Yoshitaka Kurosaki, Kazumichi Yoshida, Ryu Fukumitsu, Nobutake Sadamasa, Akira Handa, Masaki Chin and Sen Yamagata
Plaque characteristics and morphology are important indicators of plaque vulnerability. MRI-detected intraplaque hemorrhage has a great effect on plaque vulnerability. Expansive remodeling, which has been considered compensatory enlargement of the arterial wall in the progression of atherosclerosis, is one of the criteria of vulnerable plaque in the coronary circulation. The purpose of this study was risk stratification of carotid artery plaque through the evaluation of quantitative expansive remodeling and MRI plaque signal intensity.
Both preoperative carotid artery T1-weighted axial and long-axis MR images of 70 patients who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) were studied. The expansive remodeling ratio (ERR) was calculated from the ratio of the linear diameter of the artery at the thickest segment of the plaque to the diameter of the artery on the long-axis image. Relative plaque signal intensity (rSI) was also calculated from the axial image, and the patients were grouped as follows: Group A = rSI ≥ 1.40 and ERR ≥ 1.66; Group B = rSI< 1.40 and ERR ≥ 1.66; Group C = rSI ≥ 1.40 and ERR < 1.66; and Group D = rSI < 1.40 and ERR < 1.66. Ischemic events within 6 months were retrospectively evaluated in each group.
Of the 70 patients, 17 (74%) in Group A, 6 (43%) in Group B, 7 (44%) in Group C, and 6 (35%) in Group D had ischemic events. Ischemic events were significantly more common in Group A than in Group D (p = 0.01).
In the present series of patients with carotid artery stenosis scheduled for CEA or CAS, patients with plaque with a high degree of expansion of the vessel and T1 high signal intensity were at higher risk of ischemic events. The combined assessment of plaque characterization with MRI and morphological evaluation using ERR might be useful in risk stratification for carotid lesions, which should be validated by a prospective, randomized study of asymptomatic patients.
Kazumichi Yoshida, Hideki Endo, Nobutake Sadamasa, Osamu Narumi, Masaki Chin, Katsumi Inoue, Kazuaki Mitsudo and Sen Yamagata
The goal of this study was to evaluate the usefulness of long-axis black-blood MR (BB–MR) imaging for assessing plaque morphology and distribution in patients with atherosclerotic carotid artery (CA) stenosis.
Sixty-eight carotid arteries in 67 patients who were scheduled to undergo CA endarterectomy or CA stent placement due to atherosclerotic stenosis were included in this study. The patients had undergone CA BB–MR imaging and digital subtraction (DS) angiography within 3 weeks of revascularization. The DS angiography studies were performed using the transfemoral artery approach with selective common CA catheterization. The BB–MR images were acquired using a 1.5-T whole-body MR imaging unit, and T1-weighted images parallel to the long axis of the artery at 1-mm intervals were obtained. Plaque distribution was evaluated by measuring the distance between the CA bifurcation and the point that appeared to be the distal extent of the plaque on BB–MR imaging (D–MR imaging) and DS angiography images (D–DS angiography).
Plaque distribution was clearly shown in 88.2% of the cases using long-axis BB–MR images, except for 8 arteries with poor image quality. In 4 arteries, D–DS angiography could not be obtained because the distal plaque end could not be confirmed. In 56 vessels, both the D–DS angiography and D–MR imaging could be measured; the mean D–MR imaging (19.75 ± 6.85 mm [standard deviation]) was significantly longer than the average D–DS angiography (16.32 ± 7.07 mm).
Long-axis BB–MR imaging can provide a noninvasive and accurate way to show CA plaque distribution; it is of great use not only for stroke risk assessment in patients with CA atherosclerosis but also for preoperative evaluation in patients requiring CA endarterectomy or CA stent placement.
Masaomi Koyanagi, Hitoshi Fukuda, Benjamin Lo, Minami Uezato, Yoshitaka Kurosaki, Nobutake Sadamasa, Akira Handa, Masaki Chin and Sen Yamagata
Delayed cerebral ischemia (DCI) is an important complication after aneurysmal subarachnoid hemorrhage (aSAH). Although intrathecal milrinone injection via lumbar catheter to prevent DCI has been previously reported to be safe and feasible, its effectiveness remains unknown. The goal of this study was to evaluate whether intrathecal milrinone injection treatment after aSAH significantly reduced the incidence of DCI.
The prospectively maintained aSAH database was used to identify patients treated between January 2010 and December 2015. The cohort included 274 patients, with group assignment based on treatment with intrathecal milrinone injection or not. A propensity score model was generated for each patient group, incorporating relevant patient variables.
After propensity score matching, 99 patients treated with intrathecal milrinone injection and 99 without treatment were matched on the basis of similarities in their demographic and clinical characteristics. There were significantly fewer DCI events (4% vs 14%, p = 0.024) in patients treated with intrathecal milrinone injection compared with those treated without it. However, there were no significant differences between the 2 groups with respect to their 90-day functional outcomes (46% vs 36%, p = 0.31). The likelihood of chronic secondary hydrocephalus, meningitis, and congestive heart failure as complications of intrathecal milrinone injection therapy was also similar between the groups.
In propensity score–matched groups, the intrathecal administration of milrinone via lumbar catheter showed significant reduction of DCI following aSAH, without an associated increase in complications.
Hitoshi Fukuda, Alexander I. Evins, Koichi Iwasaki, Itaro Hattori, Kenichi Murao, Yoshitaka Kurosaki, Masaki Chin, Philip E. Stieg, Sen Yamagata and Antonio Bernardo
Occipital artery–posterior inferior cerebellar artery (OA-PICA) bypass is a technically challenging procedure for posterior fossa revascularization. The caudal loop of the PICA is considered the optimal site for OA-PICA anastomosis, however its absence can increase the technical difficulty associated with this procedure. The use of the far-lateral approach for accessing alternative anastomosis sites in OA-PICA bypass in patients with absent or unavailable caudal loops of PICA is evaluated.
A morphometric analysis of OA-PICA bypass with anastomosis on each segment of the PICA was performed on 5 cadaveric specimens through the conventional midline foramen magnum and far-lateral approaches. The difficulty level associated with anastomoses at each segment was qualitatively assessed in each approach for exposure and maneuverability by multiple surgeons. A series of 8 patients who underwent OA-PICA bypass for hemodynamic ischemia or ruptured dissecting posterior fossa aneurysms are additionally reviewed and described, and the clinical significance of the caudal loop of PICA is discussed.
Anastomosis on the caudal loop could be performed more superficially than on any other segment (p < 0.001). A far-lateral approach up to the medial border of the posterior condylar canal provided a 13.5 ± 2.2–mm wider corridor than the conventional midline foramen magnum approach, facilitating access to alternative anastomosis sites. The far-lateral approach was successfully used for OA-PICA bypass in 3 clinical cases whose caudal loops were absent, whereas the midline foramen magnum approach provided sufficient exposure for caudal loop bypass in the remaining 5 cases.
The absence of the caudal loop of the PICA is a major contributing factor to the technical difficulty of OA-PICA bypass. The far-lateral approach is a useful surgical option for OA-PICA bypass when the caudal loop of the PICA is unavailable.
Masaomi Koyanagi, Hitoshi Fukuda, Masaaki Saiki, Yoshihito Tsuji, Benjamin Lo, Toshinari Kawasaki, Yoshihiko Ioroi, Ryu Fukumitsu, Ryota Ishibashi, Masashi Oda, Osamu Narumi, Masaki Chin, Sen Yamagata and Susumu Miyamoto
Shunt-dependent hydrocephalus (SDHC) may arise after aneurysmal subarachnoid hemorrhage (aSAH) as CSF resorptive mechanisms are disrupted. Using propensity score analysis, the authors aimed to investigate which treatment modality, surgical clipping or endovascular treatment, is superior in reducing rates of SDHC after aSAH.
The authors’ multicenter SAH database, comprising 3 stroke centers affiliated with Kyoto University, Japan, was used to identify patients treated between January 2009 and July 2016. Univariate and multivariate analyses were performed to characterize risk factors for SDHC after aSAH. A propensity score model was generated for both treatment groups, incorporating relevant patient covariates to detect any superiority for prevention of SDHC after aSAH.
A total of 566 patients were enrolled in this study. SDHC developed in 127 patients (22%). On multivariate analysis, age older than 53 years, the presence of intraventricular hematoma, and surgical clipping as opposed to endovascular coiling were independently associated with SDHC after aSAH. After propensity score matching, 136 patients treated with surgical clipping and 136 with endovascular treatment were matched. Propensity score–matched cohorts exhibited a significantly lower incidence of SDHC after endovascular treatment than after surgical clipping (16% vs 30%, p = 0.009; OR 2.2, 95% CI 1.2–4.2). SDHC was independently associated with poor neurological outcomes (modified Rankin Scale score 3–6) at discharge (OR 4.3, 95% CI 2.6–7.3; p < 0.001).
SDHC after aSAH occurred significantly more frequently in patients who underwent surgical clipping. Strategies for treatment of ruptured aneurysms should be used to mitigate SDHC and minimize poor outcomes.