calcified cerebral emboli associated with endovascular procedures. We aimed to evaluate the incidence rates and predictors of calcified cerebral emboli in patients who underwent carotid artery stenting (CAS)/percutaneous transluminal angioplasty (PTA). PATIENTS AND METHODS: Patient demographics, clinical characteristics, and operative records of patients who underwent CAS/PTA were retrospectively analyzed. A total of 211 consecutive patients with cervical internal carotid stenosis were included in this study. Patients were categorized according to the presence of calcified cerebral emboli in postoperative computed tomography (CT) into emboli and non-emboli groups. We defined calcified emboli as a CT value of 60-400 Hounsfield units. RESULTS: On postoperative non-contrast CT, calcified emboli were detected in 5 of the 211 cases after CAS/PTA. The emboli were located in the middle cerebral artery (2/5), anterior cerebral artery (1/5), posterior cerebral artery (2/5). All of the cases of calcified cerebral emboli were clinically asymptomatic. The characteristics of patients showed no apparent difference in this study. Although the limited number may be attributed to a lack of statistical power, the average baseline activated clotting time (ACT) was lower in the emboli group than in the non-emboli group (117 vs 153, p < 0.05), and the operative time was longer in the emboli group than in the non-emboli group (147 vs 111, p < 0.05). CONCLUSION: Calcified cerebral emboli may be more common than previously known. Lower average baseline ACT and longer operative time could be predictors of calcified cerebral emboli after endovascular procedures. 　.

Clinical Features of Neurogenic Pulmonary Edema in Patients with Subarachnoid Hemorrhage.

OBJECTIVE: Neurogenic pulmonary edema (NPE) is a clinical syndrome characterized by acute onset after central nervous system injury. Here, we investigated the clinical features of NPE in patients with subarachnoid hemorrhage (SAH). METHODS: We retrospectively analyzed a total of 350 patients with SAH who were treated at our hospital from April 2014 to September 2017. Patient demographics, aneurysm size and location, clinical characteristics, and patient outcomes were reviewed and compared between an NPE and a non-NPE group. RESULTS: Sixteen patients (4.6%) presented with NPE at admission. Ten of these (62.5%) recovered from NPE immediately, and ventilatory support was withdrawn within 2 days from onset. A univariate analysis showed that patients with NPE were younger (P = 0.04), had a higher rate of vertebral artery dissection (P < 0.01), more severe World Federation of Neurosurgical Societies (WFNS) grades (P = 0.01), and lower systolic blood pressure on admission (P = 0.01). A multivariate analysis revealed significant differences in the frequency of vertebral artery dissection (odds ratio 4.83, 95% confidence interval 1.50-15.56, P < 0.01) and in WFNS grades (odds ratio 3.73, 95% confidence interval 1.02-13.66, P = 0.04) between the groups. No significant group differences were found in other factors including heart rate, radiographic sign (Fisher grade), aneurysm size and location, blood sample tests on admission, and neurologic outcomes. CONCLUSIONS: Vertebral artery dissection and severe WFNS grade on admission were confirmed as significant risk factors for NPE. However, neurologic outcomes at discharge did not differ between groups, suggesting that poor outcomes due to NPE could be reduced by appropriate diagnosis and treatment.

Predictors of subacute hematoma expansion requiring surgical evacuation after initial conservative treatment in patients with acute subdural hematoma.

BACKGROUND: The aim of this study was to clarify the factors associated with requiring subacute surgery in patients with acute subdural hematoma (ASDH) treated conservatively at admission. METHODS: Among the patients with ASDH admitted to our hospital from 2007 to 2018, we retrospectively reviewed data for 200 patients initially treated conservatively. We compared patients' characteristics, medical history, radiological findings, and clinical outcomes and differences between patients undergoing subacute surgery or no surgery. RESULTS: Of the 200 patients treated conservatively, 17 (8.5%) patients underwent subacute surgery due to deterioration of their clinical and/or computed tomography (CT) findings, while 183 (91.5%) patients did not undergo subacute surgery. There were significant differences in the presence of focal neurological deficits, modified Rankin Scale scores, degree of midline shift, hematoma thickness, hematoma volume, cella media index, Sylvian fissure ratio, and hematoma density between the two groups. CONCLUSIONS: Large hematoma, brain atrophy, and hematoma density may be useful predictors for the need for subacute surgery in patients with ASDH treated conservatively at admission. Intensive investigation of clinical findings or CT images is warranted in patients with adverse prognostic factors, even if their initial symptoms are mild.

The distance of cervical vertebral dislocation could be a risk factor for blunt vertebral artery injury after traumatic cervical spine injury.

BACKGROUND: Blunt vertebral artery injury (BVAI) is a well-known potentially fatal complication of cervical spine injury. The condition is reported to be associated with vertebral fractures and cervical hyperextension. However, appropriate patient screening methods remain to be elucidated. This study aimed to identify the risk factors associated with BVAI in patients with cervical spine injury. METHODS: We conducted a retrospective, observational, single-centered study, including 137 patients with cervical spine injury transferred to our center from April 2007 to December 2016. Evaluation for BVAI was available in 62 patients based on magnetic resonance angiography or multi-detector computed tomography angiography. BVAI was classified using the Biffl grade. RESULTS: Among the 62 patients evaluated, 13 (21%) were diagnosed with BVAI. All injuries were classified as Biffl grade 2 (50%) or 4 (50%). Univariate analysis of patients with and without BVAI showed that cervical dislocation (p = 0.041) and low average hemoglobin level (p = 0.032) were associated with BVAI. On multivariate logistic regression analysis, cervical dislocation (odds ratio 1.189; 95% confidence interval 1.011-1.399, p = 0.036) remained a significant predictor of BVAI. Based on receiver operating characteristic (ROC) analysis, a dislocation > 6.7 mm was selected as the optimal cutoff value for prediction of BVAI (sensitivity and specificity, 87.5% and 71.4%, respectively). CONCLUSIONS: BVAI frequently occurred in combination with cervical spine dislocation, and the distance of the cervical dislocation was identified as a useful predictor of BVAI.

Predictors of the Resolution of Cavernous Sinus Syndrome Caused by Large/Giant Cavernous Carotid Aneurysms After Parent Artery Occlusion with High-Flow Bypass.

OBJECTIVE: To evaluate the clinical results and factors related to the resolution of preoperative cranial neuropathy after internal carotid artery ligation with high-flow bypass in patients with symptomatic large or giant cavernous carotid aneurysms. METHODS: This study included 18 consecutive patients (15 women) with cranial neuropathy. All patients underwent therapeutic internal carotid artery ligation with high-flow bypass using a radial artery graft. Patient demographics, duration of symptoms, clinical outcomes, complications, and radiographic findings were retrospectively analyzed. The mean follow-up period was 31.0 months (range: 3-74 months). RESULTS: Patients' mean age was 66.6 years, and the mean aneurysm size was 23.7 mm. Six patients (33%) had partially thrombosed aneurysms. Preoperatively, 16 (89%) and 8 (44%) patients presented with ophthalmoplegia and facial pain, respectively. Bypass patency was confirmed in 15 patients (83%), and obliteration of the aneurysm was confirmed in all patients at the final follow-up. Preoperative ophthalmoplegia resolved in 10 patients (63%), and trigeminal pain resolved in all patients. Postoperative resolution of patients' ophthalmoplegia was significantly associated with age (P = 0.044), symptom duration before treatment (P = 0.042), and the degree of ophthalmoplegia (P = 0.046). The degree of postoperative residual ophthalmoplegia was positively correlated with the duration of ophthalmoplegia from onset to surgery (r = 0.619; P = 0.011). Preoperative trigeminal pain resolved regardless of the preoperative duration of this symptom in all patients. CONCLUSIONS: Early treatment is recommended when treating large or giant cavernous carotid aneurysms with cranial neuropathy. Complete resolution is possible in younger patients with partial neuropathy.

Resumption of Direct Oral Anticoagulants in Patients with Acute Spontaneous Intracerebral Hemorrhage.

BACKGROUND: Decisions regarding whether and when to resume direct oral anticoagulants (DOAC) after acute intracerebral hemorrhage (ICH) are challenging. We examined the timing of DOAC resumption and factors that influence decision-making in DOAC resumption. METHODS: We retrospectively analyzed 43 patients with ICH who were treated with DOAC for nonvalvular atrial fibrillation before ICH onset. All patients were divided into 2 groups (resumption of DOAC and no resumption of DOAC) during hospitalization. Clinical backgrounds, laboratory data, and stroke severity were compared between the groups. RESULTS: DOAC were resumed in 19 of 39 (49%) acute ICH survivors and were not resumed in 24 patients, including 4 deceased patients. The National Institutes of Health Stroke Scale score at admission tended to be higher in the no resumption group (median, 17) than in the resumption group (median, 6) (P = .119). The modified Rankin Scale score was slightly poorer in the no resumption group (median, 4) than in the resumption group (median, 3) (P = .070). In the resumption group, DOAC were resumed at a median of 11 days (interquartile range, 5-21 days) after ICH onset. The modified Rankin Scale score at discharge was positively correlated with the days of DOAC resumption (R2 = .31, P = .013). CONCLUSIONS: In half of patients, DOAC were resumed relatively early after ICH onset. Early resumption of DOAC for ICH in patients with nonvalvular atrial fibrillation is considered to be safe. The functional outcome was associated with not only resumption of DOAC but also the timing of resumption.

[Surgical Management of a Thromobotic Extracranial Carotid Artery Aneurysm:A Case Report].

Extracranial carotid artery aneurysms are relatively rare. We present a case involving a giant aneurysm arising from the extracranial carotid artery. The patient was a 79-year-old woman. She had a pulsating mass in the right side of her neck. However, she was neurologically intact. Contrast-enhanced CT scans of the neck showed an enhanced mass lesion with a thrombus in the right side of her neck. Angiography revealed a saccular aneurysm 3.4 cm in size near the bifurcation site of the right common carotid artery into the external carotid artery. She underwent an urgent resection of the aneurysm and a carotid artery reconstruction. Postoperatively, she recovered well and the total resection of the lesion was angiographically confirmed. Histopathological examination revealed that the wall of the aneurysm had undergone fibrosis and contained a few elastic fibers and microhemorrhages. The wall of the aneurysm was also infiltrated by inflammatory cells. The surgical strategy for and appropriate preoperative evaluation of this rare disease was discussed.