Cerebral Embolism and MINOCA Secondary to Left Atrial Myxoma after Occlusion of Atrial Septal Defect by Amplatzer Occluder: A Case Report

Primary heart tumors are rare, with atrial myxomas being the most common type. Atrial myxomas can lead to embolisms, heart obstruction, and systemic symptoms. Herein, we report a case of 72-year-old woman who presented with a left atrial myxoma at the atrial septal defect occluder, a new acute cerebral infarction, and MINOCA (myocardial infarction with no obstructive coronary atherosclerosis). Left atrial myxoma is a common primary cardiac tumor; however, left atrial myxomas arising after percutaneous atrial septal defect occlusion are rare. Additionally, the patient presented with a new case of multiple systemic emboli. The patient underwent surgical resection of a left atrial myxoma, occluder, and left atrium, and atrial septal repair, and was discharged with good recovery for outpatient follow-up. The possibility of a cardiac tumor, especially an atrial myxoma, which can lead to a series of complications, should be considered at the closure site after percutaneous atrial septal closure. Therefore, active surgical treatment and long-term follow-up are warranted in such cases.

Large Tissue Debris Causing Cerebral Embolism After Transcatheter Aortic Valve Replacement

Cerebral vascular embolism is one of the complications of transcatheter aortic valve replacement (TAVR). Thrombolytic therapy is not expected to be effective when embolic material consists of a large tissue fragment. Instead, mechanical aspiration may be more effective therapy for acute cerebral infarction after TAVR. Here, we describe the case of an 87-year-old woman with aortic valve stenosis and heart failure who underwent TAVR using a self-expandable valve. Acute cerebral infarction with left middle cerebral artery occlusion caused by a large tissue fragment developed after the procedure.

Benefit of mechanical thrombectomy in acute ischemic stroke related to calcified cerebral embolus

PURPOSE

Mechanical thrombectomies (MT) in patients with large vessel occlusion (LVO) related to calcified cerebral embolus (CCE) have been reported, through small case series, being associated with low reperfusion rate and worse outcome, compared to regular MT. The purpose of the MASC (Mechanical Thrombectomy in Acute Ischemic Stroke Related to Calcified Cerebral Embolus) study was to evaluate the incidence of CCEs treated by MT and the effectiveness of MT in this indication.

METHODS

The MASC study is a retrospective multicentric (n = 37) national study gathering the cases of adult patients who underwent MT for acute ischemic stroke with LVO related to a CCE in France from January 2015 to November 2019. Reperfusion rate (mTICI ≥ 2B), complication rate and 90-day mRS were systematically collected. We then conducted a systematic review by searching for articles in PubMed, Cochrane Library, Embase and Google Scholar from January 2015 to March 2020. A meta-analysis was performed to estimate clinical outcome at 90 days, reperfusion rate and complications.

RESULTS

We gathered data from 35 patients. Reperfusion was obtained in 57% of the cases. Good clinical outcome was observed in 28% of the patients. The meta-analysis retrieved 136 patients. Reperfusion and good clinical outcome were obtained in 50% and 29% of the cases, respectively.

CONCLUSION

The MASC study found worse angiographic and clinical outcomes compared to regular thrombectomies. Individual patient-based meta-analysis including the MASC findings shows a 50% reperfusion rate and a 29% of good clinical outcome.

[Surgery for a Massive Left Atrial Myxoma, Four Hours after a Thrombectomy for a Cerebral Embolism:Report of a Case]

A 48-year-old female patient was transferred with dysarthria and left-sided hemiplegia. Contrast-enhanced computed tomography revealed occlusion of the first branch of the right middle cerebral artery, for which an emergency thrombectomy was successfully performed within 2 hours of patient's initial symptoms. Postoperatively, transthoracic echocardiography revealed a massive mobile left atrial mass, measuring approximately 65×30 mm, a part of which moved in and out of the mitral valve without significant mitral regurgitation. Embolisms to the kidneys and the spleen were demonstrated. Another emergency cardiac surgery was performed, 4 hours after the thrombectomy, to resect the mass from the fossa oval with the atrial septum;the defect was closed using autologous pericardium. The histopathological findings of the specimen were consistent with a myxoma. The patient completely recovered and was discharged when ambulatory. We have discussed the importance of the timing of surgical intervention in the context of patients undergoing cardiac surgery after a cerebral embolism.

In vitro analysis of mechanism of pulsed-laser thrombolysis

Thrombolytic therapy in the treatment of cardiogenic acute cerebral embolism caused by coagulated blood carries the risk of hemorrhagic complications, and there is a need to develop safer and more reliable treatment methods. Laser thrombolysis therapy, which utilizes the difference in energy absorption between the thrombus and the arterial wall, has shown promise as a new treatment method because it can selectively act only on the thrombus. It has not been applied clinically, however, and one of the main reasons for this is that its underlying mechanism has not been elucidated. We developed a pulse laser thrombolysis system for treating cerebral blood vessels that consists of a diode-pumped solid-state neodymium-yttrium aluminum garnet laser, which has excellent stability and maintainability and is suitable for clinical applications coupled to a small-diameter optical fiber. Moreover, we analyzed the mechanisms that occur during pulsed laser irradiation of transparent glass tubes and gelatin phantoms. We found that bubbles form as a thermal effect in addition to ablation of the pulsed laser irradiation. Furthermore, we detected no shock waves or water jets associated with the bubbles. We analyzed the bubbles’ dynamics and growth rate, and their effect on a rabbit blood clot phantom. We concluded that the bubbles generated by the laser irradiation physically cut the thrombus and thereby had a thrombectomy effect. We believe that this study will clarify the mechanism of laser thrombolysis therapy and contribute greatly to the realization of its clinical application.

Open surgical embolectomy for cardiogenic cerebral embolism: Technical note and its advantages

BACKGROUND AND IMPORTANCE

In cardiogenic cerebral embolism, early recanalization is the most important factor for good prognosis. However, endovascular thrombectomy often fails to achieve recanalization. We present an open surgical embolectomy technique and discuss its advantages.

CLINICAL PRESENTATION

A 79-year-old woman developed right hemiparesis and severe aphasia. Magnetic resonance imaging revealed an acute cerebral infarction caused by left middle cerebral artery (MCA) occlusion. We attempted endovascular thrombectomy but failed because it was impossible to guide the catheter to the occlusion site. Hence, we converted to open surgical embolectomy. Sylvian fissure was widely opened. After confirming the range of thrombosis using indocyanine green videoangiography (ICGVAG), the proximal and distal arteries were secured, and a temporary clip was placed on the distal M2 to prevent distal thrombosis migration. MCA was cut approximately 3 mm from the bifurcation, and thrombosis was removed using micro-forceps. The proximal clip was simultaneously inserted but was not clamped because the thrombus was extruded by proximal vascular flow. Immediately after removing the thrombus, intense bleeding occurred from the proximal flow. An assistant clamped the proximal artery using the prepared clip, and the incised area of MCA was sutured using 9-0 threads. We finally confirmed blood flow after recanalization using ICGVAG. The time from skin incision to recanalization was 27 min. After the procedure, the patient developed slight aphasia but had no hemiparesis and was later transferred to a rehabilitation hospital.

CONCLUSION

Open surgical embolectomy may be a secondary rescue treatment option in the case of endovascular thrombectomy failure.

Unusual clinicopathological presentation of nontraumatic cerebral fat embolism: Two-case report

RATIONALE

Fat embolism syndrome (FES) is characterized by the classical triad of cerebral, respiratory, and cutaneous manifestations. In contrast, cerebral fat embolism (CFE), corresponding to incomplete pure type FES, is much rarer and usually follows trauma. CFE typically shows a "starfield" pattern on diffusion-weighted magnetic resonance imaging due to the involvement of multiple small arteries. We report 2 unusual cases of CFE that showed a nontraumatic etiology and the involvement of a single dominant cerebral artery.

PATIENT CONCERNS

Case 1 was a 33-year-old woman without a history of trauma who visited the emergency room due to hemiparesis and hemisensory deficits. She was a heavy smoker and had used oral contraceptives for several years. Most importantly, she had 2 experiences of autologous fat grafting 2 months previously. Magnetic resonance angiography (MRA) revealed acute occlusion of the right middle cerebral artery. Case 2 was an 80-year-old man suddenly presented with dizziness, ataxia, and left-sided sensorimotor dysfunction. He had a history of hypertension, untreated atrial fibrillation, and chronic alcoholism. MRA demonstrated the occlusion of the distal basilar artery.

DIAGNOSIS

Case 1: Microscopic findings demonstrated variable sized fat vacuoles intermixed with moderate amounts of thrombi. Case 2: Histologically, mature adipocytes were intermingled with fibrin, blood cells, and a fragment of entrapped soft tissue resembling the vessel wall.

INTERVENTION

Case 1 and 2 underwent aspirational thrombectomy guided by transfemoral cerebral angiography.

OUTCOME

Case 1 recovered well but Case 2 still suffers from gait ataxia.

LESSONS

CFE can rarely occur in various nontraumatic conditions, with or without evident etiology. Furthermore, it may not show characteristic clinicopathological manifestations. Therefore, careful follow up of those who have undergone procedures that are likely to trigger FES or who have hemodynamic or hypercoagulable risk factors is needed.

Aortogenic Embolic Stroke Diagnosed by a Pathological Examination of Endovascularly Removed Thrombus: An Autopsy Report

Complex aortic atheroma is a high-risk factor for recurrent embolic stroke. An accurate identification of stroke etiology is clinically important; however, it can be challenging. A 91-year-old man with atrial fibrillation was diagnosed with cardioembolic stroke and treated with mechanical thrombectomy. The removed thrombus microscopically contained foamy cells, suggesting an atheroembolism. An autopsy revealed an atherosclerotic lesion with ulceration, located in the aortic arch. At the lesion, the plaque had microscopically ruptured into the lumen. We therefore concluded that the aortic atherosclerotic lesion was the embolic source. Removed thrombi should be pathologically examined even if a cardioembolic stroke is clinically suspected.

Surgical embolectomy for paradoxical cerebral embolism with massive pulmonary embolism

The patient was a 68-year-old woman with a history of multiple cerebral emboli. The patient presented with dysarthria, dysphagia, and left facial paralysis. Emergent MRI demonstrated multiple emboli in the brain stem and left occipital lobe. Echocardiography and chest CT demonstrated floating emboli entrapped in the foramen ovale and pulmonary emboli in both main pulmonary arteries. Emergent pulmonary embolectomy and extraction of the emboli on the foramen ovale were successfully performed without neurological exacerbation.

Histology of Thrombectomy Specimen Reveals Cardiac Tumor Embolus in Cryptogenic Young Stroke

A 25-year-old woman presented with acute onset of right hemiplegia and global aphasia with National Institutes of Health Stroke Scale score of 19. Computed tomography angiography demonstrated occlusion of the left proximal middle cerebral artery. She was thrombolysed with intravenous recombinant tissue plasminogen activator (0.6 mg/kg) within 3 hours of onset of symptoms and was taken up for mechanical thrombectomy. The retrieved specimen appeared pale white and soft; histopathologic examination revealed a papillary neoplasm composed of papillae with hyalinized cores lined by endothelium, consistent with papillary fibroelastoma of cardiac origin. Transesophageal echocardiography showed no abnormalities, which can be explained by complete embolization of the mass into the cerebral circulation. On follow-up after 5 months, the patient recovered with only minimal aphasia and no cardiac symptoms. Our experience with this case highlights the importance of histopathologic examination of the mechanical thrombectomy specimen, as it provided the only clue to the etiology of stroke.

Mechanical Thrombectomy with the Embolus Retriever with Interlinked Cages in Acute Ischemic Stroke: ERIC, the New Boy in the Class

BACKGROUND AND PURPOSE

The Embolus Retriever with Interlinked Cages (ERIC) device is a novel stent retriever for mechanical thrombectomy. It consists of interlinked cages and could improve procedural benchmarks and clinical outcome compared with classic stent retrievers. This study compares the rates of recanalization, favorable clinical outcome, procedural adverse events, and benchmarks between the ERIC device and classic stent retrievers.

MATERIALS AND METHODS

From 545 patients treated with thrombectomy between 2012 and 2015, 316 patients were included. The mean age was 69 ±13 years, the mean baseline NIHSS score was 17 ± 5, and 174 (55%) were men. The ERIC was used as the primary thrombectomy device in 59 (19%) patients. In a propensity score matched analysis including the NIHSS score, clot location, delay to groin puncture, neurointerventionalist, and anesthetic management, 57 matched pairs were identified.

RESULTS

Patients treated with the ERIC device compared with classic stent retrievers showed equal rates of recanalization (86% versus 81%, P = .61), equal favorable 3-month clinical outcome (mRS 0-2: 46% versus 40%, P = .71), and procedural adverse events (28% versus 30%, P = 1.00). However, in patients treated with the ERIC device, thrombectomy procedures were less time-consuming (67 versus 98 minutes, P = .009) and a rescue device was needed less often (18% versus 39%, P = .02) compared with classic stent retrievers.

CONCLUSIONS

Mechanical thrombectomy with the ERIC device is effective and safe. Rates of favorable procedural and clinical outcomes are at least as good as those with classic stent retrievers. Of note, the ERIC device might be time-saving and decrease the need for rescue devices. These promising results call for replication in larger prospective clinical trials.

Mycotic Aneurysm of the Internal Carotid Artery Presenting with Multiple Cerebral Septic Emboli

Mycotic aneurysms of the extracranial carotid artery are uncommon and always warrant surgical treatment to prevent eventual rupture and death. Septic embolization to the brain is an even rarer complication of these aneurysms. We present a case of a 79-year-old male with an extracranial internal carotid artery mycotic aneurysm during Staphylococcus aureus bacteremia. He presented with hemiparesis owing to brain embolism from multiple septic emboli originating from the aneurysm. Multidetector computed tomographic angiography contributed to the diagnosis. Resection of the aneurysm and restoration of arterial supply to the brain by vein graft interpositioning was the therapeutic procedure along with long-term antibiotic treatment. A high index of suspicion is required for the diagnosis of a mycotic carotid aneurysm and aggressive treatment is always needed to prevent lethal complications.

[Neuroendovascular Treatment for Cerebral Embolism in a Patient just after Aortic Valve Replacement；Report of a Case]

A 67-year-old woman suffered from severe aortic stenosis and atrial fibrillation, and underwent aortic valve replacement with a St. Jude Medical Regent 23-mm valve and pulmonary vein isolation using an AtriCure Isolator Synergy.At 6 days after the operation, she experienced sudden onset of atrial fibrillation, left side paralysis, and dysarthria. Right internal carotid artery embolism was diagnosed via magnetic resonance imaging, and we promptly performed neuroendovascular therapy with a Solitaire FR. Neuroendovascular treatment succeeded, and her neurological function was restored to near-normal. Her post-treatment course was uneventful, and she is currently well without neurological dysfunction.

Clinical Performance of the New Gore Septal Occluder in Patent Foramen Ovale Closure: A Single-Center Experience

BACKGROUND

Several progressively refined percutaneous devices for patent foramen ovale (PFO) closure have been recently developed. We describe our single-center experience with the new Gore septal occluder (GSO).

METHODS

Between January 2012 and May 2013, all consecutive patients with a PFO and previous cerebral thromboembolic events underwent percutaneous closure with the GSO system. Device implantation was performed under local anesthesia with combined fluoroscopic and intracardiac echographic monitoring. Follow-up schedule was: transthoracic echo at day 1 and day 30, as well as transcranial Doppler at 6 months and 12 months, all with clinical concomitant evaluation.

RESULTS

Twenty-two patients (11 males and 11 females) with a mean age of 51.2 ± 13.9 years (range, 40-74 years) had PFO closure. At baseline, 4 and 18 subjects had medium-grade and large-grade right to left permanent shunt, respectively; isolated PFO was present in 13 patients and PFO with atrial septal aneurysm was present in 9 patients. Device placement was successful in all patients. Median procedural and fluoroscopic times were 40.5 minutes (range, 22-92 minutes) and 6.5 minutes (range, 3-16 minutes), respectively. Clinical and instrumental follow-up data were obtained at 12 months in 22 patients (100%). A low-grade (<5 microbubbles) permanent residual shunt was registered in 5 patients at 6 months and in 2 patients (during Valsalva only) at 12-month follow-up. Functional PFO occlusion was thus obtained in all patients.

CONCLUSION

This single-center initial experience suggests that the GSO is a safe and effective closure device, straightforward to implant with quick deployment and minimal imaging, and suitable for a range of atrial septal anatomies. Incidence and entity of residual shunts at follow-up were consistent with functional PFO occlusion in all patients.

Effectiveness of mechanical embolectomy for septic embolus in the cerebral artery complicated with infective endocarditis

There has been a controversy over data of thrombolytic and endovascular surgical treatment about cerebral infarction secondary to infective endocarditis. We report a woman who received early mechanical embolectomy as a treatment of acute stroke with infective endocarditis. A 35-yr-old woman was hospitalized due to right hemiparesis. Brain image showed cerebral infarction at the middle cerebral artery and echocardiography demonstrated vegetation at the mitral valve. She was successfully treated with embolectomy and parenteral antibiotics without any neurologic sequelae. This report shows that the early retrieve of septic cerebral emboli can be a helpful treatment of acute stroke associated with endocarditis.

Late cerebral embolization after emboli-protected carotid artery stenting

Carotid artery stenting (CAS) is nowadays considered as alternative therapeutic option to carotid endarterectomy for patients suffering from carotid artery disease. Recent studies and meta-analyses have demonstrated equal performance of carotid stenting to endarterectomy as regard as the overall adverse events (death/stroke rates), especially when periprocedural myocardial infarction and nerve pulses are also included. However, carotid stenting was inferior to endarterectomy when compared in terms of acute and late embolic events. In the present review, we collect all studies available in the published literature regarding the late embolic events. We mainly attempted to gather data regarding the silent embolic events occurring after the acute post-procedural period. We analyzed the results and reported the incidence of the problem. Finally, we aimed to identify possible causes and propose effective solutions to reduce the incidence of late embolic events.

Is mechanical embolectomy performed in nonanesthetized patients effective?

BACKGROUND AND PURPOSE

In centers performing endovascular treatment for patients with AIS, there is variability in placing patients under general anesthesia. Nonanesthetized patients might move during the procedure leading to complications and prolonging the time to revascularization due to lack of cooperation. However, general anesthesia can lead to a delay of the procedure, an inability to assess the patient during the procedure, and fluctuations of blood pressure. Our center does not routinely either use general anesthesia or sedate patients. We report our experience with nonanesthetized patients undergoing emergent mechanical embolectomy.

MATERIALS AND METHODS

We performed a retrospective analysis of 66 consecutive patients enrolled in the MERCI Registry at our center from June 2007 to June 2009. A univariate statistical analysis was performed by using the Fisher exact test for categoric variables and the Student t test for continuous variables in comparing use of general anesthesia with nonanesthetized patient demographics, procedural times, procedural complications, good outcome, and mortality.

RESULTS

Nine patients (13.6%) were placed under general anesthesia, and 57 (86.4%) were awake. Higher baseline NIHSS scores and older age were statistically associated with general anesthesia. No significant difference occurred between groups in the time to groin puncture or procedural times. Revascularization rates were 77% for general anesthesia patients and 70% for nonanesthetized patients (P = .331). The nonanesthetized group had better outcomes, but we did not control these outcomes for other factors. Complications were much more frequent in the general anesthesia patients (22%) than in the nonanesthetized patients (3.5%) (P = .0288).

CONCLUSIONS

Performing mechanical embolectomy in nonanesthetized patients at our institution does not prolong procedure time, decrease revascularization rates, increase complication rates, or decrease good outcome. Mechanical embolectomy in nonanesthetized patients is effective and should be considered an option in the treatment of the patient with AIS.

[Cardiac papillary fibroelastoma, a rare valvular source of cerebral embolism: report of two cases]

Cardiac papillary fibroelastomas are very rare and benign tumors, usually involving heart valves. They are sometimes asymptomatic. However, they become serious illnesses when associated with clinical events, as systemic embolism. Diagnosis is evoked by echocardiography and confirmed by histopathological examination. The only curative treatment consists of the excision of the tumor under cardiopulmonary bypass. This approach is safe and prevents the risk of embolism recurrence. We report the cases of two patients suffering from acute cerebral embolism. Transthoracic and transoesophageal echocardiography detected tumors of the mitral and aortic valve in the first and second patients, respectively. Preserving the valve integrity, both masses were surgically excised and pathological findings confirmed the diagnosis. As surgical management is curative, we believe that these lesions should be always removed.

A New Device For the Treatment of Thromboembolic Strokes

We present data concerning the design and testing of a new clot-sucking device for possible use in the extraction of blood clots that arise during thromboembolic strokes. Our data indicate that a jelly-like mass of 0.02 g (of an artificial clot) can be removed from plastic tubing using this vortex-creating device, which has an optimal diameter of 1 mm, in conjunction with a 6F arterial catheter that is 110-cm long and using applied suction pressures of about 50 cm Hg.

Endovascular reperfusion therapy in acute ischaemic stroke

OBJECTIVES

Endovascular reperfusion therapy in acute ischaemic stroke comprises a number of pharmacological and mechanical procedures. Mechanical embolectomy offers the promise of efficacious treatment for patients in whom pharmacological thrombolysis is contraindicated or might be ineffective. The purpose of this review is to outline endovascular reperfusion therapy in acute ischaemic stroke with focus on mechanical embolectomy.

MATERIALS & METHODS

Data on endovascular reperfusion therapy were acquired through searches in MEDLINE 1990-2006 by cross referencing relevant key words.

RESULTS

Mechanical embolectomy works well on large-volume proximal occlusions for which there was previously no effective treatment. Early safety trials are promising, efficacy in terms of recanalisation is substantial, and both safety and efficacy is expected to improve with further advances in technology.

CONCLUSIONS

Intravenous thrombolysis with tPA revolutionised acute stroke treatment a decade ago. Endovascular reperfusion therapy now offers the promise of a second revolution, expanding the number of patients eligible and the time window open for specific stroke treatment.

Experimental model evaluation of filter trapping after embolectomy using the Merci system: supplemental technique for Merci retrieval procedure

Examination of embolectomy using the Merci Retrieval System using experimental stroke models demonstrated that aspiration is not adequate to remove larger clots. The effectiveness of filter trapping was examined using the same models. A silicone model of the carotid artery system with model blood clot was incorporated in a laboratory pulsatile flow system. Embolectomy was performed using the Merci Retrieval System. Any clot not evacuated through the balloon guide catheter was trapped with a distal protection filter device developed for cervical stenting. The clot could not be sucked into the guide catheter by the recommended procedures in nine of 15 trials. Trapping failed in only one trial, in which the clot passed through a gap between the edge of the filter orifice and the inner model lumen. A clot was withdrawn to the catheter tip trapped across the edge of the orifice frame in one trial, and a very large clot was trapped across the filter orifice in two trials. Even clots made by the same method showed variation in properties, especially hardness, which may affect the effectiveness of aspiration. The aspiration procedure recommended for the Merci Retrieval System did not remove the large clots formed by embolectomy. The trapping procedure using a filter device without an orifice frame was effective to solve this problem.

Management of air embolism during HeartMate XVE exchange

Air embolism is a rare and usually fatal complication of major cardiac surgery. We present a case in which a 45-year-old man supported by a HeartMate(R) XVE left ventricular assist device required a pump exchange due to failure of the device motor. During pump dissection, a massive amount of air entered the systemic circulation. Urgent cannulation for cardiopulmonary bypass was performed, and cardiopulmonary bypass was initiated, followed by profound hypothermia, circulatory arrest, retrograde cerebral perfusion, retrograde coronary sinus perfusion, and then barbiturate coma and steroid therapy. The HeartMate XVE left ventricular assist device was removed, and a HeartMate II was implanted. After 5 days, the patient awoke with left hemiparesis, which nearly resolved with aggressive physical therapy. Forty-four days after the pump exchange operation, the patient was discharged from the hospital with only mild left hemiparesis. Exposure of the left ventricular assist device or its external components requires careful monitoring, because air can enter the pump-particularly in a hypovolemic patient. Rapid response after massive air entry into the left ventricular assist device system, as in our patient, can result in a successful outcome.

Silent brain embolism during transcatheter closure of patent foramen ovale: a transcranial Doppler study

The aim of this report is to quantify the amount of spontaneous microembolism detected in brain vessels by transcranial Doppler (TCD) during transcatheter closure of right-to-left shunt (RLS). We examined 29 patients who had had a stroke or a transient ischaemic attack (17 females and 12 males; mean age 45+/-15 years). They all underwent TCD monitoring during the procedure and microembolic signals (MES) were recorded. Detection of MES was distributed as follows: during femoral catheterisation in 8 patients (25%), during atrial catheterisation in 5 patients (17%), during transeptal crossing in 14 patients (48%), during left disc opening in 28 patients (96%) and during right disc opening in 7 patients (24%). The highest rates of MES were observed during left disc opening and less during transeptal crossing with an average count of 31 (range 3-135) and 3 (range 1-18) respectively. Brain embolism occurs throughout the procedure after femoral catheterisation for PFO closure. Our results indicate that the majority of MES reached the brain during the opening of the left disc in the left atrium: 28/29 patients exhibited MES with an average of 31 (3-135), thus supporting the notion that gas embolism accounted for the findings.

Merci Retriever in acute stroke treatment

The Merci Retriever is a device used for mechanical clot extraction in cerebral arteries. It obtained US FDA clearance in August 2004 for recanalization of cerebral arteries in acute stroke. Previously, intravenous recombinant tissue plasminogen activator administered within 3 h from symptom onset was the only other FDA-approved treatment in acute stroke. Stroke from large brain artery occlusion, which has the highest morbidity and mortality rate, is inefficiently treated with intravenous recombinant tissue plasminogen activator and has a high likelihood of hemorrhagic complication. In the multicenter prospective Mechanical Embolus Removal in Cerebral Ischemia trial that led to FDA clearance, the Merci Retriever achieved 48% vessel recanalization when used within 8 h of stroke onset, and resulted in lower morbidity and mortality in revascularized patients. Clinical efficacy trials are needed to determine the place of this device in the treatment of stroke patients.

Internal carotid artery stenosis due to atherosclerotic plaque damage after whiplash injury

Blunt traumatic occlusion or stenosis of the internal carotid artery is a rare complication of whiplash injury and may not be recognized until the onset of neurological symptoms. The clinical course can vary considerably, with regard to both the symptoms and the interval between injury and manifestation. A dissecting aneurysm and intimal tear are usually observed after blunt internal carotid artery injury. Atherosclerotic plaque is often observed in the cervical internal carotid artery and carotid bifurcation, but involvement of plaque has been confirmed in relatively few cases of blunt traumatic internal carotid injury. We describe a 58-year-old man who developed cerebral embolism due to intraplaque thrombus after a minor whiplash injury and was successfully treated with carotid endarterectomy. Because thrombosis occurred within the atherosclerotic plaque, we named the mechanism of this case "plaque injury".

Surgical Approach in Massive Intraoperative Atherosclerotic Embolism

We describe a case of massive embolization of atherosclerotic material during aortic cannulation and the surgical approach chosen to treat it, that is, retrograde cerebral perfusion and subtotal arch replacement in deep hypothermic circulatory arrest.

Model analysis of coil embolization of cerebral aneurysms: prediction of thrombus formation in aneurysms based on the coil embolization rate

OBJECTIVES

Intra-aneurysmal coil embolization has been established as a common method for the intravascular treatment of cerebral aneurysms, but few studies have evaluated its long-term results. Because there is no sufficient objective landmark of complete embolization, determination of its application depends on a surgeon's experience.

METHODS

A glass cerebral aneurysm model was produced, and the changes in intra-aneurysmal hemodynamics were examined. Nylon thread with a diameter of 0.33 mm, resembling the coils clinically used for embolization, was used to fill in the model. After perfusion of glycerin solution to represent human blood, the half life of a dye injected into the aneurysm was optically measured, and the relationship between the half life and the volume embolization rate (VER) of nylon thread in the aneurysm was examined.

RESULTS

The maximal VER obtained by filling nylon thread in the aneurysm was 41.7+/- 2.9%. The half life of the dye increased with the VER and was significantly increased at VER>30%.

DISCUSSION

The half life of the dye in the aneurysm reflected stagnation of intra-aneurysmal hemodynamics, suggesting that the prolongation of the half life enhances thrombus formation. The results of this study suggested that VER>30% is sufficient for effective coil embolization.

Evaluation of Merci Retriever by Experimental Modeling

The Merci Retriever is the first device for mechanical embolus removal in patients with cerebral ischemia. Use of the device was evaluated using experimental models. Three stroke model systems were created: silicone embolism model with flow system, pig embolism model, and silicone-pig tortuous artery model. The series of extraction procedures (capture, retrieval, and aspiration) was examined in the models under flow control. Coagulated blood clot was adopted as embolic material, to simulate embolic stroke of the carotid or middle cerebral arteries. Retrieval of the clot was successful in only one of six trials in the silicone model of the carotid artery, as the clot easily worked free from the helical tip. Aspiration was successful in three of the six trials. Retrieval was successful in two of four trials in the middle cerebral artery and aspiration was successful in two. Retrieval was successful in all five trials in the pig embolism model, and three of five trials in the silicone-pig tortuous artery model. The Merci Retriever does not always retain the embolism, and the helix tends to distort in acute or rough lumen. Aspiration is not always successful.

Cardiac hemangioma complicated with cerebral and coronary embolization

Cardiac hemangiomas are rare, benign vascular tumors of the heart. Because of their clinical manifestations, diagnosis is difficult and few surgeons can draw from extensive experience. The purpose of this study was to report an additional case of cardiac hemangioma and to analyze the unexpected aspect of this disease. In our case, echocardiography demonstrated a mass in the left ventricle. Surgical resection was done using cardiopulmonary bypass. Histopathological examination revealed that the tumor was a hemangioma. The short-term outcome was favorable.

Advanced reconstructive endovascular techniques for the treatment of cerebral aneurysms

Endovascular treatment of cerebral aneurysms with detachable coils has now been proven to be a superior alternative to open microsurgery in terms of disability-free survival 1 year following treatment. Despite this, recurrence due to recanalization of these aneurysms in 10-20% of patients after coiling is still the main drawback of the endovascular technique. In the last 5 years, access devices and endovascular tools based on new concepts, materials and endovascular reconstruction techniques that go beyond simply coiling have been described for cerebral aneurysm treatment, especially for more complicated broad-necked, fusiform and large/giant aneurysms. In this article, we review our recent experience in the treatment of complex cerebral aneurysms by means of multiple novel endovascular techniques for arterial reconstruction.

[Cerebellum abscess: first demonstration of undiagnosed infective endocarditis in an adult with corrected transposition arteries]

Neurological complications occur in approximately 30% of all patients with infective endocarditis and represent a major factor associated with an increased mortality rate. Third of these complications is represented by cerebral embolism, followed by mycotic aneurysm, meningitis or meningoencephalitis. Brain abscesses are rare; their localization to the cerebellum is exceptional. A case of cerebellum abscess occurring in a 34-year-old patient with non-operated corrected transposition of the great arteries is reported. Occurrence of this abscess was the first demonstration of undiagnosed infective endocarditis.

Mechanical Embolectomy

Mechanical embolectomy in acute ischemic stroke employs the use of novel endovascular devices to revascularize occluded intracerebral arteries. Devices like the Merci Retiever and other endovascular snares, laser thrombectomy and rheolytic/obliterative microcatheters, intracranial balloon angioplasty and stenting, and intra-arterial and transcranial ultrasound-enhanced chemical thrombolysis are intended to improve tissue rescue and diminish reperfusion hemorrhage while broadening the population eligible for therapy. Patient selection with MRI- and CT-based stroke protocols can detect tissue at risk and may obviate the classic limitations of the stroke therapeutic time window. These devices are being developed and modified at a rapid pace, requiring mounting endovascular expertise, and are being used successfully alone or in conjunction with chemical thrombolysis with relative safety.

Early external decompressive craniectomy with duroplasty improves functional recovery in patients with massive hemispheric embolic infarction: timing and indication of decompressive surgery for malignant cerebral infarction

BACKGROUND

Extensive cerebral hemispheric infarction associated with massive brain swelling is known as malignant infarction because of the rapid clinical deterioration and mortality as high as 80% unless appropriate treatment is performed. Decompressive craniectomy is an effective treatment, but patient selection, timing, functional recovery, and complications remain unclear.

METHODS

Seventy-one patients with massive embolic hemispheric infarctions (infarct volume >200 cm(3)) associated with brain swelling were retrospectively divided into 3 groups according to the therapeutic modalities: 21 patients were treated conservatively (conservative group); 50 patients were treated by external decompressive craniectomy with duroplasty in 2 groups; 29 patients treated after the appearance of clinical and radiologic findings of brain herniation (late surgery group); and 21 patients treated before the onset of brain herniation (early surgery group).

RESULTS

The mortality at 1 and 6 months in the conservative group were 61.9% and 71.4%, respectively. The mortality at 1 and 6 months in the late surgery group were significantly improved to 17.2% and 27.6%, respectively, (p < 0.01) and in the early surgery group were further improved to 4.8% and 19.1%, respectively. The functional recovery of the patients was estimated by the Glasgow Outcome Scale (GOS) and Barthel Index (BI) at 6 months after the ictus. The GOS scores of the early surgery group were significantly better than that of the late surgery group (p < 0.05). The mean BI score of the survivors in the late surgery group (26.9 +/- 30.4) was not significantly different from that of the conservative group (28.3 +/- 42.2), but was significantly improved in the early surgery group (52.9 +/- 34.2) compared with the late surgery group (p < 0.05).

CONCLUSIONS

Early decompressive craniectomy with duroplasty before the onset of brain herniation should be performed to achieve satisfactory functional recovery if the infarct volume of the hemispheric cerebral infarction is more than 200 cm(3) and computed tomography on the second day after the ictus shows mass effect.

Progressive neurological decline after partial spontaneous thrombosis of a Spetzler—Martin Grade 5 arteriovenous malformation in a patient with Leiden factor V mutation: management and outcome

✓ The coexistence of a large intracranial arteriovenous malformation (AVM) and a hypercoagulation disorder is rare. The AVM puts the patient at risk for progressive neurological deficit, seizures, and, most importantly, intracranial hemorrhage. The hypercoagulation disorder may result in an increased risk of stroke. The authors describe a 42-year-old man with a Spetzler—Martin Grade 5 AVM who experienced progressive neurological decline. He was subsequently discovered to have partial thrombosis of the AVM, deep cerebral and cortical venous thrombosis, and a hypercoagulation disorder. Hypercoagulation disorders causing neurological deficits are usually treated with anticoagulant medications; however, this approach was not thought to be safe in the presence of a large AVM. Therefore, the AVM nidus was surgically extirpated and a ventriculoperitoneal shunt was placed to treat the increased intracranial pressure caused by the cortical and deep cerebral venous thrombosis. Subsequently, lifelong oral anticoagulation was prescribed. The patient had a progressive neurological recovery and is now living independently at home. The occurrence of partial or complete spontaneous thrombosis of an AVM nidus should raise the possibility of an underlying hypercoagulation disorder.

Successful cardic surgery 24 hours after craniotomy in a patient with infective endocarditis and embolic cerebellar infarction: case report

Follow up management in a patient already treated with decompressive craniotomy for a space-occupying endocarditic stroke is difficult. While immediate valve replacement eliminates the focus and therefore the high risk of re-embolization, a neurosurgical intervention is considered a contraindication to early cardiosurgery. Herein, the first report is presented of a critically ill patient with bacterial endocarditis and a space-occupying cerebellar infarction with imminent herniation, who successfully underwent mitral valve replacement only 24 h after decompressive craniotomy. To prevent rebleeding, maximal hemostasis was ensured during the neurosurgical intervention. For cardiosurgery, the patient was cooled to 21 degrees C, mildly hyperventilated, and maintained at an adequate perfusion pressure during cardiopulmonary bypass. A bioprosthesis was used to reduce the time of anticoagulation. The patient did not develop new infarcts after either intervention, and there was only a very small hemorrhagic transformation without a relevant mass effect. At five months after surgery the patient had minimal neurological abnormalities and was able to conduct his daily life without help.