Shigeru Miyachi

Determinants of Poor Outcome After Aneurysmal Subarachnoid Hemorrhage when both Clipping and Coiling Are Available: Prospective Registry of Subarachnoid Aneurysms Treatment (PRESAT) in Japan

OBJECTIVE To examine current determinants of poor outcome after aneurysmal subarachnoid hemorrhage (SAH) when ruptured aneurysms are treated with either microsurgery (clipping) or endovascular treatment (coiling) depending on each patients characteristics. METHODS Between March 2006 and February 2007, 534 patients with SAH were enrolled in the Prospective Registry of Subarachnoid Aneurysms Treatment (PRESAT) project. Patients were treated according to the preference of investigators who were experienced in performing both clipping and coiling. Factors influencing poor outcome (12-month modified Rankin Scale [mRS], 3-6) were determined using multivariate logistic regression analyses. RESULTS In this cohort, 32.4% of patients were World Federation of Neurosurgical Societies (WFNS) grade IV-V, and 28.1% had a poor outcome. Clipping was preferably performed for small aneurysms with a wide neck and for middle cerebral artery (MCA) aneurysms, whereas coiling was preferred for larger, internal carotid artery (ICA) and posterior circulation aneurysms. In addition to increasing age, admission WFNS grade IV-V, preadmission aneurysmal rerupture, vasospasm-induced cerebral infarct, pneumonia, sepsis, shunt-dependent hydrocephalus and seizure, postclipping hemorrhagic complications (odds ratio 4.8, 95% confidence interval 1.5-15.3, P < 0.01), and postcoiling ischemic complications (odds ratio 4.4, 95% confidence interval 1.3-15.2, P < 0.05) significantly caused poor outcomes, although the complications did not affect mortality. Type of treatment modality and size and location of aneurysms did not influence outcome. CONCLUSIONS Introducing an endovascular treatment option has made aneurysm characteristics less important to outcome, but procedural complications are problematic and should be reduced to improve outcome.

Endovascular treatment for intracranial mycotic aneurysms prior to cardiac surgery

The management of patients with infective endocarditis complicated by intracranial mycotic aneurysms is controversial. We present the case of a 21-year-old man who suffered from mitral regurgitation with small vegetations due to infective endocarditis. The problem was associated with a ruptured aneurysm on the right anterior cerebral artery and an unruptured aneurysm on the left middle cerebral artery. Endovascular embolization of these aneurysms and subsequent mitral valve repair led to a successful outcome.

Risk of Aneurysmal Rupture

OBJECTIVEThe aim of the present study was to clarify the risk of rupture in terminal-type intracranial aneurysms using computational flow simulation analysis. METHODSFirst, idealized three-dimensional aneurysmal models were built from a solid voxel on the computer. We focused on round terminal-type aneurysms with the positioning of the neck orifice set according to the following three patterns in relationship to the axis of the parent artery: the Type-A neck orifice was positioned directly in line with the flow of the parent artery; the Type-B neck orifice was shifted 1.5 mm offline toward the unilateral branch; and the Type-C neck orifice was shifted 3 mm offline. Computational flow simulations were applied with Fujitsu α-Flow software (Fujitusu, Tokyo, Japan). We analyzed flow patterns using modified patient-specific models. We also investigated actual clinical situations to evaluate the differences in neck-orifice positioning between 20 ruptured aneurysms and 26 unruptured ones using three-dimensional angiograms. RESULTSThe Type-A neck orifice showed completely symmetrical stream lines in the aneurysm, whereas the Type-C orifice showed a clear round circulation. The Type-B neck orifice, on the other hand, exhibited intra-aneurysmal flow separation. The clinical research demonstrated that Type-B aneurysms were more likely to be found in the ruptured group (P < 0.05). CONCLUSIONFlow separation, recognized as one of the causes of intimal injury, could be observed only in Type-B aneurysms, a result that corresponded well with our clinical experience. From the flow-dynamics point of view, this positioning of the neck orifice may be one of the risk factors most likely to induce the rupture of unruptured aneurysms.

Dural carotid cavernous sinus fistula presenting as isolated oculomotor nerve palsy

We report five patients with dural carotid cavernous sinus fistula presenting with isolated oculomotor nerve palsy. All patients were older women with a fistula derived from the internal carotid artery, who had early filling of the supero-posterior cavernous sinus, followed by drainage posteriorly into the inferior petrosal sinus, with low shunt flow. The hypothesized pathogenesis was nerve compression by an expanding sinus, or ischemic neuropathy secondary to venous congestion or arterial steal. Dural carotid cavernous sinus fistula must be considered in patients presenting with isolated oculomotor nerve palsy.

Embolisation of cerebral arteriovenous malformations to assure successful subsequent radiosurgery

This study investigated the angiographic changes in embolised arteriovenous malformations (AVMs) pre- and post-embolisation and preradiosurgery to clarify the usefulness of embolisation as a pretreatment for radiosurgery and the strategy of embolisation for the radiosurgical success. A total of 37 patients with cerebral AVMs treated over a period of 4 years was investigated. All the AVMs were embolised with N-butyl cyanoacrylate and 2 months later they were treated by radiosurgery. The size of AVM nidus reduced just following the embolisation (mean 21.9 ml to 3.9 ml). The angiogram taken in preparation for radiosurgery showed a further size reduction in the nidus of 16 AVMs, no change in 10 and regrowth in 11. In all the cases where size was reduced, the nidus was densely packed, while all the regrown AVMs were of the diffuse type. Five AVMs disappeared following radiosurgery, all of which were size-reduction or no-change cases. In conclusion, to achieve success in subsequent radiosurgery, nidus embolisation and the occlusion of fistulous and meningeal feeders are mandatory. Imprudent proximal feeder occlusion and the use of embolic materials with a risk of recanalisation should be avoided to prevent regrowth of the nidus, which may lead to errors in planning the radiosurgery to follow.

A case of giant common carotid artery aneurysm associated with vascular Behçet disease : successfully treated with a covered stent

BACKGROUND A carotid artery aneurysm associated with vascular Behçet disease is extremely rare and often difficult to treat. In this article, we explore a definitive therapeutic strategy for pseudoaneurysm with vascular Behçet disease. CASE DESCRIPTION A 56-year-old man presented with swelling and a pulsatile subcutaneous mass of the left neck over a 6-month period. The diagnosis of vascular Behçet disease had already been established from the history of right subclavian artery aneurysm, oral ulcerations, and inflammatory skin lesions. Radiologic examination revealed a giant left CCA aneurysm (6.5 x 5.5 cm) with partial thrombosis. Another asymptomatic aneurysm was found in the right ICA. Because mass effects due to aneurysmal rupture and growth rapidly progressed, we decided on radical treatment. The endovascular reconstruction of the carotid artery was selected instead of direct surgery because of skin and connective tissue disorders at the regional site. A covered stent (8 x 60 mm, Passager, Boston Scientific, Fremont, CA) was placed from the CCA to the ICA, covering the whole aneurysmal portion. Postoperatively, the cervical mass remarkably reduced in size, and the patients symptoms dramatically improved. The left carotid artery was patent at 12-month follow-up. CONCLUSIONS A covered stent is very useful in repairing arteries with pseudoaneurysm, particularly in cases unsuitable for direct surgery with parent artery occlusion. The influence of the foreign body at the inflammatory lesion and long-term patency of covered stents should be discussed.

Dural Arteriovenous Fistula at the Anterior Condylar Confluence

We reviewed the records of eight patients with a dural arteriovenous fistula (DAVF) close to the hypoglossal canal and determined the angioarchitecture of the clinical entity at the anterior condylar confluence. Eight patients with DAVF received endovascular treatment at our institute over the past five years. Imaging with selective three-dimensional angiography and thin-slice computed tomography were used to identify the fistula and evaluate the drainage pattern. Based on the angiographic findings, the ascending pharyngeal artery was the main feeder in all cases, and the occipital, middle meningeal, posterior auricular, and posterior meningeal arteries also supplied the DAVF to varying degrees. Contralateral contribution was found in five patients. The main drainage route was the external vertebral plexus via the lateral condylar veins in four patients, the inferior petrosal sinus in three patients, and the internal jugular vein via the connecting emissary veins in one patient. Selective angiography identified the shunt point at the anterior condylar confluence close to the anterior condylar vein. Shunt occlusion with transvenous coil packing was performed in all cases; transarterial feeder embolization was also used in three patients. Two patients treated with tight packing of the anterior condylar vein developed temporary or prolonged hypoglossal palsy. Based on our results, the main confluence of the shunt is located at the anterior condylar confluence connecting the anterior condylar vein and multiple channels leading to the extracranial venous systems. To avoid postoperative nerve palsy, the side of the anterior condylar vein in the hypoglossal canal should not be densely packed with coils. Evaluating the angioarchitecture using the selective three-dimensional angiography and tomographic imaging greatly helps to determine the target and strategy of endovascular treatment for these DAVF.

Effects of Comprehensive Stroke Care Capabilities on In-Hospital Mortality of Patients with Ischemic and Hemorrhagic Stroke: J-ASPECT Study

Background The effectiveness of comprehensive stroke center (CSC) capabilities on stroke mortality remains uncertain. We performed a nationwide study to examine whether CSC capabilities influenced in-hospital mortality of patients with ischemic and hemorrhagic stroke. Methods and Results Of the 1,369 certified training institutions in Japan, 749 hospitals responded to a questionnaire survey regarding CSC capabilities that queried the availability of personnel, diagnostic techniques, specific expertise, infrastructure, and educational components recommended for CSCs. Among the institutions that responded, data on patients hospitalized for stroke between April 1, 2010 and March 31, 2011 were obtained from the Japanese Diagnosis Procedure Combination database. In-hospital mortality was analyzed using hierarchical logistic regression analysis adjusted for age, sex, level of consciousness on admission, comorbidities, and the number of fulfilled CSC items in each component and in total. Data from 265 institutions and 53,170 emergency-hospitalized patients were analyzed. Mortality rates were 7.8% for patients with ischemic stroke, 16.8% for patients with intracerebral hemorrhage (ICH), and 28.1% for patients with subarachnoid hemorrhage (SAH). Mortality adjusted for age, sex, and level of consciousness was significantly correlated with personnel, infrastructural, educational, and total CSC scores in patients with ischemic stroke. Mortality was significantly correlated with diagnostic, educational, and total CSC scores in patients with ICH and with specific expertise, infrastructural, educational, and total CSC scores in patients with SAH. Conclusions CSC capabilities were associated with reduced in-hospital mortality rates, and relevant aspects of care were found to be dependent on stroke type.

Periprocedural Cilostazol Treatment and Restenosis after Carotid Artery Stenting: The Retrospective Study of In-Stent Restenosis after Carotid Artery Stenting (ReSISteR-CAS)

Restenosis after carotid artery stenting (CAS) is a critical issue. Cilostazol can reduce restenosis after interventions in coronary or femoropopliteal arteries. We investigated whether periprocedural cilostazol treatment was related to the incidence of in-stent restenosis (ISR) or target vessel revascularization (TVR) after CAS. The study group comprised 553 of 580 patients who underwent CAS between April 2003 and August 2006 and were followed for 30 months after the procedure. ISR was defined as stenosis of at least 50% detected on angiography or ultrasonography. TVR was defined as revascularization of the treated carotid artery. During CAS, 207 patients (37.4%) were treated with cilostazol. Over 30 months, ISR occurred in 23 patients (4.2%), TVR occurred in 16 patients (2.9%), and either ISR or TVR occurred in 25 patients (4.5%). The incidence of ISR or TVR was significantly lower in the cilostazol-treated group than in the untreated group (1.4% vs 6.4%; log-rank P = .006). In a multivariate analysis, cilostazol treatment (hazard ratio [HR], 0.28; 95% confidence interval [CI], 0.08-0.95; P = .041) and stent diameter (HR, 0.73/1-mm increase; 95% CI, 0.54-0.99; P = .044) were independent factors for the occurrence of ISR or TVR. The incidence of a composite of events, including thromboembolism, hemorrhage, death, and TVR, tended to be lower in the cilostazol-treated group than in the untreated group (15.0% vs 19.9%; log-rank P = .17). Periprocedural cilostazol treatment was associated with lower rates of ISR and retreatment after CAS. A prospective randomized controlled trial is needed to clarify the effect of cilostazol on ISR after CAS.

MYELOMA MANIFESTING AS A LARGE JUGULAR TUMOR : CASE REPORT

The authors report a case of cranial plasmacytoma with multiple myelomas and palsy of the lower cranial nerves. The osteolytic lesion adjacent to the jugular foramen was demonstrated by an angiogram to be exceedingly hypervascular, with arteriovenous shunting resembling that seen in paragangliomas. Forty-five cases of cranial and intracranial plasmacytoma from the literature were reviewed. The findings indicate that a cranial plasmacytoma commonly appears to be a hypervascular tumor, whereas most dural tumors or intraparenchymal tumors have poor vascularity.