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Background The optimal timing of initiating oral anticoagulants after reperfusion therapy for ischemic stroke is unknown. Factors related to early initiation of rivaroxaban and differences in clinical outcomes of stroke patients with nonvalvular atrial fibrillation (NVAF) who underwent reperfusion therapy was investigated. Methods From data of 1,333 NVAF patients with ischemic stroke or transient ischemic attack (TIA) in a prospective multicenter study, patients who started rivaroxaban after intravenous thrombolysis and/or mechanical thrombectomy were included. The clinical outcomes included the composite of ischemic events (recurrent ischemic stroke, TIA, or systemic embolism) and major bleeding at 3 months. Results Among the 424 patients, the median time from index stroke to starting rivaroxaban was 3.2 days. On multivariable logistic regression analysis, infarct size (odds ratio [OR], 0.99; 95%CI, 0.99–1.00) was inversely and successful reperfusion (OR, 2.13; 95%CI, 1.24–3.72) was positively associated with initiation of rivaroxaban within 72 hours. 205 patients were assigned to the early group (< 72 hours) and 219 patients (≥ 72 hours) to the late group. Multivariable Cox regression models showed comparable hazard ratios between the two groups at 3 months for ischemic events (hazard ratio [HR], 0.18; 95%CI, 0.03–1.32) and major bleeding (HR, 1.80; 95%CI, 0.24–13.54). Conclusions Infarct size and results of reperfusion therapy were associated with the timing of starting rivaroxaban. There were no significant differences in the rates of ischemic events and major bleeding between patients after reperfusion therapy who started rivaroxaban < 72 hours and ≥ 72 hours after the index stroke. Clinical trial registration Unique identifier: NCT02129920; URL: https://www.clinicaltrials.gov.

Ultrasonic bone curettes have been used as with high-speed drills. However, the amount of heat generated by the ultrasonic bone curette is not well known. This study quantitatively assessed the heat generated by an ultrasonic bone curette and compared it to that by a high-speed drill. The thermal change in a swine skull during bone curetting using an ultrasonic device and a high-speed drill were assessed. The investigation focused on the type of surgical manipulation (brush-like strokes vs. pushing motion) and irrigation (room temperature vs. cold water; low-volume irrigation vs. high-volume irrigation). The thermal elevation during drill use was suppressed when using brush-like strokes compared to pushing motion (brush-like strokes, 44.7 °C; pushing motion, 69.2 °C; p

A 52-year-old woman presented with a partially thrombosed giant aneurysm of the vertebral artery (VA) manifesting as a 3-month history of left hemiparesis. She developed subarachnoid hemorrhage during hospitalization and underwent emergency surgery for surgical proximal clipping and ventricular drainage with decompressive suboccipital craniectomy. She underwent additional surgery for endovascular coil embolization of the aneurysm and the affected distal VA on the 7th postoperative day. Although she suffered transient lower cranial nerve pareses and respiratory failure, her neurological condition improved gradually and she returned home with only slight ataxia and hoarseness 3 months after surgery. Magnetic resonance imaging obtained 28 months postoperatively revealed a remarkable decrease in the size of the aneurysm as well as reduction of the mass effect on the brainstem. Combined proximal clipping and internal trapping can solve the problems associated with treatment of giant aneurysms of VA by either direct surgery or endovascular surgery, and should be considered as a therapeutic option for giant aneurysms of the VA.

Intracavernouscarotid aneurysm rarely causes SAH and is not considered to be a life-threatening lesion, although it sometimes causes compression syndrome. Therefore, asymptomatic intracavernouscarotid aneurysm is commonly treated by observation rather than surgery in spite of the recent development of endovascular treatment. We describe a rare case with subdural hematoma caused by rupture of an intracavernouscarotid aneurysm. A 55-year-old woman was brought to our hospital because of sudden headache. CT scan showed a mass of high-density region at the left cavernous sinus with sign of empty sella. She was discharged as no other lesion was observed. A few days later, she was admitted again to our hospital because of sudden headache followed by coma. Her JCS level was 200 and GCS was 4 on arrival. CT scan revealed a subdural hematoma extending from the intrasellar and suprasellar region to the bilateral hemispheric areas. Angiograms showed a left intracavernouscarotid aneurysm 10 mm in diameter. Although embolization of the aneurysm was successfully performed and her JCS level recovered to Level 3 without further rupture of the aneurysm, she died from the complication of sepsis and DIC.

BACKGROUND Aneurysms arising from the proximal portion of the anterior cerebral artery (A 1 : horizontal portion) are quite rare and are considered to be unique, because they are usually connected with other vascular anomalies and are sometimes part of a multiple aneurysm occurrence. A 1 aneurysm cases experienced over the past seven and a half years are summarized in this paper. METHODS A total of 413 patients were surgically treated including 142 patients with subarachnoid hemorrhage (SAH); the remaining 271 patients had unruptured aneurysms. Among them, nine cases were categorized as constituent A 1 aneurysms, three with SAH and six with unruptured aneurysms. RESULTS The shape of the aneurysm was saccular in all nine cases. Three of the nine cases had associated vascular malformations. The average aneurysm diameter in the three cases with SAH was 4.0 mm, which is smaller than other common aneurysms presenting with SAH. Eight aneurysms developed at the takeoff point of perforating arteries—the medial lenticulostriate artery in five cases and the recurrent artery of Heubner in three cases. In the remaining case, the aneurysm originated from the proximal end of the associated A 1 fenestration. All nine patients had an excellent outcome after surgery. CONCLUSION A 1 aneurysms require surgical elimination even if they are small. We emphasize the importance of preserving the blood flow of these perforating arteries by avoiding compression with either the clip blade or the clip body itself.

A 63-year-old man presented with hypoglycemia-induced hemiparesis manifesting as diffusion-weighted magnetic resonance (MR) imaging changes in the splenium of the corpus callosum and internal capsule which disappeared after glucose administration. Clinicians should be aware that hypoglycemia can cause reversible splenium abnormalities on MR imaging, although the underlying mechanism still remains unclear, as this may be helpful in the differential diagnosis of hypoglycemia-induced hemiparesis and stroke.

家兎の中大脳動脈を遮断して実験脳虚血を作製し, その直後にcarteololを投与して, その後の血圧, 心拍出量, 脳血流量の変化を測定した.全身血圧はcarteolol投与群で, 投与後1時間より遮断前に比べて約10%低下し, 3時間では約15%の低下とcarteololを投与しなかった群に比べて有意に低下した.心拍出量はcarteolol投与群, 非投与群共, 大きな変動はなかった.脳血流量は, carteolol投与群, 非投与群共に遮断後1時間で遮断前に比べて約40%～50%に低下し, 3時間ではcarteolo1投与群で若干の上昇を示したが非投与群に比べ有意な差はなかった.以上の結果から, 脳虚血急性期におけるcarteololの投与は全身血圧の低下をもたらすが, 脳血流には悪影響を及ぼさないと結論された.

An asymptomatic case of a large calcified chronic subdural hematoma was examined. The calcified mass was nearly totally removed at operation using a high-speed air drill. Immediately after the operation signs of brain compression seen in computed tomography scanning were somewhat relieved. However, at follow-up after 3 months, the shift was resumed and the calcification reap-peared 10 months after the operation.