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BackgroundThe efficacy of combined stent retriever (SR) and aspiration catheter (AC; combined technique: CBT) use for acute ischemic stroke (AIS) is unclear. We investigated the safety and efficacy of single-unit CBT (SCBT)—retrieving the thrombus as a single unit with SR and AC into the guide catheter—compared with single use of either SR or contact aspiration (CA).MethodsWe analysed 763 consecutive patients who underwent mechanical thrombectomy for AIS between January 2013 and January 2020, at six comprehensive stroke centers. Patients were divided into SCBT and single device (SR/CA) groups. The successful recanalization with first pass (SRFP) and other procedural outcomes were compared between groups.ResultsOverall, 240 SCBT and 301 SR/CA (SR 128, CA 173) patients were analyzed. SRFP (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2c, 43.3% vs 27.9%, p<0.001; mTICI 3, 35.8% vs 25.5%, p=0.009) and final mTICI ≥2b recanalization (89.1% vs 82.0%, p=0.020) rates were significantly higher, puncture-to-reperfusion time was shorter (median (IQR) 43 (31.5–69) vs 55 (38–82.2) min, p<0.001), and the number of passes were fewer (mean±SD 1.72±0.92 vs 1.99±1.01, p<0.001) in the SCBT group. Procedural complications were similar between the groups. In subgroup analysis, SCBT was more effective in women, cardioembolic stroke patients, and internal carotid artery and M2 occlusions.ConclusionsSCBT increases the SRFP rate and shortens the puncture-to-reperfusion time without increasing procedural complications.

Background Ornithine transcarbamylase is an enzyme of the urea cycle, which produces urea from ammonia. Although ornithine transcarbamylase deficiency mainly occurs as a severe neonatal‐onset disease, a late‐onset form that could become symptomatic from infancy to adulthood is also known. Case presentation A 34‐year‐old man presented with sudden onset of abnormal behavior, lethargy, and hyperammonemia (108 µmol/L). He had recently increased daily protein intake, which suggested urea cycle disorder. After initiation of protein‐restricted diet and treatment with arginine and sodium phenylbutyrate, his symptoms resolved, along with a decrease in the ammonia level. An R40H(c.119G > A) mutation in the OTC gene was identified. Conclusion Awareness of adult onset ornithine transcarbamylase deficiency in a patient with acute psychiatric symptoms due to hyperammonemia is important. Ornithine transcarbamylase deficiency is the most common urea cycle disorder. It is inherited in X‐linked manner and most patients display hyperammonemia in their childhood. Ornithine transcarbamylase deficiency leads to elevated serum ammonia and manifests as various neurological or psychiatric symptoms. Here, we describe a 34‐year‐old man with sudden onset of abnormal behavior and lethargy.

Background: Intracranial vertebral artery dissection (VAD) is a well-recognized cause of stroke in young and middle-aged individuals, especially in Asian populations. However, a long-term natural course remains unclear. We investigated the long-term time course of VAD using imaging findings to examine the rate and predisposing factors for improvement. Methods: We registered 56 consecutive patients (40 males; mean age, 51.8 ± 10.7 years) with acute spontaneous VAD and retrospectively investigated neuroimaging and clinical course within 1 month and at 3 months ± 2 weeks, 6 months ± 2 weeks, and 12 months ± 2 weeks after onset to ascertain predisposing factors and time course for improvement. Results: The most common presenting symptoms were headache and/or posterior neck pain, seen in 41 patients (73%). Magnetic resonance imaging showed brainstem and/or cerebellum infarction in only 32 patients (57%). Of the 56 VADs, 16 (28%) presented with pearl and string sign, 5 (9%) with pearl sign, 15 (27%) with string sign, and 20 (36%) with occlusion sign. VAD occurred on the dominant side in 20 patients and on the nondominant side in the other 36 patients. The pearl and string sign was more frequently noted on the dominant side than on the nondominant side (50 vs. 17%, p = 0.008). On the other hand, occlusion occurred more often on the nondominant side than on the dominant side (47 vs. 15%, p = 0.016). Furthermore, the pearl and string sign was more frequently seen in the improvement group (41 vs. 15%, p = 0.028), whereas the occlusion sign was evident more frequently in the nonimprovement group (21 vs. 52%, p = 0.015). Follow-up neuroimaging evaluation was performed at 1 and 3 months in 91% each, and at 6 and 12 months in 82% each. VAD aggravation was identified within 1 month after onset in 14%, while VAD improvement was seen in 14, 38, 50, and 52% at each period, mainly within 6 months after onset. Older patients and current smoking were negatively associated with VAD improvement. Conclusions: VAD improvement primarily occurs within 6 months after onset, and VAD aggravation within 1 month. It seems that older patients and current smoking are negative predictors of VAD improvement as risk factors, and as image findings, the pearl and string sign is a positive predictor and occlusion a negative predictor.

We report a rare case of metal-induced dermatitis after coil embolization for cerebral aneurysm. A 51-year-old woman experienced a rash around the lips and neck 3 weeks after coil embolization. Judging from the clinical course and results of several patch tests, platinum coils were considered to have induced the dermatitis. Symptoms were relieved with administration of oral steroids. This represents the first report of metal-induced dermatitis after neuroendovascular treatment. The possibility of metal allergy was difficult to suspect preoperatively. However, early evaluation and referral are important when skin symptoms are observed postoperatively.

Background: To determine the underlying conditions that affect the degree of calcification of carotid arterial plaques, measured quantitatively using multidetector row computed tomography (MDCT), and to study the association of carotid calcification with clinical symptomatology. Methods: We measured the calcification volume of stenotic lesions at the carotid bifurcation using MDCT in 84 consecutive patients who were scheduled to undergo carotid revascularization. These results were compared with the clinical and radiological characteristics of the patients. Results: On MDCT, calcification in the carotid plaques was present in 78 patients (93%). Compared to the other patients, patients in the highest quartile of calcification volume (quartile 4) had higher serum creatinine levels (p < 0.001) and tended to have fewer symptomatic ischemic events in the territory of the affected carotid artery in the preceding 6 months (29 vs. 49%, p = 0.099); in particular, there were fewer transient symptoms (5 vs. 27%, p = 0.032) and symptoms possibly occurring due to local embolism (14 vs. 37%, p = 0.045). On ultrasound, plaque ulceration was less prevalent in patients in quartile 4 than in the remaining patients (5 vs. 29%, p = 0.026), although the severity of carotid stenosis was similar among all the quartiles. Conclusions: Renal dysfunction was associated with enhanced carotid plaque calcification. Patients with severe carotid calcification were found to have a low risk of recent ischemic stroke, presumably due, in part, to a lower prevalence of emboligenic carotid ulceration. MDCT was valuable for the quantitative evaluation of carotid calcification.

Background: With the recent increase in the use of antithrombotic therapy, intracerebral hemorrhage (ICH) has been found to be a common complication. We determined whether the use of oral antithrombotic therapy and the patients’ preexisting comorbidities were predictive of cerebellar hemorrhage (CH; previously reported to be associated with anticoagulants) as compared to other ICH, and whether antithrombotic therapy affected the clinical severity of CH. Methods: A study of 327 consecutive patients hospitalized in our institute within 3 days after the onset of ICH, including 38 patients with a CH. Results: CH accounted for 12% of all ICH, 75% of which occurred in patients on warfarin therapy with an international normalized ratio (INR) for prothrombin time >2.5 (p < 0.0001), and 33% of which occurred in patients on ticlopidine therapy (p = 0.017). Warfarin therapy with an INR >2.5 and high blood glucose on admission were independently predictive of CH as compared to other ICH. In addition, previous ischemic stroke (p = 0.002) and heart diseases (p = 0.018) were more prevalent in patients with CH than in those with other ICH. The number of major arteriosclerotic comorbidities and risk factors was also independently predictive of CH risk. Conclusions: We confirmed that warfarin therapy with an INR >2.5 is associated with CH. Patients with CH frequently had arteriosclerotic comorbidities requiring antithrombotic therapy that can complicate their acute management.

Background: To investigate the utility of superficial temporal artery (STA) duplex ultrasonography (STDU) for evaluating the improvement of the cerebral hemodynamics after extracranial-intracranial (EC-IC) bypass. Methods: This study included 40 consecutive patients who underwent EC-IC bypass for occlusive disease of cerebral arteries. STDU was performed to measure the flow velocity, pulsatility index, and diameter of the operated STA before and 14 days after EC-IC bypass. Regional cerebral blood flow (rCBF) and acetazolamide (ACZ) reactivity of the ipsilateral middle cerebral artery (MCA) territory were evaluated by quantitative single-photon emission computed tomography with the ACZ challenge test. We investigated the correlation between STA flow velocity/diameter and rCBF/ACZ reactivity in the ipsilateral MCA territory. Results: Mean flow velocity (MFV; 26.3 ± 8.8 to 55.3 ± 16.3 cm/s, p < 0.0001) and diameter (1.57 ± 0.24 to 2.26 ± 0.29 mm, p < 0.0001) of the STA, and rCBF (29.1 ± 3.1 to 35.0 ± 6.4 ml/100 g/min, p < 0.0001) and ACZ reactivity (–0.02 ± 0.10 to 0.28 ± 0.21, p < 0.0001) of the MCA territory increased after EC-IC bypass compared with the baseline values. STA MFV was significantly correlated with the rCBF 14 days after EC-IC bypass (R = 0.70, p < 0.0001). A cutoff value of postsurgical STA MFV greater than 48.5 cm/s yielded the highest diagnostic accuracy (sensitivity 86%; specificity, 82%) for rCBF ≧32 ml/100 g/min after EC-IC bypass. Conclusions: STDU was available for evaluating postsurgical patency of the bypass flow and the rCBF of the ipsilateral MCA territory. The mean blood flow velocity of the operated STA is a highly sensitive parameter for predicting rCBF in the ipsilateral MCA territory after EC-IC bypass.

Background Volume isotropic turbo spin-echo acquisition (VISTA) is a new method similar to the 3D black-blood imaging method that enables visualization of a intramural hematoma. T1-VISTA has recently been applied in the diagnosis of intracranial arterial dissection. However, the identification of an intramural hematoma in posterior inferior cerebellar dissection (PICA-D) by T1-VISTA has only rarely been reported. Case presentation We herein report two patients who suffered from PICA-D complicated with ischemic stroke. Initial magnetic resonance arteriography was not informative, however, T1-VISTA depicted high-intensity signal areas suggesting an intramural hematoma of PICA-D in both cases. The high-intensity signal areas gradually reduced and finally disappeared at 4 months and 5 months after the onset, respectively. Conclusion Our cases demonstrate that T1-VISTA was able to assist in the diagnosis and follow-up of PICA-D.

We report a rare case of metal-induced dermatitis after coil embolization for cerebral aneurysm. A 51-year-old woman experienced a rash around the lips and neck 3 weeks after coil embolization. Judging from the clinical course and results of several patch tests, platinum coils were considered to have induced the dermatitis. Symptoms were relieved with administration of oral steroids. This represents the first report of metal-induced dermatitis after neuroendovascular treatment. The possibility of metal allergy was difficult to suspect preoperatively. However, early evaluation and referral are important when skin symptoms are observed postoperatively.

We report a rare case of metal-induced dermatitis after coil embolization for cerebral aneurysm. A 51-year-old woman experienced a rash around the lips and neck 3 weeks after coil embolization. Judging from the clinical course and results of several patch tests, platinum coils were considered to have induced the dermatitis. Symptoms were relieved with administration of oral steroids. This represents the first report of metal-induced dermatitis after neuroendovascular treatment. The possibility of metal allergy was difficult to suspect preoperatively. However, early evaluation and referral are important when skin symptoms are observed postoperatively.