A Case of Gallbladder Cancer with Trousseau Syndrome Successfully Treated Using Radical Resection

Trousseau syndrome is characterized by cancer-associated systemic thrombosis. We describe the first case of a successfully treated gallbladder adenocarcinoma accompanied by Trousseau syndrome. A 66-year-old woman presented with right hemiplegia. Magnetic resonance imaging identified multiple cerebral infarctions. Her serum carbohydrate antigen 19-9 and D-dimer levels were markedly elevated, and a gallbladder tumor was detected via abdominal computed tomography. Venous ultrasonography of the lower limbs revealed a deep venous thrombus in the right peroneal vein. These findings suggested that the brain infarctions were likely caused by Trousseau syndrome associated with her gallbladder cancer. Radical resection of the gallbladder tumor was performed. The resected gallbladder was filled with mucus and was pathologically diagnosed as an adenocarcinoma. Her postoperative course was uneventful, and she received a one-year course of adjuvant therapy with oral S-1. No cancer recurrence or thrombosis was noted 26 months postoperatively. Despite concurrent Trousseau syndrome, a radical cure of the primary tumor and thrombosis could be achieved with the appropriate treatment.

[Initial Treatment for Cerebral Infarction]

The treatment protocol for ischemic stroke has changed drastically in the past 20 years. In particular, the indications for recombinant tissue plasminogen activator(rt-PA)and thrombectomy have expanded. Using rt-PA or thrombectomy may be selected smoothly by receiving a call from the emergency team and efficiently collecting patient information, computed tomography scans, and blood samples. The total time required to prepare the equipment and devices should be reduced. To save as many patients as possible, a system should be established. A multidisciplinary approach is necessary from delivery to treatment to overcome the limitations of an individual doctor. Herein, we present our hospital's innovations to help other hospitals develop such systems.

[Acute endovascular thrombectomy for cerebral infarction]

Endovascular thrombectomy for large vessel occlusion ischemic stroke is one of the most effective treatments in medicine in the past few years, despite a serious risk of reperfusion bleeding. The Dutch guideline recommended treating patients within 6-24 hours from onset only in case of an infarct core 25 ml or less and a penumbra of at least the same size. These criteria need modification, considering the results of ANGEL-ASPECT, SELECT2 AND MR CLEAN LATE. Thrombectomy in several patients whose intervention was previously thought to be futile or dangerous has now been proven highly effective. The criteria for treatment in the later time window (> 6 hours since onset) are not very easy to implement, but here the recently published MR CLEAN LATE can offer solace: it confirmed that selection of patients in the late time window can be based on collateral circulation, so that ASPECT score and CT perfusion no longer have to be decisive.

[Application Effect of Continuous Lumbar Cistern Fluid Drainage Combined With Decompressive Craniectomy in the Treatment of Severe Craniocerebral Injury]

Objective

To analyze the application effect of continuous lumbar cistern fluid drainage combined with decompressive craniectomy in the treatment of severe craniocerebral injury.

Methods

A total of 87 patients with severe craniocerebral injury admitted to our hospital between March 2016 and March 2021 were retrospectively enrolled. They were divided into two groups according to the decompression methods applied, with 42 patients who received standard decompressive craniectomy assigned to the control group and 45 patients who received continuous lumbar cistern fluid drainage combined with standard decompressive craniectomy assigned to the observation group. The primary indicators that were monitored and compared between the two group included the amount of time for patient CT imaging to be clear of subarachnoid hemorrhage, the length-of-stay, the duration of post-operative intubation, the mannitol dose, scores for Glasgow Coma Scale (GCS), prognosis, the incidence of cerebral edema and cerebral infarction, and complications. The secondary indicators that were monitored and compared included intracranial pressure, cerebrospinal fluid antinucleosome protein SP100, and red blood cell count of the two groups before treatment and after continuous drainage for 7 days.

Results

The amount of time for CT imaging to be clear of subarachnoid hemorrhage and the length-of-stay of the observation group were shorter than those of the control group, the mannitol dose of the observation group was lower than that of the control group, the incidence of cerebral edema and the incidence of complications of the observation group were lower than those of the control group, and the rate of patients with good prognosis in the observation group was higher than that in the control group ( P<0.05). There was no significant difference in the rate of poor prognosis or mortality between the two groups ( P>0.05). The duration of postoperative intubation of the observation group was (8.24±1.09) d, while that of the control group was (9.22±1.26) d, and the difference between the two groups was statistically significant ( t=3.887, P<0.05). There were 2 cases (4.44%) of cerebral infarction in the observation group, with the infarct volume being (8.36±1.87) cm 3, while there were 9 cases (21.43%) of cerebral infarction in the control group, with the infarct volume being (8.36±1.87) cm 3, and there were statistically significant differences in the incidence and volume of cerebral infarction between the two groups ( χ 2=5.674, t=9.609, P<0.05). After treatment, the intracranial pressure and red blood cell count decreased in both groups and the intracranial pressure, cerebrospinal fluid SP100, and red blood cell count of the observation group were significantly lower than those of the control group ( P<0.05). The cerebrospinal fluid SP100 of the observation group decreased after treatment in comparison with the level before treatment ( P<0.05), while the pre- and post-treatment levels of the control group did not demonstrate any significant difference.

Conclusion

Continuous lumbar cistern fluid drainage in patients with severe craniocerebral injury effectively shortens the time required for the body to recover, significantly reduces the level of intracranial pressure, improves the levels of cerebral edema and cerebral infarction, and has a high degree of safety for prognosis and recovery.

The effect of butylphthalide on improving the neurological function of patients with acute anterior circulation cerebral infarction after mechanical thrombectomy

Butylphthalide can improve blood circulation in patients with acute cerebral infarction. Complement 3a receptor 1 (C3aR1) is involved in the regulation of innate immune response and pathogen monitoring, which is closely related to the pathophysiological processes of breast cancer, neurogenesis and lipid catabolism. Our study explored the therapeutic effect of butylphthalide on improving the neurological function of patients with acute anterior circulation cerebral infarction after mechanical thrombectomy, and evaluated the correlation between serum C3aR1 and butylphthalide on improving the neurological function after mechanical thrombectomy. 288 patients with acute anterior circulation cerebral infarction who were admitted to our hospital from January 2019 to November 2022 and were treated with mechanical thrombectomy for the first time were included in this retrospective study and divided into the butylphthalide group and control group that they received treatment methods. The National Institutes of Health Stroke Scale (NIHSS) scale was used to evaluate the patient neurological function treatment efficacy, and the modified Rankin Scale (mRS) scale was used to measure the patient neurological function status 3 months after surgery. Enzyme-linked immunosorbent assay method was used to determine the content of C3aR1 in serum. Two weeks after thrombus removal, the NIHSS efficacy of the butylphthalide group and the control group were 94.44% and 72.22%, respectively. The butylphthalide group was significantly higher than the control group (P < .001). Three months after the operation, the mRS score of the butylphthalide group was significantly lower than that of the control group (P = .001), and the excellent and good rate was significantly higher than that of the control group (P < .001). The serum C3aR1 level of the butylphthalide group was significantly lower than that of the control group 2 weeks after operation and 3 months after operation (P < .001). The serum C3aR1 was positively correlated with the efficacy of NIHSS (R = 0.815, P = .004), which was positively correlated with mRS score (R = 0.774, P = .007). Butylphthalide can improve the therapeutic effect of neurological function in patients with acute anterior circulation cerebral infarction after mechanical thrombus removal. The patient serum C3aR1 is related to the patient neurotherapy efficacy and neurological function status, and its level can reflect the patient neurological function recovery to a certain extent.

A case of moyamoya disease diagnosed as cerebral infarction in the early postpregnancy period and surgically treated by bilateral revascularization after term delivery

We treated a 37-year-old Japanese woman with moyamoya disease who developed cerebral infarction in the early period after pregnancy and had undergone infertility treatment. After being adequately informed, including regarding the risk of stroke in the perinatal period and the option to prioritize the treatment of moyamoya disease even if the pregnancy was interrupted, the patient decided to continue the pregnancy and underwent surgical treatment after a full-term delivery by caesarean section. No new stroke was observed throughout the perinatal period or postoperative course. Since serious stroke during the perinatal period has also been reported in moyamoya disease, it is important to plan "tailored" treatment by sufficiently informing patients considering individual backgrounds and for multiple medical departments, including obstetrics, neurology, and neurosurgery departments, to carry out close outpatient follow-up in the perinatal period and carefully careful medication usage and radiological examinations.

Association between Infarct Location and Hemorrhagic Transformation of Acute Ischemic Stroke following Successful Recanalization after Mechanical Thrombectomy

BACKGROUND AND PURPOSE

The association between infarct location and hemorrhagic transformation of acute ischemic stroke after mechanical thrombectomy is not understood. We aimed to evaluate the association between CTP-based ischemic core variables at admission and hemorrhagic transformation after a successful thrombectomy.

MATERIALS AND METHODS

We retrospectively analyzed patients who underwent endovascular thrombectomy for acute anterior circulation large-vessel occlusion between October 2019 and June 2021. We enrolled 146 patients with visible ischemic core on pretreatment CTP who had successful reperfusion. The ischemic core infarct territories were classified into the cortical and subcortical areas and then qualitatively and quantitatively analyzed by CTP. Logistic regression and receiver operating characteristic curve analyses were performed to determine the association between ischemic core variables and hemorrhagic transformation.

RESULTS

Of the 146 patients analyzed, 72 (49.3%) had hemorrhagic transformation and 23 (15.8%) had symptomatic intracerebral hemorrhage. Multivariate analysis showed that subcortical infarcts were independently associated with hemorrhagic transformation (OR, 8.06; 95% CI, 2.31-28.10; P = .001) and subcortical infarct volume was independently linked to symptomatic intracerebral hemorrhage (OR, 1.05; 95% CI, 1.01-1.09; P = .039). The receiver operating characteristic curve indicated that subcortical infarcts can predict hemorrhagic transformation accurately (area under the curve = 0.755; 95% CI, 0.68-0.82; P < .001) and subcortical infarct volume can predict symptomatic intracerebral hemorrhage (area under the curve = 0.694; 95% CI, 0.61-0.77; P = .002).

CONCLUSIONS

Subcortical infarcts seen on CTP at admission are associated with hemorrhagic transformation in patients after successful thrombectomy, and subcortical infarct volume may influence the risk of symptomatic intracerebral hemorrhage.

[Analysis of risk factors for readmission in elderly patients with hip fractures undergoing hip hemiarthroplasty]

OBJECTIVE

To explore the incidence and risk factors of readmission of elderly patients with hip fracture after hip hemiarthroplasty.

METHODS

A retrospective analysis of 237 elderly hip fracture patients who underwent hip hemiarthroplasty from February 2015 to October 2020 were performed. According to the readmission status of the patients at 3 months postoperatively, the patients were divided into readmission group (39 cases)and non-readmission group(198 cases). In readmission group, there were 7 males and 32 females with an average age of(84.59±4.34) years old, respectively, there were 34 males and 164 females with average age of (84.65±4.17) years old in non-readmission group. The general information, surgical status, hip Harris score and complications of patients in two groups were included in univariate analysis, and multivariate Logistic regression was used to analyze independent risk factors of patients' readmission.

RESULTS

The proportion of complications(cerebral infarction and coronary heart disease) in readmission group was significantly higher than that of non-readmission group (P<0.05), and intraoperative blood loss in readmission group was significantly higher than that of non-readmission group(P<0.05). Harris score of hip joint was significantly lower than that of non-readmission group(P<0.05). The proportion of infection, delirium, joint dislocation, anemia and venous thrombosis in readmission group were significantly higher than that of non-readmission group (all P<0.05). Multivariate Logistic regression analysis showed that the risk factors for readmission of elderly patients with hip fracture after hip hemiarthroplasty included cerebral infarction, infection, delirium, dislocation, anemia and venous thrombosis (all P<0.05).

CONCLUSION

The complications of the elderly patients who were readmission after hip hemiarthroplasty for hip fractures were significantly higher than those who were non-readmission. Cerebral infarction, infection, delirium, dislocation, anemia and venous thrombosis are risk factors that lead to patient readmission. Corresponding intervention measures can be taken clinically based on these risk factors to reduce the incidence of patient readmissions.

Decompressive craniectomy combined with temporal pole resection in the treatment of massive cerebral infarction

OBJECTIVE

To evaluate the efficacy and prognosis of decompressive craniectomy combined with temporal pole resection in the treatment of massive cerebral infarction, in order to provide basis for treatment selection.

METHODS

The clinical data of the patient with massive cerebral infarction treated in our hospital from January 2015 to December 2018 were analyzed retrospectively. According to the surgical methods, the patients were divided into control group (decompressive craniectomy) and study group (decompressive craniectomy + temporal pole resection). Intracranial pressure monitoring devices were placed in both groups. The NIHSS scores of the two groups before and 14 days after operation, the changes of intracranial pressure, length of hospital stay, length of NICU, mortality and modified Rankin scale before and after treatment were compared between the two groups.

RESULTS

The NIHSS score of the two groups after operation was lower than that before operation, and the NIHSS score of the study group was significantly lower than that of the control group (P < 0.05); The intracranial pressure in the study group was significantly lower than that in the control group (P < 0.05); One month after operation, the mortality of the study group (13.0%) was lower than that of the control group (27.8%). After one year of follow-up, the mortality of the study group (21.7%) was significantly lower than that of the control group (38.8%) (P < 0.05); The scores of mRS in the two groups were significantly improved compared with those before treatment (P < 0.05), and the scores of mRS in the study group were better than those in the control group (P < 0.05).

CONCLUSION

Decompressive craniectomy combined with temporal pole resection has a better effect in the treatment of patients with massive cerebral infarction. It has good decompression effect, the postoperative intracranial pressure is well controlled, and significantly reduced the mortality. So it has better clinical application value.

Prognostic factors for acute posterior circulation cerebral infarction patients after endovascular mechanical thrombectomy: A retrospective study

This article was to analyze the factors influencing the prognosis of posterior circulation cerebral infarction (PCCI) patients, retrospectively.One hundred forty five patients diagnosed with PCCI in Nanyang Central Hospital between June 25, 2016 and October 14, 2019 were included and underwent cerebral vascular mechanical thrombectomy. The clinical data of those patients were collected. The patients were followed up for 3 months to observe the prognostic efficacy and explore the influencing factors for poor prognosis. The potential prognostic factors for PCCI patients after emergency endovascular mechanical thrombectomy were analyzed by univariate and multivariable logistic regression. The thermodynamic diagram was drawn to explore the associations between the prognostic factors.The risk of poor prognosis in PCCI patients receiving emergency endovascular mechanical thrombectomy was reduced by 0.552 time with every 1-point increase of the Alberta Stroke Program Early CT in posterior circulation score (odds ratio [OR] = 0.448, 95% confidence interval [CI]: 0.276-0.727). The risk of poor prognosis was increased by 0.827 time for each additional grade in the digital subtraction angiography-American Society of Intervention and Therapeutic Neuroradiology grading (OR = 1.827, 95% CI: 1.221-2.733, P = .003) and increased by 0.288 time for every 1-point increase in National Institutes of Health Stroke scale at 24 hours (OR = 1.288, 95% CI: 1.161-1.429). All P < .05.Alberta Stroke Program Early CT in posterior circulation score, digital subtraction angiography-American Society of Intervention and Therapeutic Neuroradiology grading, National Institutes of Health Stroke scale score at 24 hours were factors affecting the prognosis of PCCI patients undergoing emergency endovascular mechanical thrombectomy, which might provide evidence for endovascular treatment of PCCI.

Comparative study on treatment of acute cerebral infarction between mechanical thrombectomy by micro catheter and thrombectomy by Solitaire AB stent

BACKGROUND

Acute cerebral artery occlusion is a common disease with high morbidity and mortality. At present, the commonly used mechanical thrombectomy schemes are mechanical thrombectomy and stent thrombectomy. However, the clinical differences between the two methods is not fully understood. The present study aimed to evaluate the clinical effectiveness of Solitaire AB stent thrombectomy for acute cerebral infarction (ACI).

METHODS

A retrospective study was carried out in 96 ACI patients admitted to our department from January 2017 to January 2020. According to the treatment they received, they were divided into group A (conventional microcatheter mechanical thrombectomy, n = 48) and group B (Solitaire AB stent thrombectomy, n = 48). All patients were followed up for 3 months. Their pre- and post-operative nerve function indices were compared between the 2 groups. The therapeutic effects were evaluated by thrombolysis in cerebral infarction scale system, Glasgow coma scale (GCS), National Institutes of Health Stroke Scale (NIHSS), and modified Rankin scale statistics.

RESULTS

Two groups of patients with NIHSS scores postoperative 3 and 30 days decreased significantly compared with preoperation. NIHSS score of group A 3 and 30 days postoperation was significantly higher than group B (P < .05). Two groups of patients with GCS scores postoperative 3 and 30 days increased significantly compared with preoperation. GCS score of group A 3 and 30 days postoperation was significantly lower than group B (P < .05). Group B with vascular recanalization ratio postoperative 30 days was higher than group A, however with no significant differences (P > .05). Moreover, group B with outcomes (modified Rankin scale score ≤2 points) postoperative 3 months was better than group A, however with no significant differences (P > .05).

CONCLUSION

Solitaire AB stent embolectomy shows similar efficacy as mechanical thrombectomy in the treatment of ACI patients.

Predicting hemorrhagic transformation after large vessel occlusion stroke in the era of mechanical thrombectomy

Serum biomarkers are associated with hemorrhagic transformation and brain edema after cerebral infarction. However, whether serum biomarkers predict hemorrhagic transformation in large vessel occlusion stroke even after mechanical thrombectomy, which has become widely used, remains uncertain. In this prospective study, we enrolled patients with large vessel occlusion stroke in the anterior circulation. We analyzed 91 patients with serum samples obtained on admission. The levels of matrix metalloproteinase-9 (MMP-9), amyloid precursor protein (APP) 770, endothelin-1, S100B, and claudin-5 were measured. We examined the association between serum biomarkers and hemorrhagic transformation within one week. Fifty-four patients underwent mechanical thrombectomy, and 17 patients developed relevant hemorrhagic transformation (rHT, defined as hemorrhagic changes ≥ hemorrhagic infarction type 2). Neither MMP-9 (no rHT: 46 ± 48 vs. rHT: 15 ± 4 ng/mL, P = 0.30), APP770 (80 ± 31 vs. 85 ± 8 ng/mL, P = 0.53), endothelin-1 (7.0 ± 25.7 vs. 2.0 ± 2.1 pg/mL, P = 0.42), S100B (13 ± 42 vs. 12 ± 15 pg/mL, P = 0.97), nor claudin-5 (1.7 ± 2.3 vs. 1.9 ± 1.5 ng/mL, P = 0.68) levels on admission were associated with subsequent rHT. When limited to patients who underwent mechanical thrombectomy, the level of claudin-5 was higher in patients with rHT than in those without (1.2 ± 1.0 vs. 2.1 ± 1.7 ng/mL, P = 0.0181). APP770 levels were marginally higher in patients with a midline shift ≥ 5 mm than in those without (79 ± 29 vs. 97 ± 41 ng/mL, P = 0.084). The predictive role of serum biomarkers has to be reexamined in the mechanical thrombectomy era because some previously reported serum biomarkers may not predict hemorrhagic transformation, whereas the level of APP770 may be useful for predicting brain edema.

Neutrophil-to-Albumin Ratio as a Biomarker of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

This study set out to investigate the relationships between the neutrophil-to-albumin ratio (NAR) in the early stages of aneurysmal subarachnoid hemorrhage (aSAH) and the occurrence of delayed cerebral ischemia (DCI).

METHODS

A total of 439 patients with aSAH were included in this retrospective study. NAR assessment was conducted on admission. The relationship between NAR and DCI was analyzed.

RESULTS

Eighty-four patients (23.7%) experienced DCI. NAR levels were significantly higher in patients with DCI after aSAH than without DCI (median [interquartile range] 0.350 [0.274-0.406] vs. 0.240 [0.186-0.300]; P < 0.001). NAR levels were correlated with World Federation of Neurological Surgeons (WFNS) grade and modified Fisher (mFisher) grade (r = 0.505 and 0.394, respectively). NAR and mFisher grade were the independent predictors of DCI. Under receiver operating characteristic curve, NAR levels exhibited a significant discriminatory capability (area under the curve [95% confidence interval] 0.812 [0.740-0.823]; P < 0.001). The predictive power of NAR levels was similar to mFisher grade (P > 0.05).

CONCLUSIONS

NAR, in positive correlation with the severity of hemorrhage, appears to be a novel predictive biomarker of DCI after aSAH.

[Giant Left Atrial Myxoma Complicated with Hemorrhagic Cerebral Infarction]

A 48-year-old woman developed paralysis of the left upper limb and dysarthria. Two days later, she was admitted to a local hospital due to no improvement of symptoms. Brain magnetic resonance imaging showed acute hemorrhagic cerebral infarction in the left nucleus basalis. Echocardiography demonstrated a large left atrial mass in the left atrium, shuttling between the left atrium and the left ventricle and moderate mitral regurgitation. Then, she was transferred to our hospital for surgery. Five days after the initial symptoms, resection of the left atrial mass was performed under total cardiopulmonary bypass. First, heparin sodium, and then nafamostat mesilate were used as intraoperative anticoagulation treatment. The left mitral mass was removed via an atrial septal incision and the defect was repaired using a bovine pericardium. The mitral valve was intact and there was no regurgitation. The mass was immunohistologically diagnosed as myxoma. Postoperative brain computed tomography scans demonstrated no exacerbation of the cerebral infarction. She was discharged 13 days after surgery without neurological symptoms.

Tentorial Branch of the Superior Cerebellar Artery with Retrograde Flow to Partially Thrombosed Large Superior Cerebellar Artery Aneurysm

BACKGROUND

Although the tentorial branch of the superior cerebellar artery (SCA) was reported to be a frequent finding in living subjects in 1 study, its clinical relevance, especially in surgery for aneurysms, has not been elucidated. We present our experience with the tentorial branch of the SCA identified during surgical intervention of a distal SCA aneurysm and discuss its clinical relevance.

CASE DESCRIPTION

A 71-year-old woman presented with cerebral infarction in the SCA area, and a partially thrombosed, large, fusiform aneurysm was found in the lateral pontomesencephalic segment of the SCA. Despite trapping of the aneurysm, arterial flow was observed on postprocedural Doppler flow examination and indocyanine green angiography. Careful inspection of the area led to the identification of a small tentorial branch of the SCA as a retrograde feeder. Coagulation of the artery led to the successful completion of the trapping. Postoperatively, the patient did not develop new neurologic deficits.

CONCLUSIONS

This is the first report to our knowledge of a clinical association of the tentorial branch of the SCA with a distal SCA aneurysm, which played an important role in achieving complete obliteration of the aneurysm. The recognition of this small artery is potentially important for successful cure of distal SCA aneurysms.

Malignant Cerebral Venous Infarction: Decompressive Craniectomy versus Medical Treatment

BACKGROUND

Cerebral venous thrombosis (CVT) is a common type of stroke in young adults and associated with 8% mortality. High intracranial pressure (ICP) and brain herniation are the most common causes of death in these patients. In contrast with malignant arterial middle cerebral infarction, there are few studies reporting the efficacy of decompressive craniectomy (DC) for treatment of high ICP in patients with CVT. In this study, we assess the clinical outcome of patients with CVT with impending brain herniation treated with DC versus medical management.

METHODS

In this retrospective study, medical records of all patients with CVT admitted to our hospital were reviewed. Patients with the following inclusion criteria were entered into the study: 1) CVT proven by contrast-enhanced magnetic resonance venogram and/or computed tomography venogram, 2) malignant CVT (impending brain herniation according to imaging and clinical finding), and 3) age between 16 and 80 years. Patients with deep venous system thrombosis, Glasgow Coma Scale (GCS) score of 3, and bilateral nonreactive midposition pupils or mydriasis on admission were excluded. Patients were classified into 2 groups: surgical group (DC group) including patients who received medical treatment and DC and medical group (MG) including patients who received only medical treatment. Outcomes and complications were assessed and compared between the 2 groups.

RESULTS

Of 357 patients with CVT hospitalized in our center, 48 patients entered into the study. Twenty-three patients were managed medically, and 25 patients were managed surgically. There was no significant difference between the groups concerning age, sex, presenting symptoms, transient and permanent risk factors of CVT, GCS score on admission, and pupils' reactivity on admission. All patients in the MG died during hospitalization in comparison with 8 patients in the DC group (100% vs. 32%, P < 0.001). Favorable outcome (modified Rankin scale score 0-2) was achieved in 52% of the DC group and 0% of the MG group (P < 0.001).

CONCLUSIONS

The results of our study confirmed that in contrast with DC, medical treatment could not prevent transtentorial herniation. DC is not only lifesaving for patients with CVT with impending brain herniation but also results in favorable outcome in most patients.

Recurrent thrombosis after carotid endarterectomy secondary to activated protein C resistance and essential thrombocytosis: A case report

RATIONALE

Thrombosis is a major cause of morbidity in the perioperative period. Although many risk factors are known, activated protein C resistance is a prominent risk for thrombosis. Activated protein C resistance frequently occurs with recurrent thromboembolism.

PATIENT CONCERNS

A 59-year-old Korean woman patient with hypertension was admitted due to dysarthria and left side motor weakness.

DIAGNOSIS AND INTERVENTIONS

Magnetic resonance imaging showed subacute cerebral infarction with right frontoparietal lobe and stenosis at the right internal carotid artery. She underwent right carotid endarterectomy under general anesthesia. However, recurrent thrombosis on postoperative day 1 was noted at patient's right carotid artery, which prompted emergency surgery. Additional preoperative laboratory review revealed findings for activated protein C resistance, low protein S activity, antinuclear antibody (>1:160), anti-cardiolipin IgM antibody (16.6), and thrombocytosis, Janus kinase and factor V Leiden mutations. At the intensive care unit, heparin was continually infused until postoperative day 12 and was then switched to warfarin.

OUTCOMES

Patient was discharged at postoperative day 21 without any event. Patient had no signs of recurrence within the 3-year follow-up period, and she is still on oral warfarin and clopidogrel.

LESSONS

Screening test for hypercoagulability can be used to identify patients at higher risk of postoperative complications. If hypercoagulability state is confirmed by laboratory testing, a suitable anticoagulant treatment plan should be made within the perioperative period.

Efficacy and safety of direct aspiration versus stent-retriever for recanalization in acute cerebral infarction: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND AND PURPOSE

Whether the direct aspiration approach of thrombectomy for recanalization in patients with acute ischemic stroke has a similar efficacy and safety compared to the stent-retriever remains uncertain.

METHODS

We conducted a meta-analysis of 9 studies obtained through PubMed and Embase database searches to determine whether successful recanalization rate, good functional outcome at 3 months (modified Rankin score, mRS≤2), procedure time from groin puncture to maximal revascularization and procedure-related adverse events differed between patients who underwent the direct aspiration and those receiving stent-retriever for recanalization in acute cerebral infarction.

RESULTS

There was no significant difference between the direct aspiration group and the stent-retriever group in rate of successful recanalization (summary odds ratio [OR], 0.86 [95% confidence interval (CI), 0.45-1.52]; P = .60), but a better functional outcomes in the direct aspiration group at 3 months defined as a mRS score of 0 to 2 (OR, 0.77; 95% CI, 0.66-0.97; P = .03). Furthermore, the direct aspiration patients compared with the stent-retriever patients had a tendency of shorter procedural time (Mean difference [MD], -8.77 [95% CI, from-18.90 to 1.37]; P = .09). Finally, there were less adverse events especially in symptomatic intracerebral hemorrhage (sICH) (OR, 0.56; 95% CI, 0.33-0.98; P = .04) and embolization to a new territory (ENT) (OR, 0.49; 95% CI, 0.28-0.84; P = .01) in the direct aspiration group when compared with the stent-retriever group, although no difference between them in the rate of any ICH (OR, 0.81; 95% CI, 0.41-1.60; P = .54).

CONCLUSIONS

The results support that the direct aspiration technique for those acute ischemic stroke patients may have better functional outcomes, less procedure related-adverse events and a tendency of faster revascularization time as compared to the stent-retriever thrombectomy, with a similar successful recanalization rate. However, major limitations of current evidence (mainly from retrospective and observational studies and a small number of patients population) indicate a need for adequately powered, multicenter randomized controlled trials (RCT) to answer this question.

A Young Patient with Emery-Dreifuss Muscular Dystrophy Treated with Endovascular Therapy for Cardioembolic Stroke: A Case Report

We had a case of Emery-Dreifuss muscular dystrophy (EDMD) in an 18-year-old woman who underwent endovascular therapy for a cardioembolic stroke. At 5 years old, she showed a high creatine kinase level and atrial fibrillation on electrocardiography in our hospital. Finally, she was diagnosed as having EDMD by genetic screening that revealed mutations in the LMNA gene (c.810+1G>T). Before this event, she received no medications. At 18 years old, she was admitted to our hospital>8 hours after the onset of sudden consciousness disturbance. Neurological examination on admission revealed consciousness disturbance and right hemiplegia. Magnetic resonance imaging revealed a cerebral infarction in the left insular cortex and putamen with left internal carotid artery occlusion. We performed endovascular therapy and completely recanalized her left internal carotid artery. Thereafter, her neurological symptoms improved. She was subsequently transferred to a rehabilitation hospital. EDMD is a rare genetic muscular disease that mainly presents with contractures, weakness, and cardiac conduction abnormalities. Although patients with EDMD are young with low CHADS₂ score, they have a disease-specific cardiovascular pathogenesis caused by a fatal risk factor. Therefore, we consider anticoagulant therapy necessary to prevent thrombotic events, even if the CHADS₂ score is low, in patients with EDMD.

Improved visualisation of early cerebral infarctions after endovascular stroke therapy using dual-energy computed tomography oedema maps

OBJECTIVE

The aim was to investigate whether dual-energy computed tomography (DECT) reconstructions optimised for oedema visualisation (oedema map; EM) facilitate an improved detection of early infarctions after endovascular stroke therapy (EST).

METHODS

Forty-six patients (21 women; 25 men; mean age: 63 years; range 24-89 years) were included. The brain window (BW), virtual non-contrast (VNC) and modified VNC series based on a three-material decomposition technique optimised for oedema visualisation (EM) were evaluated. Follow-up imaging was used as the standard for comparison. Contralateral side to infarction differences in density (CIDs) were determined. Infarction detectability was assessed by two blinded readers, as well as image noise and contrast using Likert scales. ROC analyses were performed and the respective Youden indices calculated for cut-off analysis.

RESULTS

The highest CIDs were found in the EM series (73.3 ± 49.3 HU), compared with the BW (-1.72 ± 13.29 HU) and the VNC (8.30 ± 4.74 HU) series. The EM was found to have the highest infarction detection rates (area under the curve: 0.97 vs. 0.54 and 0.90, p < 0.01) with a cut-off value of < 50.7 HU, despite slightly more pronounced image noise. The location of the infarction did not affect detectability (p > 0.05 each).

CONCLUSIONS

The EM series allows higher contrast and better early infarction detection than the VNC or BW series after EST.

KEY POINTS

• Dual-energy CT EM allows better early infarction detection than standard brain window. • Dual-energy CT EM series allow better early infarction detection than VNC series. • Dual-energy CT EM are modified VNC based on water content of tissue.

Cerebral infarction due to malposition of cervical pedicle screw: A case report

RATIONALE

Malposition of cervical pedicle screw (CPS) has a risk of vertebral artery (VA) injury which sometimes may cause unexpected and catastrophic outcome. A rare case of delayed onset of cerebral infarction caused by malposition of CPS was reported.

PATIENT CONCERNS

A 23-year-old man who underwent a posterior cervical reduction and fusion of C4-5 using CPS fixation and allograft for cervical spine injury is presented. The patient suffered progressively weakness and numbness for both of upper and lower extremities 1 day after the operation. Computed tomography scans revealed bilateral occupation of the pedicle screws in the foramen of C4 and C5 and the magnetic resonance imaging (MRI) displayed several areas of infarction in the brainstem and cerebellum.

DIAGNOSES

Plain radiographs of the cervical spine revealed the C4 vertebral body and MRI displayed a disruption of the anterior longitudinal ligament on the level of C4-5 and severe injury to the soft tissues of the cervical spine at admission. Brainstem and cerebellum infarction was diagnosed at postoperative.

INTERVENTION

A revision surgery was decided to remove all of the pedicle screws and place lateral mass screws instead.

OUTCOMES

The patient felt better on his all of 4 extremities following revision surgery. Fortunately, he was neurologically close to normal at a 3-month follow-up.

LESSONS

Delayed onset of cerebral infarction is rarely reported complication caused by malposition of CPS. When a CPS perforates the transverse foramen and causes symptom of cerebral infarction, a revision surgery in time is strongly recommended to prevent further sequelae.

Diagnostic Utility of Contrast-enhanced 3D T1-weighted Imaging in Acute Cerebral Infarction Associated with Graves Disease

Graves disease is rarely complicated with cerebrovascular steno-occlusive diseases. Previous studies have suggested several hypotheses for this occurrence, including excess thyroid hormone, which stimulates the sympathetic nervous system, which in turn causes an abnormal hemodynamic response with consequent atherosclerotic changes, and antithyroid antibodies cause local vascular inflammation in patients with Graves disease. However, radiological findings of vasculitis in patients with Graves disease and cerebral infarction remain less known. We report the case of a 30-year-old Japanese woman with acute cerebral infarction due to vasculitis associated with Graves disease. She was admitted to our hospital with a 4-day history of intermittent transient dysarthria and limb shaking of the left leg when standing. Three weeks before admission, she went to a local hospital because of general malaise and was diagnosed with Graves disease. Neurological examination revealed paralytic dysarthria, left central facial nerve palsy, and left hemiparesis (manual muscle testing, 4 of 5). Blood examinations showed hyperthyroidism (thyroid-stimulating hormone ≤.010 µU/mL; free T3 ≥25.0 pg/mL; free T4 ≥8.0 ng/dL) and elevation of antithyroid antibody levels (thyroid peroxidase antibody, 87 IU/mL). The vessel wall of the right internal carotid artery was markedly enhanced on contrast-enhanced three-dimensional T1-weighted magnetic resonance imaging, suggesting vasculitis. Magnetic resonance angiography revealed right internal carotid artery occlusion after the branching ophthalmic artery. Arterial stenosis due to vasculitis was considered the cause of hemodynamic ischemic stroke. Vessel wall imaging such as high-resolution contrast-enhanced T1-weighted imaging seems useful for assessing the underlying mechanism of stroke in patients with Graves disease.

Juvenile Cerebral Infarction Caused by Bow Hunter's Syndrome during Sport: Two Case Reports

We report two cases of juvenile cerebral infarction caused by bow hunter's syndrome (BHS) during sport. Case 1 was a 17-year-old male who developed a partial visual field defect after playing basketball. BHS was diagnosed because cervical ultrasonography demonstrated occlusion of the vertebral artery when the neck was rotated. After C1-2 posterior fixation was performed, his symptoms resolved. Case 2 was an 18-year-old male with recurrent visual disturbance after playing handball. Cerebral infarction occurred repeatedly despite antiplatelet therapy. After 3 years, vertebral artery dissection was diagnosed and stenting was performed, but his symptoms did not resolve. BHS was diagnosed when he was examined at our department. C1-2 posterior fixation was performed and his symptoms resolved. In these two cases, BHS was caused by sporting activity. For accurate diagnosis and treatment of BHS, neuroimaging with cervical rotation is mandatory.

Cerebral infarct volume measurements to improve patient selection for endovascular treatment

Patients who have large cerebral infarctions may not be good candidates for endovascular treatment. Various methods for determining infarct volume have been used in clinical studies. We evaluated the effectiveness of several methods for measuring infarct volume, especially regarding futile outcomes despite endovascular treatment.Patients with acute ischemic stroke in unilateral anterior circulation territory who were treated with intra-arterial thrombectomy were included. For assessing infarct volume, the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) scoring system was applied to images obtained by noncontrast computed tomography (NCCT), postcontrast CT (PCCT), and diffusion-weighted imaging (DWI). DWI stroke volume was semiquantitatively measured with the manually outlined hyperintense lesion. Infarct core volume was calculated with a threshold apparent diffusion coefficient value of 600 × 10 mm/s. Intraclass correlation coefficients (ICC) were estimated to assess inter-reader reliability for ASPECTS scoring and DWI stroke volume. Receiver operating characteristic (ROC) curve analyses, and univariable and multivariable comparative analyses, were performed with each evaluation method to predict futile outcome (modified Rankin Scale score 5-6).The mean age of the included 79 patients was 65.1 ± 15.7 years. Among them, 55 (69.6%) patients demonstrated successful reperfusion after intra-arterial thrombectomy, but 34 (43.0%) patients had futile outcomes. Inter-reader agreement was excellent for measurement of the DWI stroke volume (ICC, 0.973), DWI ASPECTS (0.940), and PCCT ASPECTS (0.859), but was moderate for NCCT ASPECTS (0.694). Regarding prediction of futile outcomes, area under ROC curve was 0.551 on NCCT ASPECTS and it was significantly smaller than that in PCCT ASPECTS (area under ROC 0.651, P = 0.030), DWI ASPECTS (0.733, P = 0.003), DWI stroke volume (0.702, P = 0.022), and infarct core volume (0.702, P = 0.021). Besides old age and high National Institutes of Health Stroke Scale score on admission, MRI parameters such as DWI ASPECTS and infarct core volume indicating large volumes were independently associated with futile outcomes in multivariable analyses.DWI ASPECTS can be a good parameter predicting futility, which is easily measured and has high prediction power.

Prediction of infarction development after endovascular stroke therapy with dual-energy computed tomography

OBJECTIVES

After intraarterial recanalisation (IAR), the haemorrhage and the blood-brain barrier (BBB) disruption can be distinguished using dual-energy computed tomography (DECT). The aim of the present study was to investigate whether future infarction development can be predicted from DECT.

METHODS

DECT scans of 20 patients showing 45 BBB disrupted areas after IAR were assessed and compared with follow-up examinations. Receiver operator characteristic (ROC) analyses using densities from the iodine map (IM) and virtual non-contrast (VNC) were performed.

RESULTS

Future infarction areas are denser than future non-infarction areas on IM series (23.44 ± 24.86 vs. 5.77 ± 2.77; p < 0.0001) and more hypodense on VNC series (29.71 ± 3.33 vs. 35.33 ± 3.50; p < 0.0001). ROC analyses for the IM series showed an area under the curve (AUC) of 0.99 (cut-off: <9.97 HU; p < 0.05; sensitivity 91.18 %; specificity 100.00 %; accuracy 0.93) for the prediction of future infarctions. The AUC for the prediction of haemorrhagic infarctions was 0.78 (cut-off >17.13 HU; p < 0.05; sensitivity 90.00 %; specificity 62.86 %; accuracy 0.69). The VNC series allowed prediction of infarction volume.

CONCLUSIONS

Future infarction development after IAR can be reliably predicted with the IM series. The prediction of haemorrhages and of infarction size is less reliable.

KEY POINTS

• The IM series (DECT) can predict future infarction development after IAR. • Later haemorrhages can be predicted using the IM and the BW series. • The volume of definable hypodense areas in VNC correlates with infarction volume.

Correlation of AOL recanalization, TIMI reperfusion and TICI reperfusion with infarct growth and clinical outcome

OBJECTIVE

To understand how three commonly used measures of endovascular therapy correlate with clinical outcome and infarct growth.

METHODS

Prospectively enrolled patients underwent baseline MRI and started endovascular therapy within 12 h of stroke onset. The final angiogram was given a primary arterial occlusive lesion (AOL) recanalization score (0-3), a Thrombolysis in Myocardial Infarction (TIMI) score (0-3) and a Thrombolysis in Cerebral Infarction (TICI) score (0-3). The scores were dichotomized into poor revascularization (AOL 0-2, TIMI 0-1 and TICI 0-2a) versus good revascularization (AOL 3, TIMI 2-3, TICI 2b-3). Patients were classified according to whether or not they had target mismatch (TMM). Good outcome was defined as a 90-day modified Rankin Scale score of 0-2.

RESULTS

Endovascular treatment was attempted in 100. A good outcome was achieved in 57% of patients with a TICI score of 2b-3 and in 24% of patients with a TICI score of 0-2a (p=0.001). Patients with TIMI scores of 2-3 and an AOL score of 3 had lower rates of good outcome (44% and 47%, respectively), which were not significantly better than those with TIMI scores of 0-1 or AOL scores of 0-2. In patients with TMM, these rates of good outcome improved with all the scoring systems and were significantly better for TIMI and TICI scores. Patients with a TICI score of 2a had rates of good functional outcome and lesion growth which were not different from those with TICI scores of 0-1 but were significantly worse than those with TICI scores of 2b-3.

CONCLUSIONS

TIMI 2-3 and TICI 2b-3 reperfusion scores demonstrated improved outcome in patients with tissue mismatch with a small infarct core and a larger hypoperfused region but AOL scores did not. Patients with a TICI score of 2a had a poorer outcome and more lesion growth than those with TICI scores of 2b-3.

[Clinical observation of middle cerebral artery angioplasty in treatment of subcortex cerebral watershed infarction with moderate or severe disabilities]

OBJECTIVE

To assess the safety and effectiveness of middle cerebral artery angioplasty in treatment of subcortical watershed infarcts (S-CWI) with moderate or severe disabilities.

METHODS

From June 2011 to May 2012, 5 S-CWI patients (six lesions) with moderate or severe disabilities combining severe stenosis in Ipsilateral middle cerebral artery received middle cerebral artery angioplasty in Interventional Radiology and Vascular Surgery Department, Peking University Third Hospital. We observed the neurological score before and after angioplasty and assessed the improvement of neurological functions.

RESULTS

The National Institute of Health stroke scale(NIHSS) scores were decreased by 4-6 points and modified Rankin scale(mRs) scores were decreased 1 point in 7 days. In the 3 months' follow-up, 4 patients' mRs scores were 1 point, and 1 patient's was 2 points. In the 1-year follow-up, there were no new strokes and instent restenosis events.

CONCLUSION

Middle cerebral artery angioplasty in treatment of S-CWI with moderate or severe disabilities is beneficial.

Perforator infarction immediately distal to the stenosis of parental artery: is it hemodynamic?

Perforator infarction accompanying intracranial atherosclerosis is usually explained by the obstruction of perforator by atheroma of the parent artery. However, the improvement of neurologic symptom after stenting is hardly explained by the concept. Here, we report a case of perforator infarction caused by the unique hemodynamic condition of the poststenotic area without any plaque at the origin of perforator, which was confirmed by high-resolution magnetic resonance image. Poststenotic area with eddying flow separating the region from the main flow may hemodynamically contribute to the perforator infarction and neurologic symptom.

Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

There are uncertainties surrounding the optimal management of patients with brain swelling after an ischemic stroke. Guidelines are needed on how to manage this major complication, how to provide the best comprehensive neurological and medical care, and how to best inform families facing complex decisions on surgical intervention in deteriorating patients. This scientific statement addresses the early approach to the patient with a swollen ischemic stroke in a cerebral or cerebellar hemisphere.

METHODS

The writing group used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge. The panel reviewed the most relevant articles on adults through computerized searches of the medical literature using MEDLINE, EMBASE, and Web of Science through March 2013. The evidence is organized within the context of the American Heart Association framework and is classified according to the joint American Heart Association/American College of Cardiology Foundation and supplementary American Heart Association Stroke Council methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive American Heart Association internal peer review.

RESULTS

Clinical criteria are available for hemispheric (involving the entire middle cerebral artery territory or more) and cerebellar (involving the posterior inferior cerebellar artery or superior cerebellar artery) swelling caused by ischemic infarction. Clinical signs that signify deterioration in swollen supratentorial hemispheric ischemic stroke include new or further impairment of consciousness, cerebral ptosis, and changes in pupillary size. In swollen cerebellar infarction, a decrease in level of consciousness occurs as a result of brainstem compression and therefore may include early loss of corneal reflexes and the development of miosis. Standardized definitions should be established to facilitate multicenter and population-based studies of incidence, prevalence, risk factors, and outcomes. Identification of patients at high risk for brain swelling should include clinical and neuroimaging data. If a full resuscitative status is warranted in a patient with a large territorial stroke, admission to a unit with neurological monitoring capabilities is needed. These patients are best admitted to intensive care or stroke units attended by skilled and experienced physicians such as neurointensivists or vascular neurologists. Complex medical care includes airway management and mechanical ventilation, blood pressure control, fluid management, and glucose and temperature control. In swollen supratentorial hemispheric ischemic stroke, routine intracranial pressure monitoring or cerebrospinal fluid diversion is not indicated, but decompressive craniectomy with dural expansion should be considered in patients who continue to deteriorate neurologically. There is uncertainty about the efficacy of decompressive craniectomy in patients ≥60 years of age. In swollen cerebellar stroke, suboccipital craniectomy with dural expansion should be performed in patients who deteriorate neurologically. Ventriculostomy to relieve obstructive hydrocephalus after a cerebellar infarct should be accompanied by decompressive suboccipital craniectomy to avoid deterioration from upward cerebellar displacement. In swollen hemispheric supratentorial infarcts, outcome can be satisfactory, but one should anticipate that one third of patients will be severely disabled and fully dependent on care even after decompressive craniectomy. Surgery after a cerebellar infarct leads to acceptable functional outcome in most patients.

CONCLUSIONS

Swollen cerebral and cerebellar infarcts are critical conditions that warrant immediate, specialized neurointensive care and often neurosurgical intervention. Decompressive craniectomy is a necessary option in many patients. Selected patients may benefit greatly from such an approach, and although disabled, they may be functionally independent.

[An ascending graft replacement surgery in acute aortic dissection with preoperative cerebral infarction responding to postoperative external and internal decompression; report of a case]

We report a case of a 71-year-old woman who had extensive cerebral infarction associated with acute type A aortic dissection. We urgently performed ascending aortic graft replacement. Postoperative computed tomography of the brain taken immediately after the aortic surgery showed further aggravation of the right cerebral edema and a midline shift. The patient underwent emergent internal and external decompression of the brain. Eventually, consciousness recovered to normal level though preoperative left paraplegia persisted. She was discharged 150 days after the operation. We conclude that immediate internal and external cerebral decompression after surgery for acute type A dissection with preoperative cerebral malperfusion can prevent postoperative higher brain dysfunction.

[A case of infected subdural hematoma accompanied by cerebral infarction]

Infected subdural hematoma(ISH)is a rare disease caused by hematogenous infection of a preexisting subdural hematoma. We report a rare case of ISH accompanied by cerebral infarction. A 76-year-old man who had suffered a closed head injury 3 months before presented fever, headache and left hemiparesis during the medical treatment of acute cholangitis and obstructive jaundice with pancreatic cancer at the department of surgical gastroenterology. At the consultation, computed tomography(CT)scan indicated right chronic subdural hematoma. We performed a burr hole opening surgery on the same day. Abscess and hematoma was aspirated from the subdural space, and methicillin-resistant Staphylococcus aureus(MRSA)was detected in this specimen. Thus the diagnosis of the infected subdural hematoma was confirmed. However, despite the antibiotics therapy, follow-up CT showed a low-density area close to the residual abscess, which suggested cerebral infarction. Cerebral angiography showed a vasospasm at the cortical segment of the right middle cerebral artery near the residual abscess. Eventually we carried out a small craniotomy to evacuate the abscess. Our case showed that prompt surgical treatment is required in case of ISH and the whole hematoma and abscess should be removed as soon as possible with an image diagnosis and an additional surgical operation.

[Stenting for cerebral infarction due to stenosis of a persistent primitive proatlantal artery: a case report]

Cerebrovascular disorders complicated by persistent primitive arteries are commonly reported, but, we herein present a 78-year-old man with cerebral infarction due to stenosis of a persistent primitive artery by itself. Cerebral angiography revealed bilateral vertebral artery aplasia to be complicated by a persistent primitive proatlantal artery which had become an important collateral circulation pathway. While the patient was hospitalized because of mild sensory impairment, he also developed visual field constriction and cerebellar symptoms due to recurrent stroke despite anticoagulation treatment. Based on the results of various examinations, cerebral embolism, probably caused by stenosis at the origin of the persistent proatlantal artery, was diagnosed. Carotid artery stenting for the stenosis was planned. A filter protection device was found to be very useful for stenting with maintenance of blood flow in the persistent primitive proatlantal artery. There have been no reports of stenting in persistent primitive proatlantal arteries, such as that our present case is considers. It provides valuable information on the management of this rare disorder.

Prognostic value of computed tomography-evident cerebral infarcts in adult patients with tuberculous meningitis and hydrocephalus treated with an external ventricular drain

OBJECTIVE

Tuberculous meningitis (TBM) frequently is complicated by hydrocephalus and cerebral infarction. Previous studies have shown radiologic evidence of cerebral infarction in TBM to be an indicator of poor outcome in both adults and children. Our objective was to assess short-term mortality in adult patients with TBM and hydrocephalus treated with an external ventricular drain and to assess the prognostic value of cerebral infarction on admission computed tomography imaging within this cohort.

METHODS

This was a retrospective case series based on an adult intensive care unit admissions database, analyzing demographic, clinical, diagnostic, and radiologic data against short-term mortality.

RESULTS

A total of 25 patients managed from 2005 to 2011 were identified. Three patients were excluded. Mean age was 31 years. British Medical Research Council clinical severity grading was grade I in 9.1%, grade II in 31.8%, and grade III in 59.1%. Short-term mortality was 68.2% overall. Cerebral infarction on admission scanning was seen in 10 patients (45.5%). Prevalence of infarcts was not significantly higher in HIV-positive patients (50.0% vs. 42.9%). Mortality in the group with infarcts was 100%, compared with 41.7% in the group without infarcts. Mortality in patients with an admission Glasgow Coma Scale of 8 or less was 91.7%. Mortality in the HIV-positive group was slightly greater, but this increase did not reach statistical significance (71.4% vs. 57.1% P = 0.6). Univariate analysis showed presence of infarcts at admission, Glasgow Coma Scale ≤8 at admission and age of 30 years or more to be significantly related to mortality. There was also a statistically significantly increased mortality according to British Medical Research Council grade.

CONCLUSION

TBM with hydrocephalus requiring cerebrospinal diversion carries a significant short-term mortality. Within this cohort, the group of patients who have computed tomography-evident cerebral infarcts at admission has an even worse outcome, with a significantly greater short-term mortality prevalence.

[A pregnant case on which EC-IC bypass was successfully performed in the acute phase of brain infarction]

A 30 year-old, 28 weeks-pregnant woman (gravida 2, para 2) suffered from a sudden onset of aphasia when she was having a chat in the upright position. Although the initial symptom soon disappeared, transient attacks of aphasia combined with weakness in the right arm occurred intermittently, particularly when she uprose. MR image disclosed a small acute infarcted focus at the genu of the left internal capsule, while MRA showed an occlusion of the intracranial portion of the left internal carotid artery. She was treated conservatively, but the transient attack continued and her consciousness was slightly lowered. Since repeated examination revealed no recanalization of the occluded artery, treatment was reinforced by using heparin and dopamine on day 1. However, her consciousness was not improved, and dopamine evoked nausea and vomiting. On day 2, superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis was carried out. Soon after surgery, she regained alertness and the transient attack subsided. Examinations could not clarify the course of the occlusion. She was treated with heparin until she delivered a sound baby in the 37th week. Although STA-MCA anastomosis for acute ischemic stroke is still debatable, it may be a good option even for a pregnant woman when suffering from intractable progressing stroke.

Ischaemic stroke after acute intracranial haemorrhage in patients with moyamoya disease: six new cases and a short literature review

BACKGROUND

We report six new cases of ischaemic stroke after cerebral haemorrhage in patients with moyamoya disease (MMD) and analyse their clinical and radiological characteristics, together with cases reported in the literature, to deduce the mechanism of cerebral infarct.

METHODS

Six (2%) of 246 patients with MMD who were admitted to our hospitals between 1993 and 2009 suffered cerebral infarct after intracranial haemorrhage. Ten patients identified in the literature with the PubMed search engine were also included in this study. All the ischaemic lesions in these 16 patients were analysed according to their location, size, and number and were compared according to the spatial relationship between the haemorrhage and infarct, as follows: (1) anterior vs posterior involvement, (2) cortical vs subcortical involvement, (3) watershed vs non-watershed infarct, (4) small vs large infarct, (5) single vs multiple infarct, and (6) adjacent vs distant involvement.

RESULTS

Acute synchronous multiple brain infarcts occurred in six (38%) patients and recurrent infarcts in three patients (19%). Cerebral infarcts had mainly cortical (72%), anterior (66%), and distant involvement (75%) and were large (69%) and non-watershed (66%). Adjacent infarct had significantly anterior involvement (P < 0.05), and distant infarcts tended to have cortical involvement. Non-watershed infarcts had significantly cortical involvement (P < 0.05). Watershed infarcts tended to be large. Vasospasm was confirmed either pathologically or angiographically in two patients with large cerebral infarcts.

CONCLUSIONS

We suggest that thromboembolism or vasospasm plays a crucial role in the pathogenesis of cerebral infarction after acute intracranial haemorrhage in patients with MMD.

Incidental major artery aneurysms in patients with non-hemorrhagic moyamoya disease

BACKGROUND

Major artery aneurysms may be found incidentally while evaluating moyamoya disease (MMD). The purpose of this study was to delineate the prevalence and characteristics of these uncommon aneurysms with a brief mention of their management and outcomes.

METHODS

We conducted a retrospective review of 249 adult patients who were diagnosed with non-hemorrhagic MMD. Cerebral angiograms obtained at the time of initial diagnosis were carefully reviewed to identify incidental aneurysms located on a major intracranial artery or near its tributaries. Aneurysms originating from distal peripheral arteries or moyamoya vessels were ineligible for this study.

RESULTS

Nine patients (3.6%) were found to have 13 major artery aneurysms, 7 (54%) of which were located in the posterior circulation, especially in older patients with bilateral MMD. The sizes of all aneurysms were less than 10 mm. Surgical clipping was performed on two aneurysms, and endovascular coiling on six (five posterior circulation aneurysms). Ischemic complications occurred in two patients after clipping of an anterior communicating artery aneurysm and in one patient after the second coiling of a recanalized basilar tip aneurysm.

CONCLUSIONS

Incidental major artery aneurysms can be found in 3.6% of adult patients with non-hemorrhagic MMD, an observed frequency that increases with age. About half of these aneurysms are located in the posterior circulation, particularly in older patients with bilateral MMD. Considering the risks of treatment-related complications, more information about the natural course of these aneurysms is needed to design proper management strategies both for the aneurysms and MMD.

[Morbidity and mortality of carotid endarterectomy]

Clinical trials in academic centers with high selected surgeons have demonstrated the effectiveness of carotid endarterectomy (CE) in addition to best medical treatment in symptomatic and asymptomatic patients with moderate to severe stenosis. International guidelines recommend that the procedure should be done in centers with morbidity and mortality rates of less than 6% for symptomatic and 3% for asymptomatic patients. We evaluated the morbidity and mortality of CE in our institution. This was defined by the presence of stroke, myocardial infarction and/or death within 30 days of surgery. Surgery was indicated in symptomatic patients with stenosis greater than 50%. For asymptomatic or symptomatic patients with stenosis = 50% treatment was decided on a case-by-case basis. All patients were examined by a neurologist with and a cardiologist before and after the procedure. Intraoperative monitoring with transcranial Doppler was routinely used in patients with adequate ultrasonic window. We evaluated 306 procedures. No deaths occurred. Perioperative morbidity was 2.6% for both, symptomatic and asymptomatic subjects. These numbers compared favorably with those reported by other centers in Latin America and Europe. In conclusion, CE can be performed in routine clinical practice with morbidity and mortality results within those recommended by international guidelines.

Sinking skin flap syndrome and paradoxical herniation after hemicraniectomy for malignant hemispheric infarction

BACKGROUND AND PURPOSE

"Sinking skin flap" (SSF) syndrome is a rare complication after large craniectomy that may progress to "paradoxical" herniation as a consequence of atmospheric pressure exceeding intracranial pressure. The prevalence and characteristics of SSF syndrome after hemicraniectomy for malignant infarction of the middle cerebral artery are not well known.

METHODS

We analyzed a prospective cohort of 27 patients who underwent hemicraniectomy for malignant middle cerebral artery infarction. All had a clinical and brain imaging follow-up at 3 months and were followed until cranioplasty.

RESULTS

Three of 27 patients (11%) had, at 3 to 5 months posthemicraniectomy, SSF syndrome with severe orthostatic headache as the main symptom. In addition, 4 patients (15%) had radiological SSF syndrome but no clinical symptoms except partial seizures in one. Patients with SSF syndrome had a smaller surface of craniectomy (76.2 cm(2) versus 88.7 cm(2), P=0.05) and a tendency toward larger infarct volume, an older age, and a longer delay to cranioplasty than those without this syndrome.

CONCLUSIONS

SSF syndrome either clinically symptomatic or asymptomatic affects one fourth of patients 3 to 5 months after hemicraniectomy for malignant middle cerebral artery infarction. It should be diagnosed as early as possible to avoid progression to a paradoxical herniation.

[Surgical outcome of external decompression associated with anterior and medial temporal lobectomy for massive hemispheric infarction due to internal carotid artery occlusion]

OBJECTIVE

Acute occlusion of the internal carotid artery (ICA) can lead the massive cerebral hemispheric infarction and cause massive cerebral edema and may result in tentorial herniation and death. The mortality rate is estimated at 80% with maximum conservative medical treatment. We have performed external decompression associated with anterior and medial temporal lobectomy (AMTL) as internal decompression for lifesaving. This study evaluated our surgical results and gives an analysis of the prognostic factors.

METHODS

Twenty one consecutive patients with massive cerebral infarction caused by internal carotid artery occlusion who underwent external decompression associated with AMTL for lifesaving between June 2000 and December 2005 were included in this retrospective analysis. Survivors were divided into two functional groups at three months after surgery: good (Barthel index; BI> or =50) and poor (B1<50). The characteristics of the two groups were compared using statistical analysis.

RESULTS

The patients consisted of 11 males and 10 females aged from 28 to 81 years with a mean age of 65.0+/-11.6 years. Eight patients had an infarction restricted to the middle cerebral artery (MCA) territory, others had additional anterior cerebral artery (ACA) or posterior cerebral artery (PCA) territory infarctions. The mean time between stroke onset and operation was 43.5+/-30 hours and ranged from 7 to 148 hours. Two patients died, so the mortality was 9.5%. Elderly patients (> or =60 years) (P=0.038), high preoperative Japan coma scale (> or =3 digit) (P=0.013), low preoperative Glasgow coma scale (GCS<8) (P=0.044), and multiple arterial territory (MCA+ACA or PCA) infarction (P=0.045) were significantly associated with poor functional outcome.

CONCLUSION

External decompression associated with AMTL can immediately relieve peduncle compression and could be effective in preserving life as effectively as "early" external decompression.

[Hyperperfusion syndrome after carotid endarterectomy]

Hyperperfusion syndrome is a complication with frequency about 3 per cent and unclear etiological factors who mostly lead to hard neurological deficit and/or death for the patient. Symptoms are headaches, fits, confusion, focal neurological sings to intracerebral hemorrhage. The prevention and control are accomplished by active monitoring of intracranial blood flow and systolic blood pressure. Hyperperfusion syndrome can be clinicaly performed with or without hemorrhage. We present a case of hyperperfusion syndrome after carotid endarterectomy of 59-years-old man operated at the Department of Vascular surgery and Angiology of "St. Ekaterina" hospital. The patient had thrombosis of one carotid artery and stenosis of the other and two old cerebral infarctions. In the early postoperative period the patient developed a clinical picture of awake coma with quadriparesis and right plegia. On the 14-th day after the surgical intervention the patient left the clinic in better condition and was directed to his neurologist for observation.