Cerebral Venous Sinus Thrombosis Associated With Subclinical Hypothyroidism: A Case Report and Literature Review.

Thyroid dysfunction is a well-known cause of cerebral venous sinus thrombosis (CVST), but most reports have focused on CVST associated with hyperthyroidism, with only a few mentioning CVST associated with hypothyroidism. Subclinical hypothyroidism, characterized by thyroid hormone levels within reference values but elevated thyroid-stimulating hormone, can also cause CVST. Here, we present a case of CVST associated with subclinical hypothyroidism. A 48-year-old man with headache, nausea, and left-sided motor weakness was admitted to our hospital, with a history of economy-class syndrome. Magnetic resonance imaging revealed occlusion of the superior sagittal sinus, right transverse sinus, and right sigmoid sinus. Digital subtraction angiography (DSA) confirmed CVST from the right common carotid artery, revealing abnormal staining of the thyroid gland. The patient was serologically in a state of subclinical hypothyroidism. Consequently, the patient was diagnosed with CVST associated with subclinical hypothyroidism. Anticoagulation therapy was initiated shortly after admission. CVST gradually resolved, and the affected sinuses were recanalized. Paraplegia improved, and the patient was discharged home 19 days after admission with a modified Rankin scale of 1. Subclinical hypothyroidism can induce CVST, underscoring the importance of screening for thyroid function in CVST patients, even without apparent thyroid dysfunction symptoms. DSA findings are valuable for diagnosing thyroid disease.

Traumatic middle meningeal arteriovenous fistula presenting with long delayed-onset facial nerve palsy without temporal bone fracture: illustrative case.

BACKGROUND: Traumatic facial nerve palsy (FNP) without temporal bone fracture (TBF) has a delayed onset in some cases; however, long delayed-onset FNP in this setting has not been reported. The middle meningeal vein (MMV) is one of the venous drainage routes from the facial nerve. Herein, the authors describe a rare case of traumatic middle meningeal arteriovenous fistula (MMAVF) presenting with the long delayed-onset FNP without TBF. OBSERVATIONS: A 42-year-old man with pulsatile tinnitus and left FNP was admitted to our hospital 4 weeks after head trauma without TBF. Cerebral angiography revealed an MMAVF between the middle meningeal artery and the MMV on the left side. Seven days after admission, the FNP showed slight improvement, and preoperative angiography revealed decreased shunt flow of the MMAVF. Transarterial coil embolization was successfully performed. Postoperative angiography showed no residual fistula. Two weeks after the procedure, there was complete resolution of the FNP. This clinical course was correlated with the angiographic findings, suggesting that the long delayed-onset FNP was caused by the traumatic MMAVF without TBF. LESSONS: In patients presenting with long delayed-onset FNP after head trauma without TBF, the vascular lesion must be evaluated to exclude MMAVF.

PON1 Q192R is associated with high platelet reactivity with clopidogrel in patients undergoing elective neurointervention: A prospective single-center cohort study.

BACKGROUND AND PURPOSE: The impact of the paraoxonase-1 (PON1) polymorphism, Q192R, on platelet inhibition in response to clopidogrel remains controversial. We aimed to investigate the association between carrier status of PON1 Q192R and high platelet reactivity (HPR) with clopidogrel in patients undergoing elective neurointervention. METHODS: Post-clopidogrel platelet reactivity was measured using a VerifyNow® P2Y12 assay in P2Y12 reaction units (PRU) for consecutive patients before the treatment. Genotype testing was performed for PON1 Q192R and CYP2C19*2 and *3 (no function alleles), and *17. PRU was corrected on the basis of hematocrit. We investigated associations between factors including carrying ≥1 PON1 192R allele and HPR defined as original and corrected PRU ≥208. RESULTS: Of 475 patients (232 men, median age, 68 years), HPR by original and corrected PRU was observed in 259 and 199 patients (54.5% and 41.9%), respectively. Carriers of ≥1 PON1 192R allele more frequently had HPR by original and corrected PRU compared with non-carriers (91.5% vs 85.2%, P = 0.031 and 92.5% vs 85.9%, P = 0.026, respectively). In multivariate analyses, carrying ≥1 PON1 192R allele was associated with HPR by original (odds ratio [OR] 1.96, 95% confidence interval [CI] 1.03-3.76) and corrected PRU (OR 2.34, 95% CI 1.21-4.74) after adjustment for age, sex, treatment with antihypertensive medications, hematocrit, platelet count, total cholesterol, and carrying ≥1 CYP2C19 no function allele. CONCLUSIONS: Carrying ≥1 PON1 192R allele is associated with HPR by original and corrected PRU with clopidogrel in patients undergoing elective neurointervention, although alternative results related to other genetic polymorphisms cannot be excluded.

Clopidogrel response predicts thromboembolic events associated with coil embolization of unruptured intracranial aneurysms: A prospective cohort study.

OBJECTIVE: Periprocedural thromboembolic events are a serious complication associated with coil embolization of unruptured intracranial aneurysms. However, no established clinical rule for predicting thromboembolic events exists. This study aimed to clarify the significance of adding preoperative clopidogrel response value to clinical factors when predicting the occurrence of thromboembolic events during/after coil embolization and to develop a nomogram for thromboembolic event prediction. METHODS: In this prospective, single-center, cohort study, we included 345 patients undergoing elective coil embolization for unruptured intracranial aneurysm. Thromboembolic event was defined as the occurrence of intra-procedural thrombus formation and postprocedural symptomatic cerebral infarction within 7 days. We evaluated preoperative clopidogrel response and patients' clinical information. We developed a patient-clinical-information model for thromboembolic event using multivariate analysis and compared its efficiency with that of patient-clinical-information plus preoperative clopidogrel response model. The predictive performances of the two models were assessed using area under the receiver-operating characteristic curve (AUC-ROC) with bootstrap method and compared using net reclassification improvement (NRI) and integrated discrimination improvement (IDI). RESULTS: Twenty-eight patients experienced thromboembolic events. The clinical model included age, aneurysm location, aneurysm dome and neck size, and treatment technique. AUC-ROC for the clinical model improved from 0.707 to 0.779 after adding the clopidogrel response value. Significant intergroup differences were noted in NRI (0.617, 95% CI: 0.247-0.987, p < .001) and IDI (0.068, 95% CI: 0.021-0.116, p = .005). CONCLUSIONS: Evaluation of preoperative clopidogrel response in addition to clinical variables improves the prediction accuracy of thromboembolic event occurrence during/after coil embolization of unruptured intracranial aneurysm.

Deep Learning-Derived High-Level Neuroimaging Features Predict Clinical Outcomes for Large Vessel Occlusion.

Background and Purpose- For patients with large vessel occlusion, neuroimaging biomarkers that evaluate the changes in brain tissue are important for determining the indications for mechanical thrombectomy. In this study, we applied deep learning to derive imaging features from pretreatment diffusion-weighted image data and evaluated the ability of these features in predicting clinical outcomes for patients with large vessel occlusion. Methods- This multicenter retrospective study included patients with anterior circulation large vessel occlusion treated with mechanical thrombectomy between 2013 and 2018. We designed a 2-output deep learning model based on convolutional neural networks (the convolutional neural network model). This model employed encoder-decoder architecture for the ischemic lesion segmentation, which automatically extracted high-level feature maps in its middle layers, and used its information to predict the clinical outcome. Its performance was internally validated with 5-fold cross-validation, externally validated, and the results compared with those from the standard neuroimaging biomarkers Alberta Stroke Program Early CT Score and ischemic core volume. The prediction target was a good clinical outcome, defined as a modified Rankin Scale score at 90-day follow-up of 0 to 2. Results- The derivation cohort included 250 patients, and the validation cohort included 74 patients. The convolutional neural network model showed the highest area under the receiver operating characteristic curve: 0.81±0.06 compared with 0.63±0.05 and 0.64±0.05 for the Alberta Stroke Program Early CT Score and ischemic core volume models, respectively. In the external validation, the area under the curve for the convolutional neural network model was significantly superior to those for the other 2 models. Conclusions- Compared with the standard neuroimaging biomarkers, our deep learning model derived a greater amount of prognostic information from pretreatment neuroimaging data. Although a confirmatory prospective evaluation is needed, the high-level imaging features derived by deep learning may offer an effective prognostic imaging biomarker.

Cerebral Venous Thrombosis after Red Blood Cell Transfusion for the Treatment of Iron Deficiency Anemia.

A 57-year-old male presented with generalized seizure who received red blood cell (RBC) transfusion for the treatment of iron deficiency anemia (IDA). Neuroradiological findings revealed cerebral venous thrombosis (CVT) on the left frontal vein. He received anticoagulants, anticonvulsants, and iron supplements. He discharged without any neurological deficit. It should be noted that RBC transfusion might increase the risk of CVT in patients with IDA.

Predicting Clinical Outcomes of Large Vessel Occlusion Before Mechanical Thrombectomy Using Machine Learning.

Background and Purpose- The clinical course of acute ischemic stroke with large vessel occlusion (LVO) is a multifactorial process with various prognostic factors. We aimed to model this process with machine learning and predict the long-term clinical outcome of LVO before endovascular treatment and to compare our method with previously developed pretreatment scoring methods. Methods- The derivation cohort included 387 LVO patients, and the external validation cohort included 115 LVO patients with anterior circulation who were treated with mechanical thrombectomy. The statistical model with logistic regression without regularization and machine learning algorithms, such as regularized logistic regression, linear support vector machine, and random forest, were used to predict good clinical outcome (modified Rankin Scale score of 0-2 at 90 days) with standard and multiple pretreatment clinical variables. Five previously reported pretreatment scoring methods (the Pittsburgh Response to Endovascular Therapy score, the Stroke Prognostication Using Age and National Institutes of Health Stroke Scale index, the Totaled Health Risks in Vascular Events score, the Houston Intra-Arterial Therapy score, and the Houston Intra-Arterial Therapy 2 score) were compared with these models for the area under the receiver operating characteristic curve. Results- The area under the receiver operating characteristic curve of random forest, which was the worst among the machine learning algorithms, was significantly higher than those of the standard statistical model and the best model among the previously reported pretreatment scoring methods in the derivation (the area under the receiver operating characteristic curve were 0.85±0.07 for random forest, 0.78±0.08 for logistic regression without regularization, and 0.77±0.09 for Stroke Prognostication using Age and National Institutes of Health Stroke Scale) and validation cohorts (the area under the receiver operating characteristic curve were 0.87±0.01 for random forest, 0.56±0.07 for logistic regression without regularization, and 0.83±0.00 for Pittsburgh Response to Endovascular Therapy). Conclusions- Machine learning methods with multiple pretreatment clinical variables can predict clinical outcomes of patients with anterior circulation LVO who undergo mechanical thrombectomy more accurately than previously developed pretreatment scoring methods.

Factors Associated with Postprocedural Diffusion-Weighted Imaging-Positive Lesions in Endovascular Treatment for Unruptured Cerebral Aneurysms.

BACKGROUND: In endovascular treatment for cerebral aneurysms, the appearance of asymptomatic thromboembolic lesions detected by postprocedural diffusion-weighted imaging (DWI) can be a surrogate marker for estimating the potential risk of symptomatic thromboembolism. The aim of this study was to clarify factors associated with postprocedural DWI-positive lesions in endovascular treatment for unruptured cerebral aneurysms. METHODS: Patients with untreated unruptured cerebral aneurysms undergoing endovascular treatment were consecutively enrolled. Treatment techniques were classified into simple coiling, balloon-assisted coiling, stent-assisted coiling, and flow-diverter placement. Head magnetic resonance imaging was performed within 3 months before and 24 hours after the procedure to assess the appearance of DWI-positive lesions. RESULTS: Among 376 aneurysms in 355 patients that were analyzed, 232 (61.7%) had postprocedural DWI-positive lesions. In univariate analyses, age (P = 0.001), dome size (P < 0.001), neck size (P < 0.001), treatment technique (P = 0.029), and total procedural time (P < 0.001) were significantly associated with postprocedural DWI-positive lesions. In the multiple logistic regression model, older age (odds ratio, 1.33; 95% confidence interval, 1.10-1.60; P = 0.003; per decade), flow-diverter placement (odds ratio, 4.93; 95% confidence interval, 1.33-20.92; P = 0.016; compared with simple coiling), and longer procedural time (odds ratio, 1.66; 95% confidence interval, 1.26-2.21; P < 0.001; per hour) were associated with postprocedural DWI-positive lesions. CONCLUSIONS: Older age, flow-diverter placement, and longer procedural time were associated with postprocedural DWI-positive lesions in endovascular treatment for unruptured cerebral aneurysms.

Different learning curves between stent retrieval and a direct aspiration first-pass technique for acute ischemic stroke.

OBJECTIVEThe clinical outcomes of a direct aspiration first-pass technique (ADAPT) and stent retriever (SR) have been reported to be similar in several observational studies. In this study, procedural and clinical outcomes with ADAPT and SR for the treatment of acute ischemic stroke with large artery occlusion were compared in different time periods.METHODSIn each specific time period, SR and ADAPT were used as the first-line treatment approach for acute ischemic stroke patients with large artery occlusion at the authors' institution. Baseline characteristics, procedural variables, and functional outcome at 90 days were compared between patients treated with SR and those treated with ADAPT. These 2 groups were divided into 3 sequential subgroups to assess the learning curve effects of the endovascular team and individual operators on the procedural variables of each treatment strategy.RESULTSOverall, 89 patients were treated. In the SR group, the recanalization rate was higher (84% vs 65%; p = 0.01) and the procedure time was shorter than in the ADAPT group (median 42 minutes vs 76 minutes, p = 0.04). On the subgroup analysis of the learning curve, the SR group showed more rapid improvement in procedure time than the ADAPT group (p = 0.01 for the team; p < 0.01 for individual operators).CONCLUSIONSIn this initial experience, a higher recanalization rate and shorter procedure time were achieved with SR than with ADAPT. A high recanalization rate with SR was possible with relatively less clinical experience, whereas procedure time dramatically decreased with experience. These observed effects on the learning curve might be useful when choosing the method for initial endovascular treatment of acute ischemic stroke at relatively small stroke centers.

Effect of intrathecal milrinone injection via lumbar catheter on delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage.

OBJECTIVE Delayed cerebral ischemia (DCI) is an important complication after aneurysmal subarachnoid hemorrhage (aSAH). Although intrathecal milrinone injection via lumbar catheter to prevent DCI has been previously reported to be safe and feasible, its effectiveness remains unknown. The goal of this study was to evaluate whether intrathecal milrinone injection treatment after aSAH significantly reduced the incidence of DCI. METHODS The prospectively maintained aSAH database was used to identify patients treated between January 2010 and December 2015. The cohort included 274 patients, with group assignment based on treatment with intrathecal milrinone injection or not. A propensity score model was generated for each patient group, incorporating relevant patient variables. RESULTS After propensity score matching, 99 patients treated with intrathecal milrinone injection and 99 without treatment were matched on the basis of similarities in their demographic and clinical characteristics. There were significantly fewer DCI events (4% vs 14%, p = 0.024) in patients treated with intrathecal milrinone injection compared with those treated without it. However, there were no significant differences between the 2 groups with respect to their 90-day functional outcomes (46% vs 36%, p = 0.31). The likelihood of chronic secondary hydrocephalus, meningitis, and congestive heart failure as complications of intrathecal milrinone injection therapy was also similar between the groups. CONCLUSIONS In propensity score-matched groups, the intrathecal administration of milrinone via lumbar catheter showed significant reduction of DCI following aSAH, without an associated increase in complications.

Improving treatment times for patients with in-hospital stroke using a standardized protocol.

BACKGROUND: Previous reports have shown significant delays in treatment of in-hospital stroke (IHS). We developed and implemented our IHS alert protocol in April 2014. We aimed to determine the influence of implementation of our IHS alert protocol. METHODS: Our implementation processes comprise the following four main steps: IHS protocol development, workshops for hospital staff to learn about the protocol, preparation of standardized IHS treatment kits, and obtaining feedback in a monthly hospital staff conference. We retrospectively compared protocol metrics and clinical outcomes of patients with IHS treated with intravenous thrombolysis and/or endovascular therapy between before (January 2008-March 2014) and after implementation (April 2014-December 2016). RESULTS: Fifty-five patients were included (pre, 25; post, 30). After the implementation, significant reductions occurred in the median time from stroke recognition to evaluation by a neurologist (30 vs. 13.5min, p<0.01) and to first neuroimaging (50 vs. 26.5min, p<0.01) and in the median time from first neuroimaging to intravenous thrombolysis (45 vs. 16min, p=0.02). The median time from first neuroimaging to endovascular therapy had a tendency to decrease (75 vs. 53min, p=0.08). There were no differences in the favorable outcomes (modified Rankin scale score of 0-2) at discharge or the incidence of symptomatic intracranial hemorrhage between the two periods. CONCLUSION: Our IHS alert protocol implementation saved time in treating patients with IHS without compromising safety.

Short-Term Results of Carotid Endarterectomy and Stenting After the Introduction of Carotid Magnetic Resonance Imaging: A Single-Institution Retrospective Study.

OBJECTIVE: Although carotid artery stenting (CAS) has been gaining popularity as an alternative to carotid endarterectomy (CEA), perioperative stroke rate following contemporary CAS remains significantly higher than stroke rate after CEA. The purpose of this study was to assess perioperative (within 30 days) therapeutic results in patients with carotid stenosis (CS) after introduction of preoperative carotid magnetic resonance imaging plaque evaluation in a single center performing both CEA and CAS. METHODS: Based on prospectively collected data for patients with CS who were scheduled for carotid revascularization, retrospective analysis was conducted of 295 consecutive patients with CS. An intervention was selected after consideration of periprocedural risks for both CEA and CAS. Concerning risk factors for CAS, results of magnetic resonance imaging plaque evaluation were emphasized with a view toward reducing embolic complications. RESULTS: CAS was performed in 114 patients, and CEA was performed in 181 patients. Comparing baseline characteristics of the 295 patients, age, T1 signal intensity of plaque, symptomatic CS, urgent intervention, and diabetes mellitus differed significantly between CAS and CEA groups. Among patients who underwent CAS, new hyperintense lesions on diffusion-weighted imaging were confirmed in 47 patients. New hyperintense lesions on diffusion-weighted imaging were recognized in 21.4% of patients who underwent CEA (n = 39), significantly less frequent than in patients who underwent CAS. CONCLUSIONS: The overall short-term outcome of CEA and CAS is acceptable. Preoperative carotid magnetic resonance imaging evaluation of plaque might contribute to low rates of ischemic complications in CAS.

Healthcare resource utilization and clinical outcomes associated with acute care and inpatient rehabilitation of stroke patients in Japan.

OBJECTIVE: To investigate healthcare resource utilization and changes in functional status in stroke patients during hospitalization in an acute hospital and a rehabilitation hospital. DESIGN: Retrospective cohort study. SETTING: One acute and one rehabilitation hospital in Japan. PARTICIPANTS: Patients who were admitted to the acute hospital due to stroke onset and then transferred to the rehabilitation hospital (n = 263, 56% male, age 70 ± 12 years). MAIN OUTCOME MEASURES: Hospitalization costs and functional independence measure (FIM) were evaluated according to stroke subtype and severity of disability at discharge from the acute hospital. RESULTS: Median (IQR) costs at the acute hospital were dependent on the length of stay (LOS) and implementation of neurosurgery, which resulted in higher costs in subarachnoid hemorrhage [$52 413 ($49 166-$72 606) vs $14 129 ($11 169-$19 459) in cerebral infarction; and vs $15 035 ($10 920-$21 864) in intracerebral hemorrhage]. The costs at the rehabilitation hospital were dependent on LOS, and higher in patients with moderate disability than in those with mild disability [$30 026 ($18 419-$39 911) vs $18 052 ($10 631-$24 384)], while those with severe disability spent $25 476 ($13 340-$43 032). Patients with moderate disability gained the most benefits during hospitalization in the rehabilitation hospital, with a median (IQR) total FIM gain of 16 (5-24) points, compared with a modest improvement in patients with mild (6, 2-14) or severe disability (0, 0-5). CONCLUSIONS: The costs for in-hospital stroke care were substantial and the improvement in functional status varied by severity of disability. Our findings would be valuable to organize efficient post-acute stroke care.

Carotid artery plaque assessment using quantitative expansive remodeling evaluation and MRI plaque signal intensity.

OBJECTIVE: Plaque characteristics and morphology are important indicators of plaque vulnerability. MRI-detected intraplaque hemorrhage has a great effect on plaque vulnerability. Expansive remodeling, which has been considered compensatory enlargement of the arterial wall in the progression of atherosclerosis, is one of the criteria of vulnerable plaque in the coronary circulation. The purpose of this study was risk stratification of carotid artery plaque through the evaluation of quantitative expansive remodeling and MRI plaque signal intensity. METHODS: Both preoperative carotid artery T1-weighted axial and long-axis MR images of 70 patients who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) were studied. The expansive remodeling ratio (ERR) was calculated from the ratio of the linear diameter of the artery at the thickest segment of the plaque to the diameter of the artery on the long-axis image. Relative plaque signal intensity (rSI) was also calculated from the axial image, and the patients were grouped as follows: Group A = rSI ≥ 1.40 and ERR ≥ 1.66; Group B = rSI< 1.40 and ERR ≥ 1.66; Group C = rSI ≥ 1.40 and ERR < 1.66; and Group D = rSI < 1.40 and ERR < 1.66. Ischemic events within 6 months were retrospectively evaluated in each group. RESULTS: Of the 70 patients, 17 (74%) in Group A, 6 (43%) in Group B, 7 (44%) in Group C, and 6 (35%) in Group D had ischemic events. Ischemic events were significantly more common in Group A than in Group D (p = 0.01). CONCLUSIONS: In the present series of patients with carotid artery stenosis scheduled for CEA or CAS, patients with plaque with a high degree of expansion of the vessel and T1 high signal intensity were at higher risk of ischemic events. The combined assessment of plaque characterization with MRI and morphological evaluation using ERR might be useful in risk stratification for carotid lesions, which should be validated by a prospective, randomized study of asymptomatic patients.

Platelet reactivity and hemorrhage risk in neurointerventional procedures under dual antiplatelet therapy.

BACKGROUND AND PURPOSE: Hemorrhagic complications during neurointerventional procedures have various etiologies and can result in severe morbidity and mortality. This study investigated the possible association between low platelet reactivity measured by the VerifyNow assay and increased hemorrhagic complications during elective neurointervention under dual antiplatelet therapy. METHODS: From May 2010 to April 2013 we recorded baseline characteristics, P2Y12 reaction units (PRU), and aspirin reaction units using VerifyNow. The primary endpoint was post-procedural hemorrhagic complications. RESULTS: A total of 279 patients were enrolled and 31 major hemorrhagic complications (11.1%) were identified. From receiver-operating characteristic curve analysis, PRU values could discriminate between patients with and without major hemorrhagic complications (area under the curve 0.63). Aspirin reaction unit values had no association with the primary outcome. The optimal cut-off for the primary outcome (PRU ≤175) was used to identify the low platelet reactivity group. The incidence of hemorrhagic complications was 20.0% in this group and 8.9% in the non-low platelet reactivity group. Multivariate analysis identified low platelet reactivity as an independent predictor for hemorrhagic complications. CONCLUSIONS: The risk of hemorrhagic complications during elective neurointervention including cerebral aneurysm coil embolization and carotid artery stenting under dual antiplatelet therapy is associated with the response to clopidogrel but not to aspirin. A PRU value of ≤175 discriminates between patients with and without hemorrhagic complications. Future prospective studies are required to validate whether a specific PRU value around 170-180 is predictive of hemorrhagic complications.

Reduced cerebrovascular reserve is associated with an increased risk of postoperative ischemic lesions during carotid artery stenting.

BACKGROUND: Reduced cerebrovascular reserve (CVR) is associated with increased risk of ischemic events in carotid steno-occlusive diseases. OBJECTIVE: To determine whether pretreatment CVR can predict postoperative ischemic lesions after carotid artery stenting (CAS) by retrospective analysis. METHODS: We retrospectively reviewed the medical records of 46 patients (42 men; mean age 74.2±8.3 years) who underwent CAS and preprocedural cerebral blood flow measurement by quantitative single-photon emission CT. Ischemic lesions were evaluated by diffusion-weighted image (DWI) within 72 h after the intervention. We also evaluated plaque characteristics using black-blood MR plaque imaging. RESULTS: New ipsilateral DWI-positive lesions were found in 11 cases (23.9%). Patients were classified into two groups based on the presence or absence of new DWI-positive lesions, and no significant differences in characteristics were found between the DWI-positive and DWI-negative groups, except for age and CVR of the ipsilateral middle cerebral artery (MCA) territory. The DWI-positive group was significantly older than the DWI-negative group (79.7±4.1 vs 72.5±8.6 years; p=0.0085) and had lower average regional CVR (1.4±18.2% vs 22.4±25.8%; p=0.016). MR plaque imaging showed no significant difference in relative overall plaque MR signal intensity between the two groups (1.53±0.37 vs 1.34±0.26; p=0.113). In multivariate logistic regression analysis, lower CVR of the ipsilateral MCA territory (<11%) was the only independent risk factor for new ischemic lesions following CAS (OR=6.99; 95% CI 1.17 to 41.80; p=0.033). CONCLUSIONS: Impaired pretreatment CVR was associated with increased incidence of new infarction after CAS.

Milrinone via lumbar subarachnoid catheter for vasospasm after aneurysmal subarachnoid hemorrhage.

INTRODUCTION: Delayed ischemic neurological deficit (DIND) due to symptomatic vasospasm is a major cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). The aim of this study was to elucidate the safety and feasibility of intrathecal milrinone infusion via lumber subarachnoid catheter for prevention of DIND after aSAH. METHODS: We diagnosed 425 consecutive patients with aSAH who received clipping or coil embolization within 48 h after arrival. Patients with the evidence of vasospasm on CT angiography (CTA) received the milrinone therapy via lumbar subarachnoid catheter. DIND, delayed cerebral infarction (DCI), and modified Rankin scale at 3 months after SAH were used for the assessment of outcome. RESULTS: Of 425 patients, 170 patients (40.0 %) with CTA-proven vasospasm received the milrinone therapy. DIND was observed in 68 patients (16.0 %), DCI in 30 patients (7.1 %), and the overall mortality was 7.2 %. In patients with WFNS grade IV and V aSAH, 26 out of 145 patients (17.9 %) were presented with DIND, 12 (8.3 %) with DCI, and the mortality was 16.0 %. No major complication related to the milrinone injection was observed. CONCLUSION: Intrathecal milrinone injection via lumbar catheter was safe and feasible, and further randomized prospective studies are needed to confirm the effectiveness of this regimen in the patients with SAH.

Is aneurysm repair justified for the patients aged 80 or older after aneurysmal subarachnoid hemorrhage?

BACKGROUND: With the advancement of an aging society in the world, an increasing number of elderly patients have been hospitalized due to aneurysmal subarachnoid hemorrhage (aSAH). There is no study that compares the elderly cases of aSAH who receive the definitive treatment with those who treated conservatively. The aim of this study was to investigate the feasibility of the definitive surgery for the acute subarachnoid cases aged 80 or older. METHODS: We reviewed 500 consecutive cases with acute aSAH with surgical indication for aneurysm repair. Inoperable cases such as dead-on-arrival and the cases with both pupils dilated were excluded. We compared the cases aged 80 or older that received clipping or coil embolization with the controls that the family selected conservative treatment. RESULTS: 69 cases were included in this study (ranged 80-98, male:female=9:60). 56 cases (81.2%) had an aneurysm in the anterior circulation. 23 cases received clipping, 20 cases coil embolization and 26 cases treated conservatively. The cases with aneurysm repair showed significantly better clinical outcome than the controls, while World Federation of Neurological Surgeons (WFNS) grade on admission and premorbid modified Rankin Scale showed no difference between them. CONCLUSIONS: Better prognosis was obtained when ruptured aneurysm was repaired in the elderly than it was treated conservatively. From the results of this study, we should not hesitate to offer the definitive surgery for the elderly with aSAH.

[Cost Comparison of Carotid Endarterectomy versus Carotid Stenting in Japan].

Carotid artery stenting (CAS) has been covered by the health insurance system in Japan since 2008. There have been few studies concerning medical costs and charges for patients who received CEA or CAS in Japan. The aim of this study was to elucidate the difference in the costs between the patients who received CEA and those who received CAS in Japan. Between 2010 and 2011, 19 patients who received CEA and 20 patients who received CAS were retrospectively reviewed. Age, sex, symptomatic/asymptomatic, emergent/scheduled, length of stay, outcome, cost for the procedure (professional fee), supply for the operation, the total medical service fee, and copayment of the patients was compared between the two treatment groups. No significant difference was detected between the two groups except for the supply of the operation and the total medical service fee (CEA:mean 1,565,580 yen vs CAS 2,758,360 yen, p=0.0001). On the other hand, no significant difference was obtained in the copayment of the patients (CEA 71,895 yen, CAS 72,458 yen). Even when limited to the scheduled cases, similar results were obtained. There is a monthly copayment limit in the health insurance system in Japan, which results in a reasonable charge for patients who received CAS, despite the fact that the rest of the fee including high costs for the supplies was paid by the company and the nation. To reduce the medical costs, Japanese have to be aware of the high costs in CAS, most of which is due to the supplies.

Perimesencephalic nonaneurysmal subarachnoid hemorrhage with unilateral third cranial nerve palsy: two case reports.

Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSAH) is a benign form of subarachnoid hemorrhage and is usually not associated with any focal deficit. We describe two rare cases of PNSAH with unilateral third cranial nerve palsy. Both patients were treated conservatively. The outcomes of our two cases were excellent. The third cranial nerve palsy resolved gradually in both patients, suggesting that the prognosis for third cranial nerve palsy concomitant with PNSAH is favorable. Unilateral third cranial nerve palsy may occur as the first clinical manifestation of PNSAH.