Acute large-vessel occlusion due to an infected thrombus formation induced by invasive sphenoid sinus aspergillosis: illustrative case.

BACKGROUND: The authors describe a rare case of acute large-vessel occlusion due to an infected thrombus formation that was induced by invasive sphenoid sinus aspergillosis. OBSERVATIONS: An 82-year-old man with a history of immunoglobulin G4-related disease and long-term use of steroids and immunosuppressants was admitted to the authors' hospital with severe right hemiparesis. Cerebral angiography revealed occlusion of the left internal carotid artery (ICA). He underwent thrombectomy, resulting in successful recanalization. However, severe stenosis was evident in the left ICA cavernous segment. Pathological analysis of the retrieved thrombus identified Aspergillus. Postoperative magnetic resonance imaging revealed sinusitis in the left sphenoid sinus as a possible source of the infection. The patient's general condition deteriorated during the course of hospitalization due to refractory aspiration pneumonia, and he died 46 days after thrombectomy. Pathological autopsy and histopathological investigation of the left ICA and the left sphenoid sinus showed that Aspergillus had invaded the wall of the left ICA from the adjacent sphenoid sinus. These findings indicate a diagnosis of acute large-vessel occlusion due to infected thrombus formation induced by invasive sphenoid sinus aspergillosis. LESSONS: Pathological analysis of a retrieved thrombus appears useful for identifying rare stroke etiologies such as fungal infection.

Successful carotid stenting of a carotid arterial dissection after straightening the tortuosity using an inflated balloon guiding catheter and the delivery wire of an anchored stent retriever.

The authors present a patient with carotid dissection in a tortuous arterial segment who successfully underwent carotid artery stenting (CAS) by straightening the tortuosity using an inflated balloon guiding catheter (BGC) and a stent retriever (SR). A 56-year-old man was transferred to our institute with right hemiparesis and a National Institutes of Health Stroke Scale score of 9. Magnetic resonance imaging showed left internal carotid artery (ICA) occlusion and ischemic change in the parietal lobe. Emergent angiography revealed tapered extracranial ICA occlusion sugg carotid artery dissection (CAD). CAS was attempted for CAD due to a mismatch of the motor area on clinical imaging. However, several attempts to navigate the stent delivery system over a guidewire failed. Therefore, we deployed a Trevo NXT ProVue SR (3 × 32 mm) in the middle cerebral artery, inflated a BGC, and then pulled on both to straighten the tortuous carotid artery, which resulted in successful navigation of the stent delivery system. The patient's symptoms improved after the recanalization. This case demonstrates the utility of a technique for navigation of a stent delivery system through a tortuous carotid artery in which the tortuosity is straightened by pulling on an inflated BGC and the delivery wire of the SR.

A case of intracerebral hemorrhage due to cerebral hyperperfusion after stenting for acute cervical carotid artery dissection.

Urgent carotid artery stenting (CAS) is effective for treatment-resistant cervical internal carotid artery dissection (CICAD). We experienced a 37-year-old woman who presented with sudden onset of cervical pain, blurred vision in the right eye, and numbness in the left upper and lower extremities. Due to neurological deterioration resulting from hemodynamic impairment, urgent CAS was performed under general anesthesia. Brain perfusion single-photon emission computed tomography performed immediately after CAS showed increased blood flow in the right hemisphere despite no evidence of hemorrhage or ischemic lesion on brain computed tomography (CT). Systolic blood pressure was therefore strictly controlled below 110 mm Hg perioperatively. However, the day after CAS, a follow-up CT showed intracerebral hemorrhage in the right temporal lobe. Urgent CAS in patients with progressive deterioration of hemodynamic impairment caused by CICAD may induce intracerebral hemorrhage due to cerebral hyperperfusion. Care should be taken to recognize and manage this phenomenon during the perioperative period.

Using a low-metal-density stent for thrombectomy-resistant vertebrobasilar occlusion due to thrombus migration from a thrombosed vertebral artery aneurysm: illustrative case.

BACKGROUND: Thrombosed intracranial aneurysms can lead to large vessel occlusion as a result of spontaneous thrombosis. Although mechanical thrombectomy is likely effective, recurrent thromboembolism can occur if the thrombotic source remains untreated. The authors describe a case of recurrent vertebrobasilar artery occlusion due to thrombus migration from a large thrombosed vertebral artery (VA) aneurysm that was successfully treated with mechanical thrombectomy followed by stenting. OBSERVATIONS: A 61-year-old male previously diagnosed with a large, thrombosed VA aneurysm presented with right hypoesthesia. Imaging on admission showed left VA occlusion and an acute ischemic lesion in the left medial medulla. His symptoms worsened, with complete right hemiparesis and tongue deviation occurring 3 hours after admission, and mechanical thrombectomy was performed to recanalize the left-dominant VA. Despite several attempts, reocclusion of the vertebrobasilar system occurred after each mechanical thrombectomy because of repeated thrombus formation in the thrombosed aneurysm. Therefore, a low-metal-density stent was deployed to prevent thrombus migration into the parent artery, which resulted in complete recanalization and rapid improvement of the symptoms. LESSONS: Stenting with a low-metal-density stent for recurrent embolism secondary to thrombus migration from a large thrombosed aneurysm was feasible in the acute stroke setting.

Ruptured Aneurysm at the Origin of an Anomalous Callosomarginal Artery Arising from the A1 Segment of the Anterior Cerebral Artery-A Case Report.

Aneurysms of the A1 segment of the anterior cerebral artery tend to develop in combination with various vascular anomalies of the A1 segment. Arterial branches that originate from the A1 segment and perfuse cortical regions are known to be rare. In this report, we describe a 48-year-old woman who presented with a ruptured aneurysm at the origin of an anomalous cortical artery arising from the A1 segment, for which microsurgical neck clipping was performed. Intraoperatively, the anomalous artery was seen to originate from the A1 segment, running into the interhemispheric fissure. An aneurysm was located at the bifurcation of the anomalous artery and the A1 segment. Postoperative angiography showed that the anomalous artery has branched into the fronto-orbital artery and the frontopolar artery and terminated as the anterior internal frontal arteries. We report a rare case of an aneurysm arising from an anomalous callosomarginal artery that arose from the A1 segment and perfused the cortical region. It is of significance to recognize that an aneurysm can develop at the origin of an anomalous artery that arises from the A1 segment.

The Effect of Goreisan on the Prevention of Chronic Subdural Hematoma Recurrence: Multi-Center Randomized Controlled Study.

The relatively high rate of post-operative recurrence in the treatment of chronic subdural hematoma (CSDH) is a significant problem. Goreisan is an herbal medicine that exhibits a hydragogue effect by inhibiting the expression of aquaporins, and its efficacy in preventing post-operative CSDH recurrence has been suggested by several case trials. This multi-center prospective randomized controlled trial was performed to investigate the preventative effect of goreisan on post-operative CSDH recurrence. Patients with symptomatic CSDH over 60 years old undergoing burr hole surgery were enrolled in this study. The patients were randomly allocated to the control group or the goreisan group, in which oral administration of goreisan (7.5 g daily) was continued for 12 weeks. The primary end-point was the post-operative recurrence rate at 12 weeks and the secondary end-point was hematoma volume reduction rates on computed tomography scan at 12 weeks. The analyses were performed not only on patients of all ages older than 60 years, but also on patients divided into those over or under 75 years old. One hundred and eighty patients were followed and analyzed (the control group, n = 88; the goreisan group, n = 92). The recurrence rates considering patients of all ages and patients under 75 years old were relatively low in the goreisan group but without a significant difference. The hematoma volume reduction rates showed no significant difference. Based on the results of the present study, a larger-scale study including more cases is necessary in future to confirm the efficacy of goreisan.

Clinical and angiographic long-term outcomes of vertebral artery-subclavian artery transposition to treat symptomatic stenosis of vertebral artery origin.

OBJECT: Although angioplasty and stent placement for vertebral artery (VA)-origin stenosis have been performed using endovascular techniques, a high likelihood of restenosis has been observed in the long term. Therefore, the authors assessed the long-term clinical and angiographic outcomes in patients after VA-subclavian artery (SA) transposition. METHODS: Thirty-six patients (31 men, 5 women; mean age 64.3 years, range 46-76 years) underwent clinical evaluation (modified Rankin Scale [mRS]) and cervical angiographic evaluation preoperatively and within 1 month of and 6 months after VA-SA transposition undertaken to treat symptomatic stenosis of VA origin. RESULTS: Postoperative neurological deficits due to intraoperative brain ischemia did not occur, and MR imaging demonstrated no new postoperative ischemic lesions in any of the patients. One patient died of acute myocardial infarction 2 months after surgery and another developed a left thalamic hemorrhage (mRS score of 5) at 42 months postsurgery. None of the remaining 34 patients experienced further ischemic events, and the mRS score in all of these patients remained unchanged during a mean follow-up period of 54 months. The degree of VA-origin stenosis (preoperative mean 84%) was reduced to < or = 30% after surgery (mean 2%). Long-term follow-up angiography in 29 patients (81%) revealed the absence of restenosis, defined as > 50% luminal narrowing, in all of them. CONCLUSIONS: The clinical and angiographic long-term outcomes demonstrated here suggest that VA-SA transposition will be useful in patients with symptomatic stenosis of VA origin.

Quantitative analysis of magnetic resonance imaging susceptibility artifacts caused by neurosurgical biomaterials: comparison of 0.5, 1.5, and 3.0 Tesla magnetic fields.

Magnetic resonance (MR) imaging is an important diagnostic tool for neurosurgical diseases but susceptibility artifacts caused by biomaterial instrumentation frequently causes difficulty in visualizing postoperative changes. The susceptibility artifacts caused by neurosurgical biomaterials were compared quantitatively by 0.5, 1.5, and 3.0 Tesla MR imaging. MR imaging of uniform size and shape of pieces ceramic (zirconia), pure titanium, titanium alloy, and cobalt-based alloy was performed at 0.5, 1.5, and 3.0 Tesla. A linear region of interest was defined across the center of the biomaterial in the transverse direction, and the susceptibility artifact diameter was calculated. Susceptibility artifacts developed around all biomaterials at all magnetic field strengths. The artifact diameters caused by pure titanium, titanium alloy, and cobalt-based alloy increased in the order of 0.5, 1.5, to 3.0 Tesla magnetic fields. The artifact diameter of ceramic was not influenced by magnetic field strength, and was the smallest of all biomaterials at all magnetic field strengths. The artifacts caused by biomaterials except ceramic increase with the magnetic field strength. Ceramic instrumentation will minimize artifacts in all magnetic fields.

Vascular reconstruction using interposition of saphenous vein graft for symptomatic stenosis at the extradural-intradural junction of the vertebral artery. Case report.

BACKGROUND: Symptomatic, medically refractory vertebrobasilar stenosis carries a poor prognosis and is an indication for vascular reconstruction. CASE PRESENTATION: A 67-year-old man suffered medically refractory recurrent vertigo due to artery-to-artery embolism caused by long, eccentric, and severe stenosis at the extradural-intradural junction of the right vertebral artery. Transluminal angioplasty was deferred because of the occurrence of critical brain ischemia during temporary balloon occlusion. After an occipital artery to posterior inferior cerebellar artery bypass, the vascular lesion in the right vertebral artery was resected and was reconstructed with interposition of a saphenous vein graft. The postoperative course was uneventful, and the patient did not experience further symptoms. Postoperative angiography revealed a widely patent right vertebral artery. CONCLUSION: This surgical procedure is useful for the vascular reconstruction of symptomatic stenosis at the extradural-intradural junction of the vertebral artery when transluminal angioplasty is contraindicated and when bypass surgery is not sufficient.

[A case of multiple cerebral infarction accompanied by a cor triatriatum].

A cor triatriatum is a congenital malformation of the heart which, in almost all cases, is diagnosed in childhood, whereas adult cases are very rare. The hemodynamics of the cor triatriatum is similar to that of mitral stenosis, which sometimes, but rarely, causes embolism. We present a case of multiple cerebral infarctions accompanied with a cor triatriatum. A 57-year-old female suddenly displayed impaired consciousness and hemiparesis immediately after cranioplasty for another disease, and was diagnosed by a diffusion weighted MRI as having multiple infarctions. A transesophageal echocardiography detected a membrane-like, echo-dense structure across the left atrium, suggesting a cor triatriatum. We suspect that her multiple infarctions were caused by embolism due to a cor triatriatum. Here, we discuss the relationship between her embolic stroke and the cor triatriatum, with references to literature on the subject.

Diffusion tensor imaging in patients with major cerebral artery occlusive disease.

Diffusion tensor (DT) imaging provides quantitative information about the magnitude and the directionality (anisotropy) of water diffusion in vivo and can detect pathologic changes in brain ischemia. This study tried to detect ischemic brain damage using DT imaging in patients with symptomatic chronic major cerebral artery occlusive disease. DT imaging was performed using a 3.0 Tesla magnetic resonance (MR) scanner in 50 patients with unilateral internal carotid artery or middle cerebral artery stenosis or occlusion, who had no obvious infarct lesions on conventional MR imaging. Thirty-three patients underwent DT imaging before and after vascular reconstruction surgery. Fractional anisotropy (FA) was calculated in the middle cerebral artery territory. Preoperative FA values in the ipsilateral side were significantly lower than those in the contralateral side. After surgery, the FA value was significantly increased. DT imaging may indicate ischemic brain damage, not visualized by conventional MR imaging, in patients with major cerebral artery occlusive disease.

Prediction and monitoring of cerebral hyperperfusion after carotid endarterectomy by using single-photon emission computerized tomography scanning.

OBJECT: The purpose of this study was to determine whether the preoperative measurement of acetazolamide-induced changes in cerebral blood flow (CBF), which is performed using single-photon emission computerized tomography (SPECT) scanning, can be used to identify patients at risk for hyperperfusion following carotid endarterectomy (CEA). In addition, the authors investigated whether monitoring of CBF with SPECT scanning after CEA can be used to identify patients at risk for hyperperfusion syndrome. METHODS: Cerebral blood flow and cerebrovascular reactivity (CVR) to acetazolamide were measured before CEA in 51 patients with ipsilateral internal carotid artery stenosis (> or = 70% stenosis). Cerebral blood flow was also measured immediately after CEA and on the 3rd postoperative day. Hyperperfusion (an increase in CBF of > or = 100% compared with preoperative values) was observed immediately after CEA in eight of 12 patients with reduced preoperative CVR. Reduced preoperative CVR was the only significant independent predictor of post-CEA hyperperfusion. Forty-three patients in whom hyperperfusion was not detected immediately after CEA did not exhibit hyperperfusion on the 3rd postoperative day and did not experience hyperperfusion syndrome. In two of eight patients in whom hyperperfusion occurred immediately after CEA, CBF progressively increased and hyperperfusion syndrome developed, but intracerebral hemorrhage did not occur. In the remaining six of eight patients in whom hyperperfusion was detected immediately after CEA, the CBF progressively decreased and the hyperperfusion resolved by the 3rd postoperative day. CONCLUSIONS: Preoperative measurement of acetazolamide-induced changes in CBF, which is performed using SPECT scanning, can be used to identify patients at risk for hyperperfusion after CEA. In addition, post-CEA monitoring of CBF performed using SPECT scanning results in the timely and reliable identification of patients at risk for hyperperfusion syndrome.

Transcranial regional cerebral oxygen saturation monitoring during carotid endarterectomy as a predictor of postoperative hyperperfusion.

OBJECTIVE: Hyperperfusion syndrome is a rare but potentially devastating complication that can occur after carotid endarterectomy (CEA). The purpose of this study was to determine whether intraoperative transcranial regional cerebral oxygen saturation (rSO(2)) monitoring via near-infrared spectroscopy could be reliably used to identify patients at risk for post-CEA hyperperfusion. METHODS: rSO(2) was intraoperatively monitored for 50 patients undergoing CEA for treatment of ipsilateral internal carotid artery stenosis (>/=70%). Cerebral blood flow (CBF) was also assessed, with single-photon emission computed tomography, before and immediately after CEA. RESULTS: Post-CEA hyperperfusion (CBF increase of >/=100%, compared with preoperative values) was observed for six patients. A significant linear correlation was observed between the rSO(2) increases immediately after declamping of the internal carotid artery and the CBF increases immediately after CEA (r(2) = 0.247, P = 0.0002). The sensitivity and specificity of the rSO(2) increases for detection of post-CEA hyperperfusion were 100 and 86.4%, respectively, with a cutoff point of 5%. A strong linear correlation was observed between the rSO(2) increases at the end of the procedure and the CBF increases immediately after CEA (r(2) = 0.822, P < 0.0001). Both the sensitivity and the specificity of the rSO(2) increases for detection of post-CEA hyperperfusion were 100% with a cutoff point of 10%. Hyperperfusion syndrome developed for one patient with post-CEA hyperperfusion, but intracerebral hemorrhage did not occur. CONCLUSION: Intraoperative rSO(2) monitoring can reliably identify patients at risk for hyperperfusion after CEA.

Very early and standard Tc-99m ethyl cysteinate dimer SPECT imaging in a patient with reperfusion hyperemia after acute cerebral embolism.

It has been reported that Tc-99m ethyl cysteinate dimer (ECD) SPECT imaging may not show reperfusion hyperemia in patients with subacute stroke. The authors describe a patient with embolic middle cerebral artery occlusion who was examined using xenon-133 and dynamic and standard Tc-99m ECD SPECT immediately after early recanalization. Standard Tc-99m ECD SPECT images revealed hypoactivity in the ipsilateral middle cerebral artery territory. In contrast, the dynamic Tc-99m ECD SPECT images from the first scan (very early images acquired 36 seconds after injection) showed hyperactivity in the same region and provided imaging contrast comparable to what would be obtained with xenon-133 tomography. Hemorrhagic transformation later developed in this region. These results indicate that images from very early dynamic Tc-99m ECD SPECT of areas with irreversible changes produced by acute stroke can reveal reflow hyperemia that standard Tc-99m ECD SPECT images fail to show.

Quantification of susceptibility artifacts produced on high-field magnetic resonance images by various biomaterials used for neurosurgical implants. Technical note.

Although various biomaterials such as ceramics or titanium alloy are widely used in neurosurgery, the susceptibility artifacts that appear around these materials cause problems when a magnetic resonance (MR) imager is used to assess lesions after surgery. The purpose of the present study was to quantify the susceptibility artifacts produced by various biomaterials used for neurosurgical implants. Using a 3-tesla MR imaging unit, we obtained MR images of various biomaterials, including six types of ceramics, a cobalt-based alloy (Elgiloy), pure titanium, a titanium alloy, and stainless steel. All implants shared a uniform size and shape. In each image, a linear region of interest was defined across the center of the biomaterial in the transverse direction, and the diameter of the susceptibility artifact was calculated. The ceramics produced a considerably smaller artifact diameter than those produced by other biomaterials. Among the types of ceramics, zirconia was found to produce the smallest artifact diameter. Among the remaining biomaterials, the diameters of the artifacts decreased in order from that associated with stainless steel to those associated with cobalt-based alloys, pure titanium, and titanium alloy. Little difference was observed between the artifact diameters associated with pure titanium and titanium alloy. Ceramics are the most suitable biomaterials for minimizing artifacts in high-field MR imaging.

Combining time-resolved and single-phase 3D techniques in contrast-enhanced carotid MR angiography.

We established an easy-to-use technique for performing contrast-enhanced carotid MR angiography (MRA) with a commercial scanner. Twenty-three patients with suspected carotid or vertebral arterial lesions were prospectively studied. Two techniques were applied in the study. After performing sagittal time-resolved acquisitions, we undertook a coronal single-phase 3D acquisition, in which the injection timing was estimated from the preceding images. In each case, we obtained multidirectional images with sufficient venous suppression. The combined use of time-resolved and single-phase 3D MRA is a feasible technique for obtaining selective arterial images without the use of special applications or hardware.