吉野 義一

BACKGROUND: Endovascular treatment has become the preferred approach for managing unruptured cerebral aneurysms, with simple and balloon-assisted coil embolization as the standard first-line therapy. However, recanalization after coil embolization remains a major clinical concern. This study aimed to evaluate the predictive factors for recanalization using time-of-flight magnetic resonance (TOF-MR) angiography. METHODS: This retrospective multicenter study analyzed data from 241 patients with unruptured cerebral aneurysms who underwent coil embolization at five stroke centers. Aneurysms were evaluated using TOF-MR angiography within 7 days post-procedure and at follow-up. The study investigated the role of aneurysm characteristics and the Postoperative TOF-MR Angiography (PTMA) classification in predicting recanalization. RESULTS: Of the 241 aneurysms analyzed, 79 (32.7%) exhibited recanalization, and 15 (6.2%) required retreatment. Aneurysms with a maximum diameter of ≥10 mm were associated with a higher risk of recanalization (odds ratio (OR), 3.27; 95% confidence interval (CI), 1.38-7.75; p<0.01). The PTMA classification, which indicated incomplete occlusion (SN/RN/PO), also showed a significant association with recanalization (OR, 4.82; 95% CI, 2.17-10.7; p<0.01). The modified Raymond-Roy classification (Class IIIb) also contributed to the prediction of recanalization (OR, 3.09; 95% CI, 1.50-6.38; p<0.01). CONCLUSIONS: Aneurysm size, the modified Raymond-Roy classification, and PTMA classification within 7 days of coil embolization were significant predictors of recanalization. This study suggests that TOF-MR angiography may be accurate, and that PTMA classification may serve as an appropriate predictor of aneurysm recanalization. Further prospective studies with larger cohorts are required to validate our findings.

OBJECTIVES: Distal anterior cerebral artery (DACA) aneurysms account for 1%-9% of all intracranial aneurysms. Microsurgical treatment is generally preferred for DACA aneurysms; however, it presents challenges owing to the anatomical complexities. Advances in neuro-interventional techniques have yielded promising results. This study aims to compare the clinical outcomes of DACA aneurysms treated with microsurgery and endovascular treatment (EVT) to elucidate the efficacy of EVT. MATERIALS AND METHODS: A multicenter observational registry comprising 16 stroke centers was utilized for this study. Data was retrospectively and prospectively analyzed from 166 patients with DACA aneurysms in our database, which included 4,552 consecutive patients with ruptured or unruptured intracranial aneurysms who underwent microsurgical or endovascular treatment between January 2013 and December 2021. RESULTS: Surgical clipping was performed in 115 patients, and 51 underwent coil embolization. The median follow-up duration was 15.3 months. No significant differences were observed in patient characteristics between the two treatment modalities. There were no differences in complication-related morbidity between the microsurgical treatment and EVT groups in either unruptured (10.5% vs. 9.1%, p=1.00) or ruptured aneurysms (5.2% vs. 6.9%, p=0.66). Coil embolization resulted in higher recurrence and retreatment rates than surgical clipping did, especially for ruptured aneurysms (2.6% vs. 27.6%, p<0.01). CONCLUSIONS: Endovascular treatment is an alternative to microsurgery for DACA aneurysms especially in unruptured cases or the patients who have difficulty undergoing craniotomy due to their general condition, albeit with considerations for higher recurrence and retreatment rates, particularly in ruptured cases. Close follow-up is crucial for the effective management of these challenges. Further studies are needed to refine the treatment strategies for DACA aneurysms.

PURPOSE: The quick establishment of adequate vascular access is essential for the technical success of mechanical thrombectomy (MT). Focusing on shifts in aortic arch geometry and aging-related changes, we propose an imaging parameter for predicting access difficulty using chest CT. METHODS: Patients with acute anterior circulation large-vessel occlusion who underwent MT from April 2020 to September 2021 were included in this retrospective multicenter observational study. The distance from the sternum to the ascending aorta (S-AAD) was defined as the surrogate marker of access difficulty. Access was defined as difficult when the time from femoral sheath placement to guiding catheter induction (guiding time: GT) ≥ 30 minutes, and the patients were dichotomized into groups with short GT (sGT: GT < 30 min) and long GT (lGT: GT ≥ 30 min). RESULTS: One hundred fifteen patients were included. There were 12 patients (10.4 %) in lGT group. The median (IQR) S-AAD was 11.9 mm (6.3, 18.3 mm) in sGT group and 6.6 mm (4.0, 10.3 mm) in lGT group, and a significant difference in S-AAD was observed (P = 0.026). In multivariate analyses, dyslipidemia and S-AAD < 5 mm were significantly associated with difficult access (OR, 5.938 [95 % CI, 1.468, 24.022], P = 0.012 for dyslipidemia; OR, 5.147 [95 % CI, 1.267, 20.917], P = 0.022 for S-AAD < 5 mm). CONCLUSION: S-AAD is a simple and reliable imaging parameter to predict access difficulty. This parameter may be helpful in selecting the appropriate devices and access routes in preinterventional practice.

Introduction  Predicting the shape of the occluded middle cerebral artery (MCA) from the contralateral MCA might help catheterization in endovascular mechanical thrombectomy (EMT). Materials and Methods  We analyzed magnetic resonance (MR) angiography in 100 consecutive patients who had MR imaging for diseases other than acute ischemic stroke. To assess the symmetricity of MCA, the shape of M1, length of M1, number of M2, number of early branches (EBs), and distance from the top of the internal carotid artery to EB were investigated. Results  The shape of M1 was upward in 42%, horizontal in 47%, and downward in 11%. The M1 shape was the same on both sides in 64%, which exceeded the probability assumed to be left-right independent. The number of M2 trunks and EBs matched left and right in 86 and 55% of patients, respectively; however, these agreement rates were not higher than those with independent left and right sides. No left-right correlation was found between the M1 length and the distance from the internal carotid artery to EB. Conclusion  Based on our data, the symmetry of MCA was observed only in the shape of the M1 segment. This finding could be beneficial for EMT targeting MCA embolisms.

AIM: Assessing the indication for elective neuro-endovascular treatment (EVT) in older patients requires consideration of the impact of systemic comorbidities on their overall reduced life expectancy. The objective of this study was to determine the long-term outcomes of elective neuro-EVT in patients aged ≥80 years, and to investigate the impact of pre-existing cancer on their long-term outcomes. METHODS: Of the patients enrolled in multicenter observational registry, those aged ≥80 years undergoing elective neuro-EVT between 2011 and 2020 were enrolled. A history of cancer was defined as a pre-existing solid or hematologic malignancy at the time of EVT. The primary outcome was time to death from elective neuro-EVT. RESULTS: Of the 6183 neuro-EVT cases implemented at 10 stroke centers, a total of 289 patients (median age, 82 years [interquartile range 81-84 years]) were analyzed. A total of 58 (20.1%) patients had a history of cancer. A total of 78 patients (27.0%) died during follow up. The 5-year survival rate of enrolled patients was 64.6%. Compared with patients without a history of cancer, those with a history of cancer showed significantly worse survival (log-rank test, P = 0.001). Multivariate Cox proportional hazards analysis showed history of cancer was an independent predictor of time to death from elective neuro-EVT (HR 1.74, 95% CI 1.01-3.00, P = 0.047). Cancer was the leading cause of death, accounting for 25.6% of all deaths. CONCLUSIONS: The present study showed that history of cancer has a significant impact on time to death from elective neuro-EVT in patients aged ≥80 years. Geriatr Gerontol Int 2024; 24: 211-217.

INTRODUCTION: Hybrid emergency room systems (HERSs) have shown promise for the management of severe trauma by reducing mortality. However, the effectiveness of HERSs in the treatment of acute ischemic stroke (AIS) remains unclear. This study aimed to evaluate the impact of HERSs on treatment duration and neurological outcomes in patients with AIS undergoing endovascular therapy. MATERIALS AND METHODS: This single-center retrospective study included 83 patients with AIS who were directly transported to our emergency department and underwent endovascular treatment between June 2017 and December 2023. Patients were divided into the HERS and conventional groups based on the utilization of HERSs. The primary outcome was the proportion of patients achieving a favorable neurological outcome (modified Rankin Scale score 0-2) at 30 days. The secondary outcomes included door-to-puncture and door-to-recanalization times. Univariate analysis was performed using the Mann-Whitney U test for continuous variables and the chi-squared test or Fisher's exact test for categorical variables, as appropriate. RESULTS: Of the 83 eligible patients, 50 (60.2%) were assigned to the HERS group and 33 (39.8%) to the conventional group. The median door-to-puncture time was significantly shorter in the HERS group than in the conventional group (99.5 vs. 131 min; p = 0.001). Similarly, the median door-to-recanalization time was significantly shorter in the HERS group (162.5 vs. 201.5 min, p = 0.018). Favorable neurological outcomes were achieved in 16/50 (32.0%) patients in the HERS group and 6/33 (18.2%) in the conventional group. The HERS and conventional groups showed no significant difference in the proportion of patients achieving favorable neurological outcomes (p = 0.21). CONCLUSION: Implementation of the HERS significantly reduced the door-to-puncture and door-to-recanalization times in patients with AIS undergoing endovascular therapy. Despite these reductions in treatment duration, no significant improvement in neurological outcomes was observed. Further research is required to optimize patient selection and treatment strategies to maximize the benefits of the HERS in AIS management.

RATIONALE: Thromboembolism is a serious complication of endovascular treatment for ruptured cerebral aneurysms. The administration of antiplatelet agents before endovascular treatment for ruptured cerebral aneurysms may reduce the risk of thromboembolic complications. AIM: This study aimed to assess the safety and efficacy of preoperative aspirin administration in endovascular treatment for ruptured cerebral aneurysms. SAMPLE SIZE ESTIMATES: Assuming a 15% incidence rate of both intraoperative thromboembolic morbidity and symptomatic ischemic lesions on magnetic resonance imaging diffusion-weighted imaging scans assessed by an Independent Review Committee, a sample size of 484 will be required to detect a 10% improvement with aspirin administration with 90% power using the Pearson's chi-square test at a two-sided significance level of 2.5% for each primary outcome, after accounting for a 5% dropout rate. METHODS AND DESIGN: ASTOP is a multicenter, randomized, double-blind, placebo-controlled clinical trial. A total of 484 patients with ruptured cerebral aneurysms receiving coil embolization within 72 h of onset will be randomly assigned 1:1 to receive 200 mg of aspirin or placebo before the procedure. STUDY OUTCOMES: The primary outcomes will be the incidence rates of intraoperative thromboembolic complications and symptomatic ischemic lesions on magnetic resonance imaging diffusion-weighted imaging scans evaluated by the Independent Review Committee. The secondary outcomes will be the incidence rate of cerebral ischemic events and all bleeding events within 14 days of enrollment and functional outcomes defined by the modified Rankin Scale score at 90 days. DISCUSSION: This trial will provide valuable data on the role of antiplatelet agents during endovascular treatment for ruptured cerebral aneurysms. TRIAL REGISTRATION: Registration: Japan Registry of Clinical Trials, Identifier: jRCTs031210421.

A flow-diverter (FD) device is a well-established tool for the treatment of unruptured intracranial aneurysms. Time-of-flight (TOF) MR angiography (MRA) is widely used for postoperative assessment after the treatment with FD; however, it cannot fully visualize intra-aneurysmal and intrastent flow signals due to the magnetic susceptibility from the FD. Recently, the utility of MRA with ultra-short TE (UTE) sequence and arterial spin labeling technique in assessing the therapeutic efficacy of intracranial aneurysms treated with metallic devices has been reported, but long image acquisition time is one of the drawbacks of this method. Herein, we introduce a novel UTE MRA using the subtraction method that enables the reduction in susceptibility artifacts with a short image acquisition time.

A 68-year-old man received hemodialysis (HD) for the treatment of end-stage renal failure for 6 years. Five years prior to carotid artery stenting (CAS), a neck ultrasound performed to screen for carotid atherosclerosis revealed an asymptomatic right internal carotid artery stenosis. One month prior, the stenotic lesion progressed to 74% by cerebral angiography; therefore, CAS was performed. To evaluate the influence of right internal carotid artery stenosis on the intradialytic cerebral circulation and oxygenation, cerebral regional oxygen saturation (rSO2) at bilateral forehead was measured using the INVOS 5100c oxygen saturation monitor (Covidien Japan, Japan) during HD before and after CAS. Before CAS, right cerebral rSO2 was maintained during HD, whereas left cerebral rSO2 gradually increased from the initiation to end of HD. However, the differences of intradialytic cerebral rSO2 changes between bilateral sides disappeared after CAS. In the present case, before CAS, the intradialytic increase in left cerebral rSO2 might reflect the increase in the left cerebral blood flow to compensate for the ultrafiltration-associated decreases in the right cerebral blood flow and perfusion pressure. Furthermore, the preserved right cerebral rSO2 before CAS might reflect the mechanism maintaining the right cerebral blood flow from the collateralized circle of Willis during HD. Throughout our experience, cerebral oxygenation monitoring during HD might disclose intradialytic changes in cerebral blood flow distribution between the ipsilateral and contralateral side in HD patients with carotid artery stenosis.

BACKGROUND: Postoperative cerebral embolic stroke is a serious complication of pulmonary lobectomy, occurring in 1.1% of patients undergoing lobectomy through video-assisted thoracoscopic surgery (VATS). The mechanism of this complication is thought to be embolic stroke caused by thrombus formed due to stagnation in the pulmonary vein stump after VATS lobectomy. There have been few reports demonstrating the utility of endovascular treatment (EVT) for cerebral embolic stroke after VATS lobectomy. CASE DESCRIPTION: In our case series, cerebral embolic stroke occurred after VATS pulmonary lobectomy for lung cancer, including the left upper lobe in three cases and the right lobe in one. The median duration of ischemic stroke after VATS was 4.5 days (interquartile range, 2-9 days). The median time from stroke onset to puncture was 130 min. Successful recanalization was achieved in all cases, and two patients achieved favorable clinical outcomes (modified Rankin scale, 0-2). CONCLUSION: We report a case series of four patients who underwent EVT for acute embolic stroke after VATS lobectomy for lung cancer. EVT is considered a reasonable and feasible therapeutic option for this condition.

OBJECTIVE: We report a patient with chronic headache due to idiopathic intracranial hypertension (IIH) associated with transverse sinus (TS) stenosis. The symptom improved after stent placement at the site of stenosis. CASE PRESENTATION: The patient was a 37-year-old woman with progressive headache and diplopia as chief complaints. She had severe bilateral papilledema. Magnetic resonance imaging (MRI) and angiography revealed stenosis of the bilateral TS. Lumbar puncture demonstrated raised intracranial pressure and IIH was tentatively diagnosed. Visual impairment progressed despite oral acetazolamide therapy. A venous pressure gradient was monitored during stent placement. The pressure gradient improved after stenting. Dual antiplatelet therapy was initiated 1 week before the procedure. Papilledema and headache resolved immediately after the procedure. No in-stent stenosis or occlusion occurred during the follow-up period. CONCLUSION: Stent placement for TS stenosis can improve the cerebral venous return in IIH patients. Although restenosis is possible, venous sinus stenting is considered an effective treatment.

Acute ischemic stroke (AIS) caused by major vessel occlusion has potentially poor outcomes. Early successful recanalization after symptom onset is an important factor for favorable outcomes of AIS. We present the case of a 74-year-old man with AIS who underwent the entire process from diagnosis to thrombolysis and endovascular treatment in a hybrid emergency room (ER) equipped with a multidetector computed tomography (CT) scanner and an angiography suite set-up. A hybrid ER can facilitate evaluation and definitive interventions in patients with AIS more quickly and safely and in one place, without the requirement for transfer to a CT scanner or angiography suite set-up. In the present case, the door-to-puncture time and door-to-reperfusion time were 85 and 159 min, respectively, which were shorter than those in the group conventionally treated for stroke in our institution. Further study is needed to confirm the effect of the hybrid ER system.

血管内治療において現在一般的に使用されている全身麻酔薬のプロポフォールとセボフルランについて、これら麻酔薬の違いが脳血管の脳循環にどのような違いを及ぼすのか、頸部内頸動脈から各脳血管(眼動脈(OA)、前大脳動脈(ACA)、中大脳動脈(MCA)、深部静脈(Galen)、頭頂静脈(PV))までの循環時間を、脳血管造影画像を用いて評価した。対象は、当院で全身麻酔下に定時コイル塞栓術を受ける米国麻酔学会術前状態分類クラス3以下の前方循環脳動脈瘤患者20例とした。試験デザインはクロスオーバーデザインとし、麻酔導入前にセボフルラン-プロポフォール群(SP群)またはプロポフォール-セボフルラン群(PS群)に1:1に無作為に割り付けた。データ解析は15名(SP群7名、PS群8名)において行われた。血管造影画像解析をトレーニングした2名の解析者によって、匿名化されたDigital Subtraction Angiography(DSA)画像を用いて頸部内頸動脈の基準点と5点の関心領域(OA:眼動脈の最初の屈曲点、ACA:ACAの膝部、MCA:最

未破裂脳動脈瘤に対し外来で経過観察を行い、脳動脈瘤破裂によるクモ膜下出血で入院し、少なくとも2回以上画像検査を行った4例を対象とした。症例1は74歳女性で、右前大脳動脈遠位部に4mm、右中大脳動脈に2mmの動脈瘤を指摘された。大きさに変化はなく経過していたが、106ヵ月後に右ACAの動脈瘤が破裂した。破裂の動脈径は6mmと増大を認めた。症例2は73歳女性で、左内頸動脈後交通動脈(IC-PC)のinfundibular dilatationを指摘された。74ヵ月の経過で3.3mm大に増大した。経過観察していたが、93ヵ月目に破裂した。破裂時の動脈径は4.5mmと増大を認めた。症例3は52歳女性で、IC-PCの破裂動脈瘤でneck clippingを施行した。その際、右IC-PCにも2.0mm大の動脈瘤を指摘された。52ヵ月後、3.1mm大に増大した。109ヵ月の経過で破裂、破裂時の動脈径は6.6mmと増大を認めた。症例4は82歳女性で、脳底動脈に10mm大の動脈瘤を指摘され、18mm大に増大した。170ヵ月の経過で破裂し、破裂時の動脈径は18.8mmとさらなる増大

Ruptured intracranial aneurysms are rare in the pediatric population compared to adults. This has incited considerable discussion on how to treat children with this condition. Here, we report a child with a ruptured saccular basilar artery aneurysm that was successfully treated with coil embolization. A 12-year-old boy with acute lymphoblastic leukemia and accompanying abdominal candidiasis after chemotherapy suddenly complained of a severe headache and suffered consciousness disturbance moments later. Computed tomography scans and cerebral angiography demonstrated acute hydrocephalus and subarachnoid hemorrhage caused by saccular basilar artery aneurysm rupture. External ventricular drainage was performed immediately. Because the patient was in severe condition and did not show remarkable signs of central nervous system infection in cerebrospinal fluid studies, we applied endovascular treatment for the ruptured saccular basilar artery aneurysm, which was successfully occluded with coils. The patient recovered without new neurological deficits after ventriculoperitoneal shunting. Recent reports indicate that both endovascular and microsurgical techniques can be used to effectively

Dural arteriovenous fistulas (DAVFs) of the anterior cranial fossa are rare anomalies that invariably present with cortical venous reflux because of the absence of dural sinus in the affected region. Previous reports have identified intracranial hemorrhage as the major symptom and have confirmed that good surgical outcome can be obtained by open surgery. Recently, however, the widespread use of MRI has led to an increase in the incidental detection of asymptomatic DAVFs of the anterior cranial fossa. Treatments for these asymptomatic lesions are now a focus of discussion.<br> We treated four patients with anterior cranial fossa DAVFs between 2005 and 2010. One of the patients presented intracranial hemorrhage and the other three were asymptomatic.<br> The three patients with intracranial hemorrhage underwent open surgery and the other asymptomatic patient underwent endovascular surgery. The latter patient initially underwent transarterial embolization with only partial success. The patient was completely cured by the transvenous approach with platinum coils. All four patients were successfully treated without any adverse events.<br> Previous papers reported similarly high annual intracranial hemorrhage rates from DAVFs with cortical venous reflux. This suggests that surgical treatment for asymptomatic patients with anterior cranial fossa DAVFs should be considered. Direct surgery has been the treatment of choice for this disease so far. For asymptomatic patients, however, endovascular treatment with transvenous embolization may serve as an effective alternative to open surgery.<br>