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External ventricular drainage (EVD) is required to resolve acute hydrocephalus associated with intraventricular hemorrhage (IVH). The correlation of scoring systems of IVH with indications for EVD for acute hydrocephalus related to IVH is currently unknown.We identified 213 hypertensive patients with IVH and divided them into 2 groups according to treatment method: 187 patients receiving blood pressure control alone and 26 patients undergoing EVD. The following patients were excluded: pediatric patients, patients undergoing intracranial hematoma removal, patients with fetal status, and patients without sufficient clinical data. We compared the Glasgow Coma Scale score, Graeb score, LeRoux score, Evans index, and bicaudate index values between the 2 groups and determined the prognostication accuracy of each scoring system.There were significant differences in all 4 scoring systems between the 2 groups (P 0.001). The cutoff values (sensitivity and specificity) of each scoring system were as follows: Glasgow Coma Scale, 8 (65.4%, 87.7%); Graeb score, 6 (80.8%, 75.4%); LeRoux score, 9 (80.8%, 76.5%); Evans index, 0.245 (80.8%, 67.9%); and bicaudate index, 0.186 (76.9%, 76.5%). The value of the area under the curve of each scoring system (95% confidence interval) was as follows: Glasgow Coma Scale, 0.806 (0.705-0.907); Graeb score, 0.852 (0.779-0.925); LeRoux score, 0.875 (0.812-0.937); Evans index, 0.788 (0.702-0.875); and bicaudate index, 0.778 (0.673-0.883).The LeRoux score is better for identifying patients with IVH who are more likely to have EVD.

The trans-cell approach using a low-profile visualized intraluminal support (LVIS) device is sometimes used for aneurysm coil embolization. However, factors related to microcatheter passage remain uninvestigated. We aimed to examine in-vitro factors related to microcatheter passage using the trans-cell approach with an LVIS.Silicone vessel models (inner diameter, 4 mm) were created with different bend segments and a 4-mm hole assuming an aneurysm neck on the side of the greater curvature. The LVIS Blue (4.5 × 32 mm) was deployed at the bend segment, and passability on the trans-cell surface was evaluated by passing the microcatheter along the micro guidewire. A total of 800 passage experiments were performed using two types of microcatheter, ten types of silicone vessel, four cell widths, five cells with the same LVIS device, and two micro guidewire directions in the aneurysm.The Headway Duo microcatheter (35.5%, 142/400) tended to have better passability compared with the Headway 17 microcatheter (29.3%, 117/400) (p = 0.070). As the cell width and angle between the trans-cell surface and microcatheter direction increased, passability significantly increased (p = 0.027 and p 0.001, respectively). There was no significant difference in passability when the micro guidewire was directed to the proximal side versus the distal side (p = 0.45).A large cell width and an obtuse angle between the trans-cell surface and microcatheter direction facilitated good passability. Although statistically marginal, microcatheters with small ledges and small tips had relatively good passability.

Objectives Thrombi in cerebral large vessel occlusion associated with active cancer are often fibrin and platelet-rich white thrombi. However, evaluating the thrombus composition in a short time before thrombectomy is often ineffective. We sought to determine factors related to white thrombi in acute ischemic stroke due to large vessel occlusion in cancer patients. Methods Consecutive cancer patients undergoing thrombectomy for acute ischemic stroke due to large vessel occlusion between January 2018 and May 2022 were retrospectively reviewed. The patients were classified into white thrombus and red thrombus groups on the basis of the pathological findings of retrieved thrombi. Patient characteristics and laboratory findings were compared between the two groups. Results There were 12 patients in the white thrombus group and 11 patients in the red thrombus group. Active cancer was significantly more in the white thrombus group than in the red thrombus group (91.7% vs. 36.3%, p = 0.0094). Internal carotid artery occlusion was significantly less in the white thrombus group than in the red thrombus group (0% vs. 36.4%, p = 0.037). Among laboratory findings, D-dimer levels were an independent factor associated with white thrombi (odds ratio 8.97 [95% confidence interval 1.71–368.99], p < 0.0001). The cutoff value of D-dimer levels for predicting white thrombi was 3.5 μg/mL (83.3% sensitivity and 100% specificity). Conclusions In acute ischemic stroke in cancer patients, active cancer, no internal carotid artery occlusion, and higher D-dimer levels (≥3.5 μg/mL) may be associated with occlusion with fibrin and platelet-rich white thrombi.

Surgical clipping of anterior communicating artery (ACoA) aneurysms remains challenging due to their complex anatomy. Anatomical risk factors for ACoA aneurysm surgery require further elucidation. The aim of this study is to investigate whether proximity of the midline perforating artery, subcallosal artery (SubCA), and associated anomaly of the ACoA complex affect functional outcomes of ACoA aneurysm surgery. A total of 92 patients with both unruptured and ruptured ACoA aneurysms, who underwent surgical clipping, were retrospectively analyzed from a multicenter, observational cohort database. Association of ACoA anatomy with SubCA origin at the aneurysmal neck under microsurgical observation was analyzed in the interhemispheric approach subgroup (n = 56). Then, we evaluated whether anatomical factors associated with SubCA neck origin affected surgical outcomes in the entire cohort (both interhemispheric and pterional approaches, n = 92). In the interhemispheric approach cohort, combination of A1 asymmetry and aneurysmal size ≥ 5.0 mm was stratified to have the highest probability of the SubCA neck origin by a decision tree analysis. Then, among the entire cohort using either interhemispheric or pterional approach, combination of A1 asymmetry and aneurysmal size ≥ 5.0 mm was significantly associated with poor functional outcomes by multivariable logistic regression analysis (OR 6.76; 95% CI 1.19–38.5; p = 0.03) as compared with A1 symmetry group in the acute subarachnoid hemorrhage settings. Combination of A1 asymmetry and larger aneurysmal size was significantly associated with SubCA aneurysmal neck origin and poor functional outcomes in ACoA aneurysm surgery. Interhemispheric approach may be proposed to provide a wider and unobstructed view of SubCA for ACoA aneurysms with this high-risk anatomical variant.

Background and purpose In this post-hoc analysis using acute dual study dataset, the impacts of cerebral microbleeds (MBs) after mild stroke on clinical outcome were investigated. Methods The number of MBs on admission was categorized as 1) no MBs, 2) MBs 1–4, 3) MBs 5–9, and 4) MBs ≥ 10. The efficacy outcome was defined as neurological deterioration and stroke recurrence within 14 days. Safety outcomes included ICH and/or SAH as well as extracranial hemorrhages. Results Of the 1102 patients, 780 (71%) had no MBs on admission, while 230 (21%) had MBs 1–4, 48 (4%) had MBs 5–9, and 44 (4%) had MBs ≥ 10. The number of MBs was not associated with the neurological deterioration and/or stroke recurrence (p = 0.934), ICH and/or SAH (p = 0.743), and extracranial hemorrhage (p = 0.205). Favorable outcome was seem in 84% in the No MBs group, 83% in the MBs 1–4, 94% in the MBs 5–9, and 85% in the MBs ≥ 10 (p = 0.304). Combined cilostazol and aspirin therapy did not alter any rates of efficacy and safety outcomes among the no MBs, MBs 1–4, MBs 5–9, and MBs ≥ 10 groups compared to aspirin alone (all p > 0.05). By multivariate regression analysis, a history of ICH and diastolic blood pressure were the independent parameters to all of the MBs criteria (presence, MBs ≥ 5, and MBs ≥ 10). Conclusions MBs did not alter the clinical outcome at 3 months of onset. Elevated diastolic blood pressure and a history of ICH were the essential parameters related to the MBs.

When a microcatheter is in the aneurysm, it may move due to low-profile visualized intraluminal support (LVIS) deployment. This study was designed to determine this mechanism.Six silicon aneurysm models were created by combining the aneurysm location (side wall or bifurcation) and the parent vessel configuration (straight, ipsilateral bending, or contralateral bending). After adjusting the microcatheter tip position in the aneurysm by pushing or pulling, an LVIS stent was deployed to cover the aneurysm neck, and the changes in the microcatheter tip position was measured. Pushing and pulling were performed 15 times each for each model, for a total of 180 experiments.In all experiments, the microcatheter tip moved with LVIS deployment. The total movement distance was 3.00±1.59 mm, which was significantly different between the push and pull groups (p = 0.049), between the three side-wall aneurysm models (p0.0001), and between the three bifurcation aneurysm models (p0.0001). Backward movement in the aneurysm occurred in 21% (37/180). The frequency of backward movement was significantly different between the side-wall and bifurcation aneurysm models (p = 0.0265) and between the push and pull groups (p0.0001). The forward movement distance was significantly different between the side-wall (n = 78) and bifurcation (n = 65) aneurysm models (p0.0001).The aneurysm location, the parent vessel configuration, and adjustment of the microcatheter tip position by pushing or pulling may affect the total movement distance and forward/backward movement of the microcatheter tip due to LVIS deployment.

Background: Many randomized controlled trials (RCT) have assessed new treatments in subarachnoid hemorrhage (SAH), yet most show no treatment efficacy. One explanation is the statistical analysis of the primary endpoint was not as efficient as possible. We reanalyzed SAH RCTs with various statistical tests to determine whether the statistical method affects RCT primary outcome.Methods: Individual patient data for the primary outcome (Glasgow outcome scale [GOS]) of two SAH RCTs were analyzed using 15 statistical methods. For tests requiring outcome dichotomization, multiple cut-points in the 5-level GOS were assessed. Next, a synthetic dataset generated using random sampling with replacement from ten SAH RCTs was assessed using the same statistical tests. A Friedman test (two-way non-parametric analysis of variance) determined which tests produced the highest average absolute Z-values. The number of times each test reported significance of pResults: Bootstrapping with replacement produced the best-ranking results, followed by three χ2-tests: one differentiating excellent (GOS=5) from good (GOS=4), poor (GOS=2-3), or dead (GOS=1) outcomes; one differentiating favorable (GOS=4-5) from poor or dead outcomes; and one differentiating favorable (GOS=4-5) from unfavorable outcomes. Each of these reported statistical significance for both RCTs, as did the following ranked tests, respectively: Wilcoxon median test, Student’s t-test, ordinal logistic regression, median test, and a chi-square dichotomizing excellent (GOS≥4) and inferior outcomes. Statistical significance for one or neither RCT was reported by two Cochrane-Armitage tests and two logistic regressions with alternate versions of bucketing, the Kolmogorov-Smirnov test and chi-square test differentiating surviving from dead patients. The synthetic dataset returned similar results, with the same nine most and six least efficient tests.Conclusions: Bootstrapping produced the most efficient results but is time-and resource-intensive. Chi-square tests grouping outcomes into dichotomous or multiple buckets are also efficient, and their ease of use and popularity make them appropriate candidates for statistical analysis in future SAH RCTs.

Introduction: Subarachnoid hemorrhage (SAH) mortality is decreasing, but data on functional outcomes over time is lacking. Methods: We created trends of good (Glasgow Outcomes Scale [GOS] of 4 or 5) and optimal (GOS of 5) functional outcomes and mortality (GOS of 1) using linear regression in 15 SAH trials and registries from 1982 to 2014. Models adjusted for age, sex, history of hypertension, World Federation of Neurological Surgeons grade, Fisher grade, aneurysm size, location, and repair modality, and whether data was from a clinical trial or registry. Analyses were repeated separately for the clinical trials and registries. Missing data were handled with multiple imputation. Results: Overall, 13,343 SAH patients were included. 9,524 (71%) patients had good functional outcome, while 1,608 (12%) died. There was a 0.6% adjusted improvement (95% confidence interval [CI]: 0.5% to 0.7%; p Conclusions: SAH morbidity and mortality decreased from the 1980s to 2010s. This data can be helpful for researchers planning trials, clinicians discussing expected outcomes with patients and family members, and healthcare administrators planning resource utilization.

Background Our previous trial acute dual study (ADS) reported that dual antiplatelet therapy (DAPT) using cilostazol and aspirin did not reduce the rate of short-term neurological worsening in non-cardioembolic stroke patients. Present post-hoc analysis investigated whether the impact of combined cilostazol and aspirin differed among stroke subtypes and factors associated with neurological deterioration and/or stroke recurrence. Methods Using the ADS registry, the rate of neurological deterioration, defined as clinical worsening and/or recurrent stroke, including transient ischemic attack was calculated. Stroke subtypes included large-artery atherosclerosis (LAA), small vessel occlusion (SVO), other determined etiology (Others), and undetermined etiology of stroke (Undetermined). Results Data of 1022 patients were analyzed. Deterioration was seen in 104 (10%) patients, and the rates were not markedly different between patients treated with DAPT vs. aspirin in any stroke subtypes: LAA, 19% vs. 11%, (p=0.192); SVO, 10% vs. 10% (p=1.000); Others, 6% vs. 6% (p=1.000); Undetermined, 11% vs. 8% (p=0.590). Diabetes mellitus was the independent factor associated with deterioration (odds ratio 4.360, 95% confidence interval 1.139–16.691, p=0.032) in the LAA group. Age (1.030 [1.004–1.057], p=0.026), systolic blood pressure (1.012 [1.003–1.022], p=0.010), and infarct size (2.550 [1.488–4.371], p=0.001) were associated with deterioration in SVO group, and intracranial stenosis/occlusion was associated with it in the Undetermined group (3.744 [1.138–12.318], p=0.030). Conclusions Combined cilostazol and aspirin did not reduce the rate of short-term neurological deterioration in any clinical stroke subtype. The characteristics of patients whose condition deteriorates in the acute period may differ based on the stroke subtypes.

OBJECTIVEShunt-dependent hydrocephalus (SDHC) may arise after aneurysmal subarachnoid hemorrhage (aSAH) as CSF resorptive mechanisms are disrupted. Using propensity score analysis, the authors aimed to investigate which treatment modality, surgical clipping or endovascular treatment, is superior in reducing rates of SDHC after aSAH.METHODSThe authors’ multicenter SAH database, comprising 3 stroke centers affiliated with Kyoto University, Japan, was used to identify patients treated between January 2009 and July 2016. Univariate and multivariate analyses were performed to characterize risk factors for SDHC after aSAH. A propensity score model was generated for both treatment groups, incorporating relevant patient covariates to detect any superiority for prevention of SDHC after aSAH.RESULTSA total of 566 patients were enrolled in this study. SDHC developed in 127 patients (22%). On multivariate analysis, age older than 53 years, the presence of intraventricular hematoma, and surgical clipping as opposed to endovascular coiling were independently associated with SDHC after aSAH. After propensity score matching, 136 patients treated with surgical clipping and 136 with endovascular treatment were matched. Propensity score–matched cohorts exhibited a significantly lower incidence of SDHC after endovascular treatment than after surgical clipping (16% vs 30%, p = 0.009; OR 2.2, 95% CI 1.2–4.2). SDHC was independently associated with poor neurological outcomes (modified Rankin Scale score 3–6) at discharge (OR 4.3, 95% CI 2.6–7.3; p < 0.001).CONCLUSIONSSDHC after aSAH occurred significantly more frequently in patients who underwent surgical clipping. Strategies for treatment of ruptured aneurysms should be used to mitigate SDHC and minimize poor outcomes.

OBJECTIVEAlthough endovascular therapy is favored for acutely ruptured intracranial aneurysms, hematological factors associated with acute subarachnoid hemorrhage (SAH) may predispose to procedure-related ischemic complications. The aim of this study was to evaluate whether an elevated level of plasma D-dimer, a parameter of hypercoagulation in patients with acute SAH, is correlated with increased incidence of thromboembolic events during endovascular coiling of ruptured aneurysms.METHODSThe authors analyzed data from 103 cases of acutely ruptured aneurysms (in 103 patients) treated with endovascular coil embolization at a single institution. Factors associated with elevated D-dimer level on admission were identified. The authors also evaluated whether D-dimer elevation was independently correlated with increased incidence of perioperative thromboembolic events.RESULTSAn elevated D-dimer concentration (≥ 1.0 μg/ml) on admission was observed in 70 (68.0%) of 103 patients. Increasing age (p < 0.001, Student t-test) and poor initial neurological grade representing World Federation of Neurosurgical Societies (WFNS) grade IV or V (p = 0.0018, chi-square test) were significantly associated with D-dimer elevation. Symptomatic thromboembolic events occurred in 11 cases (10.7%). Elevated D-dimer levels on admission (OR 1.34, 95% CI 1.10–1.62, p = 0.0029) independently carried a higher risk of thromboembolic events after adjustment for potential angiographic confounders, including wide neck of the aneurysm and large aneurysm size.CONCLUSIONSElevated D-dimer levels on admission of patients with acute SAH were significantly associated with increased incidence of thromboembolic events during endovascular coiling of ruptured aneurysms.

Background Pituitary apoplexy (PA) is a life-threatening syndrome. The usage of a dopamine agonist, such as bromocriptine or cabergoline, is considered a predisposing factor for PA, which commonly occurs 1.5 years within commencement. Case Description A 64-year-old female with a >15-year history of cabergoline therapy for pituitary prolactinoma was referred to our department of neurosurgery after complaining of headache, blurred vision, diplopia, and ptosis for 3 days during hospital admission for chemotherapy of chronic myelocytic leukemia. Computed tomography and magnetic resonance imaging revealed findings indicative of PA. As the patient was experiencing thrombocytopenia related to chemotherapy, blood transfusion was preceded, and after a platelet count of 15.0 × 104/μL was confirmed, transnasal neuroendoscopic surgery was performed 5 days from the onset of symptoms. The majority of the prolactinoma was removed, and the prolactinoma in the cavernous sinus was intentionally left. The postoperative course was generally good. The ptosis and diplopia improved, and the blurred vision resolved. Conclusions PA related to dopamine agonist therapy can occur in cases of elevated bleeding tendency, even in long-term users, suggesting that attention should be paid in the administration of a dopamine agonist in the patient experiencing thrombocytopenia. Surgical intervention should be performed after the preoperative platelet number and adequate response to transfusion are confirmed, and the aggressive removal of prolactinoma in the cavernous sinus should be avoided to reduce the risk of hemorrhagic complications.

OBJECTIVEDelayed 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.METHODSThe 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.RESULTSAfter 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.CONCLUSIONSIn 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.

Metronidazole induced encephalopathy (MIE), an encephalopathy brought by an antibiotic, is characterized with cerebellar dysfunction, altered mental status and extrapyramidal symptoms. MIE can result in an acute manifestation, but MIE has not been reported as a stroke mimic. An 86-year-old patient undergoing metronidazole therapy for Clostridium difficile enteritis presented to our hospital with sudden disoriented status and motor weakness of the left extremities. Computed tomography (CT) was unrevealing of intracranial hemorrhagic change, and CT angiography did not show any apparent major occlusion or stenosis of the intracranial vessels. However, CT perfusion (CTP) revealed a decrease in peripheral blood flow in the right cerebral hemisphere, and tissue plasminogen activator was administrated for a possible acute ischemic stroke. The findings of follow-up magnetic resonance imaging (MRI) were typical for MIE, revealing areas of hyperintensity on fluid attenuated inversion recovery (FLAIR) signal intensity in the dentate nuclei, the splenium of the corpus callosum, and in the dorsal midbrain. The degree of hyperintensity was stronger in the left dentate nucleus than in the right left dentate on FLAIR and the apparent diffusion coefficient map. The asymmetric findings of the left dentate nucleus on MRI were considered to be responsible for the clinical symptoms and the findings of CTP. We report a rare case of MIE mimicking an acute ischemic stroke, and hypothesize the relationship between the findings of CTP and that of MRI based on the anatomical connection of the dentate nucleus and the cerebral hemisphere.

Vertebral arteriovenous fistula (VAVF), which can cause subarachnoid hemorrhage (SAH) when having a perimedurally drainage, has been reported as a rare vascular abnormality in patients with neurofibromatosis type 1 (NF-1). In addition, extracranial vertebral aneurysm (EVAn) coexisting with VAVF and NF-1 is considered rare, and further complication with SAH is extremely rare in patients. There is only one reported case of NF-1 complicated with SAH from VAVF with an EVAn. Here, we present a case of a middle-aged patient with NF-1. The VAVF accompanied by an EVAn was detected with an episode of SAH. The VAVF with an EVAn in our case was accompanied with an epidural varix, lacking of perimedullary drainage, which could be a cause for SAH. We speculate the mechanism of SAH from the VAVF with an EVAn lacking of perimedurally drainage, focusing on hemodynamic stress of the VAVF and the tissue fragility related to NF-1.

Background Perforator infarction is a procedure-related complication of surgical clipping of ruptured anterior communicating artery (ACoA) aneurysms. Patients with perforator infarction may present with specific clinical features. The aim of this study was to elucidate incidence, risk factors, clinical course, and outcomes of perforator infarction following surgical clipping of ruptured ACoA aneurysms. Methods Retrospective analysis was performed of 104 patients from a single-center, observational cohort database who underwent surgical clipping for ruptured ACoA aneurysm. Risk factors of perforator infarction were identified. Correlation of perforator infarction with clinical course during hospitalization was investigated, focusing on dysfunction of hypothalamus and cerebral limbic system. We also evaluated any associations between perforator infarction and poor outcomes. Results Perforator infarction was observed in 24 (23.1%) patients. Use of temporary clip ( P = 0.019, χ 2 test) and intraoperative rupture ( P 2 test) were significantly associated with perforator infarction. Patients with perforator infarction had increased likelihood of hyponatremia (odds ratio 6.41 [95% confidence interval 2.27–18.1], P P = 0.004) in the subacute stage of subarachnoid hemorrhage by multivariate analyses. Perforator infarction was an independent risk factor of poor functional outcomes at 3 months (modified Rankin Scale score 3–6; odds ratio 5.29 [95% confidence interval 1.62–17.2], P = 0.006). Conclusions Perforator infarction following surgical clipping of ruptured ACoA aneurysms caused region-specific complications, including hyponatremia and insufficient oral intake, and was associated with poor functional outcomes.

OBJECTIVEPlasma D-dimer levels elevate during acute stages of aneurysmal subarachnoid hemorrhage (SAH) and are associated with poor functional outcomes. However, the mechanism in which D-dimer elevation on admission affects functional outcomes remains unknown. The aim of this study is to clarify whether D-dimer levels on admission are correlated with systemic complications after aneurysmal SAH, and to investigate their additive predictive value on conventional risk factors for poor functional outcomes.METHODSA total of 187 patients with aneurysmal SAH were retrospectively analyzed from a single-center, observational cohort database. Correlations of plasma D-dimer levels on admission with patient characteristics, initial presentation, neurological complications, and systemic complications were identified. The authors also evaluated the additive value of D-dimer elevation on admission for poor functional outcomes by comparing predictive models with and without D-dimer.RESULTSD-dimer elevation on admission was associated with increasing age, female sex, and severity of SAH. Patients with higher D-dimer levels had increased likelihood of nosocomial infections (OR 1.22 [95% CI 1.07–1.39], p = 0.004), serum sodium disorders (OR 1.11 [95% CI 1.01–1.23], p = 0.033), and cardiopulmonary complications (OR 1.20 [95% CI 1.04–1.37], p = 0.01) on multivariable analysis. D-dimer elevation was an independent risk factor of poor functional outcome (modified Rankin Scale Score 3–6, OR 1.50 [95% CI 1.15–1.95], p = 0.003). A novel prediction model with D-dimer had significantly better discrimination ability for poor outcomes than conventional models without D-dimer.CONCLUSIONSElevated D-dimer levels on admission were independently correlated with systemic complication, and had an additive value for outcome prediction on conventional risk factors after aneurysmal SAH.

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.

Introduction: The evaluation of ischemic core is important in acute cerebral infarction with large vessel occlusion. The ischemic core is thought to approximate the region that is difficult to receive collateral circulation. We classified the ischemic core distribution pattern into four types on the basis of the tendency of cerebral blood volume (CBV) decrease in the ischemic core, and examined the prognostic ability. Methods: We included M1 or ICA occlusion which completely recanalized (TICI3) by thrombectomy in our institute from January 2015 to May 2019. The ischemic core was defined as a region where CBV were reduced less than 1.9 ml/100cc. Ischemic core distribution pattern was classified into the following 4 types. Type A: absent of ischemic core. Type B: ischemic core is confined to the basal ganglia and white matter. Type C1: ischemic core is present in the cortex but less than half of MCA region. Type C2: ischemic core is present in the cortex, and more than half of MCA region. The patient characteristics, temporal parameters, ASPECTS and ischemic core distribution pattern were analyzed with mRS0-2 at discharge as a good outcome group. Results: A total of 47 cases (14 ICA, 33 M1) were included. Ischemic core distribution pattern correlated well with mRS at discharge (p Conclusions: The distribution pattern of ischemic core defined by reduced CBV have good correlation with outcome. There is a possibility that it can be used as a simple tool to predict prognosis using CT perfusion in anterior circulation acute large vessel occlusion.

Hypothesis: Our previous study, ADS reported that dual antiplatelet therapy (DAPT) using cilostazol and aspirin did not reduce the rate of short-term neurological worsening in non-cardioembolic stroke patients. The aim of the present study is to investigate 1) whether the impact of cilostazol addition to aspirin differ among each stroke subtype, and 2) factors associated with neurological deterioration and/or stroke recurrence in order to find therapeutic target. Methods: This is a retrospective analysis using the ADS databank. Neurological worsening and the rates of stroke recurrence within 14 day of onset were evaluated. Stroke subtype included large-artery atherosclerosis (LAA), lacunae infarct (LI), branch atheromatous disease (BAD), other, and undetermined. Results: Data on 1,160 patients (773 [67%] men; median age, 69 [61-77] years, NIHSS score was 2 [1-4]) were analyzed. At discharge, 167 (14%) were diagnoses as having LAA; LI, 532 (46%); BAD, 173 (15%); other, 132 (11%); and undetermined, 156 (14%). Neurological deterioration and/or recurrence were seen in 130 (11%) patients, and the rates were not different between patients treated with DAPT and aspirin in any stroke subtypes: LAA, 19% (DAPT) vs. 11% (aspirin alone), (p=0.185); LI, 4% vs. 3% (p=0.645); BAD, 33% vs.34%, (p=0.872), other, 8% vs.14% (p=0.272); undetermined, 13% vs. 8% (p=0.301). When we evaluated factors related to the deterioration/recurrence, age (p1.5cm (p Conclusions: Dual antiplatelet therapy using cilostazol and aspirin does not reduce the rate of short-term neurological worsening in each clinical stroke subtype. Improvement of hyperacute therapy targeting the elder patients with elevated blood pressure, large infarct and intracranial stenosis/occlusion should be required.

Background We hypothesized that administration of cilostazol may clarify the occult atrial fibrillation (AF) during hospitalization in mild stroke patients, who has no history of AF. Methods From our prospective non-cardioembolic stroke study, randomized to dual antiplatelet therapy using cilostazol and aspirin or aspirin alone trial (ADS), data on the presence or absence of AF were retrospectively analyzed. In the ADS, during hospitalization, as a routine examination, presence of AF was investigated using electrocardiogram (ECG), ECG monitoring and Holter ECG. Multivariate regression analysis was conducted to evaluate the independent parameters related to the AF. Clinical outcome at 3 months was evaluated using modified Rankin Scale (mRS) score. Results Data on 1194 patients (793 [66%] men; median age [interquartile range] of 69 [61–77] years, National Institutes of Health Stroke Scale score 2 [1–4], onset-to-admission 10.8 [4.7–20.5] hours) were retrospectively analyzed. AF was newly detected in 41 (3%) patients (3 by ECG, 21 by the ECG monitoring and 17 by the Holter ECG) during hospitalization. Patients treated with combined cilostazol and aspirin therapy frequently had the AF than those took aspirin alone (5% vs. 2%, p = .007). Multivariate regression analysis showed that cilostazol administration was one of the independent factors for new-AF (odds ratio 2.672, 95%CI: 1.205–5.927, p = .016). The frequency of mRS 0-1 was 68% in the new-AF group and 67% in the non-AF group (p = 1.000). Conclusion Cilostazol therapy may increase the detectability of AF in acute non-cardioembolic stroke, though the new-AF was not related to clinical outcome at 3 months.

The surgical removal of giant solid hemangioblastoma involves a high risk of perioperative bleeding and requires attentive hemostasis. Here, we present a case of a giant solid hemangioblastoma accompanied with hemophilia which was previously undiagnosed. A 35-year-old man without any past medical history was admitted with diplopia and ocular motility disorder. computed tomography (CT) and magnetic resonance imaging (MRI) revealed obstructive hydrocephalus and a solid giant tumor of more than 4.0 cm in diameter in the right cerebellopontine angle (CPA). Hemangioblastoma was suspected on cerebral angiography. After ventriculoperitoneal shunt for obstructive hydrocephalus, oozing from the skin incision continued for several days. Hemophilia type A was diagnosed based on the result of laboratory blood coagulability examination. Supplemental administration of factor VIII and coil embolization of the feeding arteries of the lesion on the CPA were performed, and the tumor was subtotally resected without hemorrhagic complications. The histopathological diagnosis was hemangioblastoma. We report this case to emphasize the importance not to overlook previously undiagnosed coagulopathy before surgical excision of hemangioblastoma. And, with appropriate perioperative management for coagulopathy, surgical treatment involving a high risk of perioperative bleeding can be safely undertaken.

Objectives The goal of this study was to compare the risk of stroke between patients with carotid artery disease with and without the presence of intraplaque hemorrhage (IPH) on magnetic r...

The epidemiology of patients with traumatic brain injury (TBI) has changed dramatically over recent decades as a result of rapid advances in aging societies. We assessed the influence of age on outcomes of patients with TBI and sought to identify prognostic factors for in-hospital mortality of TBI among elderly patients.Using a nationwide database, we analyzed data from 5651 patients with TBI. Univariate analysis was conducted to compare patient demographics, neurologic status on admission, radiologic findings, systemic complication rates, length of hospital stay, in-hospital mortality, and home discharge rates between elderly and nonelderly groups. Multivariable analysis was conducted to determine prognostic factors for in-hospital mortality among elderly patients.Overall in-hospital mortality was significantly higher in elderly patients (12.8% vs. 19.3%; P0.001). In-hospital mortality of elderly patients with mild TBI increased significantly at7 days after admission, whereas that of elderly patients with moderate or severe TBI was significantly higher immediately after admission. Age (odds ratio [OR], 1.62; P = 0.024), male sex (OR, 1.30; P = 0.004), Japan Coma Scale score on admission (OR, 5.95, P0.001), and incidence of acute subdural hematoma (OR, 1.89; P0.001) were associated with in-hospital mortality in elderly patients with TBI.Elderly patients with TBI showed significantly higher in-hospital mortality. Delayed increases in in-hospital mortality were observed among elderly patients with mild TBI. Level of consciousness on admission was the strongest predictor of in-hospital mortality among elderly patients.

Introduction: The survey of atrial fibrillation (AF) is routinely recommended in acute stroke case, even in patients without AF on admission, because the AF leads to a sever stroke. Cilostazol is often used for stroke patients without AF in Japan; however, it has the adverse events of palpitation due to the vessels dilatation by increased nitric oxide. We hypothesized that administration of cilostazol may clarify the burden AF in stroke patients without AF. Methods: From our prospective randomized control study, (randomized to dual antiplatelet therapy using cilostazol and aspirin or aspirin alone targeted patients for non-cardioembolic stroke [ADS]), patients assessed the presence of AF were retrospectively analyzed. Presence of AF was detected using ECG monitoring and Holter ECG. All patients were divided into the AF group and the non-AF group and imaging and laboratory findings were compared between the 2 groups. Multivariate regression analysis was conducted to evaluate the independent factors related to new AF. Results: 1194 patients (793 [66%] men; median age [IQR] of 69 [61-77] years, NIHSS score 2 [1-4], onset-to-admission 10.8 [4.7-20.5] hours) patients were included. AF was newly detected in 41 patients (3 by ECG, 21 by the ECG monitoring and 17 by the Holter ECG) during hospitalization. Patients randomized to the combined cilostazol and aspirin therapy frequently had the AF than those to aspirin alone (29/596 [5%] vs. 12/598 [2%], p=0.007). AF group was older than the non-AF group (76 [72-82] vs. 68 [60-77] years, p1.5cm) (p Conclusion: Administration of cilostazol increases the detectability of AF in acute non-cardioembolic stroke.

Purpose: Cerebral hyperperfusion syndrome (CHS) is a rare devastating complication associated with hyperperfusion after carotid endarterectomy. Single photon emission computed tomography (SPECT) is usually used with acetazolamide challenge to measure the cerebrovascular reserve (CVR), and a decreased CVR is indicative of a high risk of post CEA hyperperfusion. However, acetazolamide administration can rarely cause serious adverse effects, and thus, alternative methods may be required. Perfusion computed tomography (PCT) is a rapid, more accessible modality, which can be acquired with CT angiography. PCT seems to be useful as a screening tool in identifying groups at high-risk of hyperperfusion, but its usefulness has not sufficiently investigated. Our purpose was to clarify the relationship between hyperperfusion and the preoperative PCT parameters of cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT). Method: We included patients who underwent carotid endarterectomy in our hospital from 2014 December to 2018 April. PCT was obtained preoperatively and on postoperative day 1. Hyperperfusion is defined as a postoperative CBF of the middle cerebral artery area which has increased twice that of the preoperative value. CHS was defined as any symptom and imaging findings related with hyperperfusion, which include headache, seizure, neurological dysfunction, and any intracranial hemorrhage in the related area. Preoperative CBF, CBV, MTT and other patient characteristics are statistically analyzed between a hyperperfusion group and non-hyperperfusion group. Result: There are 73 patients who underwent CEA during the study period, and hyperperfusion was observed in 5 cases, from which 2 were considered as CHS. In the hyperperfusion group, the preoperative CBF was significantly lower (p=0.0008), and the CBV and MTT significantly higher (p=0.0196, p=0.0002). ROC analysis showed that the PCT parameters with the maximal area under the receiver-operating characteristic curve for hyperperfusion was preoperative MTT with an optimal threshold at 8.0 seconds (sensitivity 100%, specificity 100%). Conclusion: Patient with prolonged preoperative MTT tend to develop hyperperfusion, which is related to CHS.

Introduction: From the results of NASCET and ECST, surgical treatment for carotid artery near occlusion (NO) has not been as effective as of that for severe stenosis. A meta-analysis published in 2015 supported surgical treatment for NO, but this is still controversial because recent large prospective studies such as CREST or ICSS exclude NO. Method: We conducted a retrospective single center case-controlled study in Japan. Among all NO cases from May 2006 to May 2017, we selected those who had internal carotid artery (ICA) without collapse, with collapse but with detection of vascular lumen from neck to intracranium by angiography and MRI, and without mechanical changes of vessel wall. We excluded patients who had ICA with full collapse and without the possibility for expansion. The carotid artery endarterectomy (CEA) or carotid artery stenting (CAS) was performed according to plaque character, position, and expectancy of expansion. The primary outcome was ipsilateral stroke within 90 days after surgery. Secondary outcomes included restenosis of more than 50%, and perioperative complications (postoperative procedural DWI positive, myocardial infarction, death). Result: In the eligible 60 patients, 56 were male, and the median age was 73±6.3. The number of symptomatic lesions and string signs were 27 and 5, and the CEA and CAS groups consisted of 33 and 27 patients, respectively. There was no significant difference between each group in the patient backgrounds other than the age and follow-up period (71 and 76 [p = 0.0093], 63 and 39 months, respectively [p = 0.0185]). Ipsilateral stroke within 90 days after surgery occurred in 0 and 4 patients (p = 0.0328), and restenosis in 7 (3 needed additional CAS) and 3 patients (p = 0.490). The postoperative DWI positive was 7 and 11 (p = 0.095), and all of them were asymptomatic or transient. There were no cases of perioperative myocardial infarction, and perioperative death occurred in 1 patient. Conclusion: CEA group had the advantage of procedural safety but also the risk of restenosis. In CAS group, we can expect good expansions of ICA, but perioperative complications are relatively high. Our results suggest that there exist specific factors including surgical indication which lead to good outcome by surgical treatment.

The goal of this study was to compare the risk of stroke between patients with carotid artery disease with and without the presence of intraplaque hemorrhage (IPH) on magnetic resonance imaging.IPH in carotid stenosis increases the risk of cerebrovascular events. Uncertainty remains whether risk of stroke alone is increased and whether stroke is predicted independently of known risk factors.Data were pooled from 7 cohort studies including 560 patients with symptomatic carotid stenosis and 136 patients with asymptomatic carotid stenosis. Hazards of ipsilateral ischemic stroke (primary outcome) were compared between patients with and without IPH, adjusted for clinical risk factors.IPH was present in 51.6% of patients with symptomatic carotid stenosis and 29.4% of patients with asymptomatic carotid stenosis. During 1,121 observed person-years, 66 ipsilateral strokes occurred. Presence of IPH at baseline increased the risk of ipsilateral stroke both in symptomatic (hazard ratio [HR]: 10.2; 95% confidence interval [CI]: 4.6 to 22.5) and asymptomatic (HR: 7.9; 95% CI: 1.3 to 47.6) patients. Among patients with symptomatic carotid stenosis, annualized event rates of ipsilateral stroke in those with IPH versus those without IPH were 9.0% versus 0.7% (50% stenosis), 18.1% versus 2.1% (50% to 69% stenosis), and 29.3% versus 1.5% (70% to 99% stenosis). Annualized event rates among patients with asymptomatic carotid stenosis were 5.4% in those with IPH versus 0.8% in those without IPH. Multivariate analysis identified IPH (HR: 11.0; 95% CI: 4.8 to 25.1) and severe degree of stenosis (HR: 3.3; 95% CI: 1.4 to 7.8) as independent predictors of ipsilateral stroke.IPH is common in patients with symptomatic and asymptomatic carotid stenosis and is a stronger predictor of stroke than any known clinical risk factors. Magnetic resonance imaging might help identify patients with carotid disease who would benefit from revascularization.

OBJECT 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.

OBJECT The purpose of the present study was to investigate the association between carotid artery (CA) expansive remodeling (ER) and symptoms of cerebral ischemia. METHODS One hundred twenty-two consecutive CAs scheduled for CA endarterectomy (CEA) or CA stent placement (CAS) were retrospectively studied. After excluding 22 CAs (2 were contraindicated for MRI, 8 had near-occlusion, 6 had poor image quality, and 6 had restenosis after CEA or CAS), there were 100 CAs (100 patients) included in the final analysis. The study included 50 symptomatic patients (mean age 73.6 ± 8.9 years, 6 women, mean stenosis 68.5% ± 21.3%) and 50 asymptomatic patients (mean age 72.0 ± 5.9 years, 5 women, mean stenosis 79.4% ± 8.85%). Expansive remodeling was defined as enlargement of the internal carotid artery (ICA) with outward plaque growth. The ER ratio was calculated by dividing the maximum distance between the lumen and the outer borders of the plaque perpendicular to the axis of the ICA by the maximal luminal diameter of the distal ICA at a region unaffected by atherosclerosis using long-axis, high-resolution MRI. RESULTS The ER ratio of the atherosclerotic CA was significantly greater than that of normal physiological expansion (carotid bulb; p < 0.01). The ER ratio of symptomatic CA stenosis (median 1.94, interquartile range [IQR] 1.58–2.23) was significantly greater than that of asymptomatic CA stenosis (median 1.52, IQR 1.34–1.81; p = 0.0001). When the cutoff value of the ER ratio was set to 1.88, the sensitivity and specificity to detect symptoms were 0.6 and 0.78, respectively. The ER ratio of symptomatic patients was consistently high regardless of the degree of stenosis. CONCLUSIONS There was a significant correlation between ER ratio and ischemic symptoms. The ER ratio might be a potential indicator of vulnerable plaque, which requires further validation by prospective observational study of asymptomatic patients.

Carotid endarterectomy (CEA) requires complete control of the blood backflow. An anomalous ascending pharyngeal artery (AphA) has been reported to result in incomplete control of the blood flow during CEA. Here, we present a case of symptomatic right internal carotid stenosis for which CEA was performed. An anomalous AphA was confirmed based on its origin from the distal internal carotid artery (ICA) on 3-dimensional rotational angiography (3DRA). The anomalous AphA arose near the distal end of the plaque, and the origin of the AphA was located in the dorsal wall of the ICA, hidden from the surgical view. The origin of the AphA was detected with rotation of the ICA within the carotid sheath (CS). Intraoperatively, the blood flow from the AphA was completely controlled with clamping of the origin of the AphA. We emphasize the importance of the 3DRA to detect an anomalous AphA and propose the use of the CS as an anchor to rotate the ICA for optimizing the surgical view behind the ICA. This simple surgical technique facilitates to detect and clamp an anomalous AphA arising from the ICA.

Background Primary intracranial leiomyosarcoma is a very rare occurrence, and primary leiomyosarcoma with intratumoral hemorrhage has not been described previously. We present a case of a rapidly enlarging primary intracranial leiomyosarcoma with intratumoral hemorrhage. Case Description A 41-year-old female presented with right hemiparesis and gait disturbance. She had a brain tumor on the frontal lobe that was growing rapidly. An intratumoral hemorrhage had occurred suddenly. We removed the tumor after hemorrhage. After the operation, postoperative chemotherapy and radiotherapy were not performed, but the tumor did not recur. Conclusions To the best our knowledge, this is the first report of primary intracranial leiomyosarcoma with intratumoral hemorrhage.

Hypothesis: The aim of the present study was to investigate the efficacy and safety of antiplatelet (aspirin plus cilostazol) dual therapy for non-cardioembolic stroke patients within 48 h of symptom onset. Methods: ADS is an investigator initiated, a prospective, multicenter (34 hospitals in Japan), randomized, and an aspirin-controlled study. Acute stroke patients with non-cardioembolic stroke within 48 hours of onset were studied. Only patients with preadmission mRS score 0-2 were included. Subjects were randomly allocated to the combination therapy with aspirin 81-200mg plus cilostazol 200mg (Dual group) and the single therapy with aspirin 81-200mg (Aspirin group) for 14 days. After the 14 days, all patients took the cilostazol 200mg for 3 months. Primary outcomes include 1) the neurological worsening within 14 day of onset; and 2) the rates of transient ischemic attack (TIA), stroke recurrence, intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH) within 14 days of onset. Secondary outcome included mRS score at 3 months after stroke. Results: 1,201 patients (796 [66%] men; median age [interquartile range], 69 [61-77] years) were randomized 1:1 to either the dual group or the aspirin group. Initial National Institutes of Health Stroke Scale score was similar as 2 (1-4) in both groups (p=0.617). As a primary outcome, the neurological worsening within 14 days was similarly observed in the dual and in the aspirin group (10.5% vs. 9.7%, P=0.701). The rates of TIA and stroke recurrence in the dual and in the aspirin group were also similar as 0.2% vs. 0.2% (p=1.000), and 1.2% vs. 1.3% (p=1.000), respectively. As a safety outcome, each group had one patient with ICH (0.2% vs. 0.2%, p=1.000). Only 1 patient (0.2%) in the dual group complained of SAH within 14 days of stroke onset, though it was asymptomatic (p=1.000). Regarding the secondary outcome, although preadmission mRS score of 0 was infrequent in the dual group (84% vs. 89%, p=0.054), the rate of mRS 0-1 at 3 months seemed to be frequent in the dual group than aspirin group (69% vs. 64% p=0.075). Conclusions: Dual antiplatelet therapy using cilostazol and aspirin does not reduce the rate of short-term neurological worsening. However, this combined therapy may improve the clinical outcome at 3 months of onset.

Background: Ischemic events caused by carotid artery stenosis are affected not only by stenosis but also by the instability of plaque. In symptomatic low-grade stenosis cases medical treatment is generally performed, but there are cases with repeated recurrence. The purpose of this study is to clarify the clinical features and long-term outcomes in cases of symptomatic low-grade stenosis. Methods: We included seventy-one symptomatic patients with carotid low-grade stenosis ( Results: The mean stenosis rate, rSI and ERR on admission were 20.4, 1.75 and 1.96, respectively. Seventy percent of cases involved intraplaque hemorrhage and positive remodeling. During a mean of 52-months follow-up, a recurrence of ischemic events was confirmed in 33 cases (46%), from which the duration until recurrence was within 7 days (33%), 3 months (18%), 1 year (18%), 2 years (21%), and over 2 years (15%). Nine cases had impending stroke, 3 of which were associated with major artery occlusion. CEA was performed in 28 cases (39%) for impending stroke (25%), recurrence of ischemic events (46%), asymptomatic infarction (7%), and stenosis rate progression (11%). During a mean of 47-months follow-up after CEA, 2 cases of death (fetal intracerebral hemorrhage, asphyxia) and one case of brain stem lacunar infarction were observed, but an ipsilateral ischemic event was not observed. Conclusion: Most of the symptomatic patients with low-grade stenosis had both intraplaque hemorrhage and positive remodeling. The risk of recurrence and stenosis progression was high. CEA might have had a preventive effect against ischemic events in low-grade stenosis.

[Aim]: In patients with carotid plaque, intraplaque hemorrhage arising from ruptured neovascular vessels within the neointima is an important cause of stroke. The expression of Vasohibin-1 (VASH1), a negative feedback regulator of angiogenesis, occurs in the microvessel endothelial cells of various solid tumors and the arterial wall. However, the roles of VASH1 in the pathogenesis of atherosclerotic diseases remain unclear. The present study aimed to clarify the relevance of the VASH1 expression and plaque instability in human carotid plaques. [Methods]: We used quantitative real-time PCR and immunostaining to examine 12 atheromatous plaque specimens obtained via carotid endarterectomy. The distal areas of specimens lacking macroscopic atherosclerotic lesions served as controls. [Results]: Compared with that observed in the controls, the VASH1 gene expression increased significantly in the atheromatous plaque (p=0.018). Moreover, the VASH1 mRNA levels correlated positively with those of VEGFA, CD31 and VCAM1 (r=0.788, p=0.004; r=0.99, p＜0.001; r=0.94, p＜0.001, respectively). Finally, the immunohistochemical analyses revealed the VASH1 expression in the neointimal microvessel endothelial cells of carotid plaque. [Conclusions]: The VASH1 expression levels in atheroma reflect both enhanced neovascularization and the inflammatory burden. Therefore, the VASH1 level may be a novel biomarker for evaluating plaque instability in patients with carotid arteriosclerosis and predicting ischemic stroke.

Objective To evaluate the efficacy of flow control of the internal carotid artery (ICA) by the clamping of the common carotid artery, external carotid artery, and superior thyroid artery during surgical ICA dissection to reduce ischemic complications after carotid endarterectomy (CEA). Methods Sixty-seven patients (59 men; age, 70.5 ± 6.2 years) who underwent CEA by the same surgeon were retrospectively studied. Both conventional CEA (n = 29) and flow-control CEA (n = 38) were performed with the patient under general anesthesia and with the use of somatosensory-evoked potential and near-infrared spectroscopy monitoring as a guide for selective shunting. The number of new postoperative infarcts was assessed with preoperative and postoperative diffusion-weighted images (DWIs) obtained within 3 days of surgery. In addition to surgical technique, the effects of the following factors on new infarcts also were examined: age, side of ICA stenosis, high-grade stenosis, symptoms, and application of shunting. Results New postoperative DWI lesions were observed in 7 of 67 patients (10.4%), and none of them was symptomatic. With respect to operative technique, the incidence rate of DWI spots was significantly lower in the flow-control group (2.6%) than in the conventional group (20.7%), odds ratio: 0.069; 95% confidence interval: 0.006–0.779; P = 0.031). On multiple logistic regression analysis, age, side of ICA stenosis, high-grade stenosis, symptoms, and the use of internal shunting did not have significant effects on new postoperative DWI lesions, whereas technique did have an effect. Conclusion The proximal flow-control technique for CEA helps avoid embolic complications during surgical ICA dissection.

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. 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. 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. 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.

Backgrounds and Purpose— Predictive value of reflux of anterior spinal artery for recurrent posterior circulation ischemia in bilateral vertebral arteries steno-occlusive disease was evaluated. Methods— We retrospectively reviewed 55 patients with symptomatic posterior circulation stroke caused by bilateral stenotic (>70%) lesions of the vertebral artery. We investigated any correlation of clinical and angiographic characteristics including collateral flow patterns, with recurrent stroke. Risk factors for poor 3-month functional outcome were also evaluated. Results— Recurrent posterior circulation stroke was observed in 15 (27.3%) patients. Multivariable analysis using Cox proportional hazards model showed anterior spinal artery reflux as a significant risk factor for stroke recurrence (adjusted hazard ratio, 19.3 [95% confidence interval, 5.35–69.9]; P P =0.028). Conclusions— In patients with symptomatic bilateral vertebral artery occlusive disease, anterior spinal artery reflux predicted recurrent posterior circulation stroke and poor functional outcome.

Introduction: Plasma D-dimer levels elevate during acute stage of aneurysmal subarachnoid hemorrhage (SAH) and are associated with poor functional outcomes. However, the mechanism in which D-dimer elevation on admission affects functional outcomes remains unknown. Hypothesis: We hypothesize that D-dimer levels on admission are correlated with systemic complications rather than neurological complications, and therefore have an additive predictive value on conventional risk factors for poor functional outcomes. Methods: A total of 187 patients with aneurymal SAH were retrospectively analyzed from a single center, observational cohort database. Correlations of plasma D-dimer levels on admission with patients’ characteristics, initial presentation, neurological complications, and systemic complications were identified. We also evaluated additive value of D-dimer elevation on admission for poor functional outcomes by comparing predictive models with and without D-dimer. Result and Conclusions: D-dimer elevation on admission was associated with increasing age, women, and severity of SAH. Patients with higher D-dimer levels had increased likelihood of nosocomial infections (OR 1.22 [95% CI 1.07-1.39], p = 0.004), serum sodium disorders (OR 1.11 [95% CI 1.01-1.23], p = 0.033), and cardiopulmonary complications (OR 1.20 [95% CI 1.04-1.37], p = 0.01) by multivariable analysis. D-dimer elevation was an independent risk factor of poor functional outcomes (modified Rankin scale 3-6, OR 1.50 [95% CI 1.15-1.95], p = 0.003). A novel prediction model with D-dimer had significantly better discrimination ability for poor outcomes than conventional models without D-dimer, evaluated by C statistics, net reclassification improvement, and integrated discrimination improvement methods. These results suggest that elevated D-dimer levels on admission were independently correlated with systemic complications, and had an additive value for outcome prediction on conventional risk factors after aneurysmal SAH.

Background Risk of delayed cerebral ischemia (DCI) in patients with aneurysmal subarachnoid hemorrhage (aSAH) with asymptomatic angiographic vasospasm on admission is unclear in the literature. The goal of this study is to identify predictors of clinical DCI in this group of patients. Methods An exploratory subgroup analysis was conducted in the SAHIT (Subarachnoid Hemorrhage International Trialists) data repository to identify predictors of clinical DCI in patients with good-grade aSAH (World Federation of Neurological Surgeons grade I and II) with angiographic vasospasm on admission. Predictors considered include age, sex, systolic blood pressure at presentation, World Federation of Neurological Surgeon grade, Fisher grade, aneurysm size and location, treatment modality, hydrocephalus requiring external ventricular drain insertion, and severity of vasospasm. The predictors were ranked based on dominance analysis with R2 as fit statistics and assessed in a set of logistic regression analysis models. Results Four data sets out of 16 studies in the SAHIT database were analyzed, with a total of 4125 patients. One hundred and ninety-one patients (4.6%) had asymptomatic angiographic vasospasm at admission. Of those, 78 patients (40.8%) developed clinical DCI. Univariate analysis showed significant associations between severe vasospasm on admission and development of clinical DCI (odds ratio, 9.5, 95% confidence interval, 2.07–43.50; P = 0.004). None of the studied predictors was associated with the development of clinical DCI on multivariate analysis. Conclusions Asymptomatic angiographic vasospasm in patients with good-grade aSAH on admission is uncommon. Further studies are needed to identify high-risk patients for the development of DCI in the context of asymptomatic early vasospasm.