kato yoko

Objective: We retrospectively analyzed thromboembolic complications for unruptured cerebral aneurysms treated with stent assisted coil embolization (SAC).<br>Patients and methods: Between 2010 September and 2012 March, 36 unruptured broad neck aneurysms in 35 patients were treated by SAC following dual antiplatelet medication with aspirin and clopidogrel. Aspirin and clopidogrel were started 1–14 days before the procedure. After the procedure, diffusion weighted MR imaging (DWI) was performed within seven days. DWI findings were graded into A to D depending on the number and the size of bright spots: A, no bright lesions; B, 1–5 small (＜10 mm) lesions; C, six or more small lesions; D, any large (≧10 mm) lesions.<br>Results: Angiography showed complete occlusion was achieved in 13 aneurysms (36%), neck remnant in nine (25%), and body filling in 14 (39%). Symptomatic thromboembolic complications occurred in six cases (17%). The symptoms were transient in four of the six patients, and two patients had persisting minor symptoms (modified Rankin Scale 1 and 2). The DWI grade of SAC cases was A in two patients, B in six, C in 16, and D in eight. Among SAC cases, there was a tendency of higher incidence of Grade D when clopidogrel was started earlier than three days before the procedure.<br>Conclusions: SAC is a feasible and effective technique for treating broad neck aneurysms. Starting clopidogrel three or more days before the procedure may half reduce thromboembolic complications. <br>

BACKGROUND: For cardiac arrest (CA) victims, brain computed tomography (CT) may serve as a prognosticator. Loss of gray-white matter discrimination (GWMD) and sulcal edema/effacement are reliable CT signs of hypoxia, and a time window may exist for development of these signs. Most data are derived from CA victims of cardiac etiology, however, and CT signs have rarely been evaluated in victims of CA secondary to subarachnoid hemorrhage (SAH). METHODS: A retrospective study was conducted to clarify the incidence, temporal profile, and prognostic significance of early CT signs in resuscitated SAH-CA patients. RESULTS: During a 6-year period, 35 SAH-CA patients were identified. CT signs were observed in 94 %: loss of GWMD was observed in 94 %, whereas sulcal edema/effacement was observed in 77 %. In 29 patients, the interval between CA and the return of spontaneous circulation (ROSC) was estimated. CT signs developed almost invariably when the CA-ROSC interval exceeded 10 min. Loss of GWMD always preceded sulcal edema/effacement. None of the 35 patients achieved long-term survival, regardless of the presence of the CT signs. CONCLUSION: CT signs may develop earlier in patients with SAH-CA than CA of cardiac origin. Because of a poor prognosis, early CT signs are not useful prognosticators in that population.

Objective: The authors present a patient with acute ischemic stroke due to severe stenosis of the left internal carotid artery who was successfully treated with carotid artery stenting (CAS) in the acute stage.Case: A 76-year-old man presented with aphasia and right hemiparesis. Intravenous administration of rt-PA was not indicated because the patient was outside the time-window. As perfusion CT revealed a large ischemic penumbra in the territory of the left middle cerebral artery, we attempted neuroendovascular therapy to rescue the penumbra from infarction. The regional saturation of oxygen (rSO2) was monitored by near-infrared spectroscopy (NIRS) during the procedure. Before the procedure, rSO2 in the left frontal area was decreased by 10% compared with that on the right side. The self-expanding stent was deployed after predilation. Just after deployment, rSO2 on the left side increased by 10% and we intentionally did not perform postdilation to avoid hyperperfusion. The procedure was finished within 6 hours and 30 minutes after ischemic onset. The postoperative course was good and there were no hemorrhagic complications.Conclusion: NIRS monitoring allows observation of real time changes in cerebral perfusion during the dilatative procedure, which provides useful information for intraoperative decision-making on whether stenting should be added after angioplasty and then, whether postdilation should be performed during carotid artery stenting in the acute stage.

Giant aneurysms have a dismal natural history, thus necessitating early management. These pose a great challenge to the vascular neurosurgeon. The complexity of their anatomy, parent vessels or branches and perforators warrants additional measures for maintaining distal perfusion. Here we try to define the minimally invasive management of these aneurysms. This study compares reconstruction and bypass.<br> This study covers 40 large and 5 giant cases of aneurysms treated in our institute. Giant aneurysms are those with a dome diameter 25 mm or more. 3D CT scan and DSA were the primary investigative procedures, and 3D CT scan was especially useful in thrombosed aneurysms. Aneurysms that had involved a major portion of the parent wall were reconstructed, thus avoiding bypass.<br> Based on our experience, not only basic technique of trapping and evacuation and clipping of the aneurysm neck but also reconstruction of the artery bearing the aneurysm is vital for good postoperative results. Different clipping methods are also used to reconstruct the parent artery. Bypass techniques are also gaining importance in the management of giant aneurysms in difficult cases. However, we feel that bypass procedures are too extensive and are associated with attendant complications. Acute graft occlusion is one of the commonest complications. Aneurysmal rupture is one more complication of bypass procedures. Prolonged occlusion can also cause neurological deficits. <br> Considering the difficulties with bypass and our experience in parent vessel reconstruction with multiple clipping, we feel bypass should be considered only in exceptional cases.<br>

Giant aneurysms have a dismal natural history, thus necessitating early management. These pose a great challenge to the vascular neurosurgeon. The complexity of their anatomy, parent vessels or branches and perforators warrants additional measures for maintaining distal perfusion. Here we try to define the minimally invasive management of these aneurysms. This study compares reconstruction and bypass.<br> This study covers 40 large and 5 giant cases of aneurysms treated in our institute. Giant aneurysms are those with a dome diameter 25 mm or more. 3D CT scan and DSA were the primary investigative procedures, and 3D CT scan was especially useful in thrombosed aneurysms. Aneurysms that had involved a major portion of the parent wall were reconstructed, thus avoiding bypass.<br> Based on our experience, not only basic technique of trapping and evacuation and clipping of the aneurysm neck but also reconstruction of the artery bearing the aneurysm is vital for good postoperative results. Different clipping methods are also used to reconstruct the parent artery. Bypass techniques are also gaining importance in the management of giant aneurysms in difficult cases. However, we feel that bypass procedures are too extensive and are associated with attendant complications. Acute graft occlusion is one of the commonest complications. Aneurysmal rupture is one more complication of bypass procedures. Prolonged occlusion can also cause neurological deficits. <br> Considering the difficulties with bypass and our experience in parent vessel reconstruction with multiple clipping, we feel bypass should be considered only in exceptional cases.<br>