The prognosis of patients with subarachnoid hemorrhage (SAH) who also develop cardiopulmonary arrest (CPA) is highly unfavorable, and hence they are often not aggressively treated. Presently, the therapeutic indications and factors that affect the prognosis of patients who experienced CPA remain unclear. Therefore, we analyzed SAH patients who experienced CPA, comparing the characteristics of the patients who survived with those who did not. The 36 patients were divided into the survivor group (n = 4) and the dead group (n = 32). The patient's age, sex, location of the aneurysm, the presence of intracranial hematoma, duration of cardiopulmonary resuscitation (CPR), the presence/absence of bystanders, initial electrocardiogram waveform, recovery of brainstem reflexes with motor response, and administration of vasopressors were compared between the 2 groups. There were no significant differences in age, sex, location of the aneurysm, and presence of intracranial hematoma between the 2 groups. More than 90% of patients in the dead group had a non-shockable rhythm on the initial electrocardiogram waveform. The duration of CPR in the survivor group tended to be shorter than that in the dead group. Bystander CPR was performed on 14 patients, including all 4 of the survivors. All patients in the survivor group achieved recovery of brainstem reflexes with motor response. In the survivor group, all patients either did not need or only transiently needed the administration of vasopressors after the return of spontaneous circulation (ROSC). Our analysis suggested the following as favorable prognostic factors in SAH patients with CPA: shockable arrhythmia on the initial electrocardiogram waveform, young age, bystander CPR, a short time from CPA to ROSC, recovery of brainstem reflexes with a motor response, and no or transient use of vasopressors. Our results indicate that aggressive treatment may be indicated in SAH patients with CPA who have stable vitals and show improvements in neurological symptoms.

Computed tomography (CT) and magnetic resonance imaging of cerebral perfusion are useful in determining the indication of mechanical thrombectomy (MT) for acute ischemic stroke. RAPID (iSchemaView, Menlo Park, CA, USA) is the most common software for analyzing brain perfusion images worldwide, but various other software are also available. The optimal threshold value for each software is different, and each has its characteristics. This study investigated the relationship between the quantitative evaluation of ischemic core volume (ICV) and the Alberta Stroke Program Early CT Score (ASPECTS) using CT Perfusion 4D (GE Healthcare Inc., Milwaukee, WI, USA), a software used in our hospital. Among patients who underwent MT between April 2015 and February 2023, those with modified Rankin Scale: 0-2, obstruction by embolic mechanism, and thrombolysis in cerebral infarction: 2b or higher were selected retrospectively. Patients with middle cerebral artery M1 segment (M1) and internal carotid artery (ICA) occlusions (90 and 46 patients) were included. We quantitatively analyzed ICV at relative cerebral blood flow (rCBF) <20% and cerebral blood volume (CBV) <1 mL/100 g and evaluated the relationship with ASPECTS scores in 3 groups: M1 + ICA, M1, and ICA occlusion groups. The median ICV was rCBF <20%: 44.7 cm3 and CBV <1 mL/100 g: 34.6 cm3, and there was no statistically significant difference between the 2 groups (p = 0.23). There was a negative correlation between ICV and ASPECTS scores in each occlusion group in all groups. The quantitative evaluation of ICV at rCBF <20% and CBV <1 mL/100 g was negatively correlated with the ASPECTS score in GE's CT Perfusion imaging analysis software.

Thromboembolism is one of the main causes of severe complications in the endovascular treatment of cerebral aneurysms, and antiplatelet therapy (APT) is necessary to prevent such complications. Conversely, prolonged APT has the potential risk of hemorrhagic complications; therefore, the timing of dose reduction or discontinuation is an important aspect of periprocedural APT. However, no clinical evidence of an optimal regimen of APT for cerebral aneurysms exists, and the selection, dosage, duration, or combination of antiplatelets has been dependent on physicians for unruptured or ruptured cerebral aneurysms. Many reports have shown that preoperative APT can reduce ischemic complications without increasing hemorrhagic complications, and some reports have shown that the P2Y12 reaction unit (PRU) value measured using the VerifyNow (Werfen, Barcelona, Spain) system is associated with periprocedural ischemic and hemorrhagic complications. Appropriate dose and duration management adjustments based on the platelet reactivity test, aneurysm morphology, treatment, and patient background may contribute to good outcomes. Although accumulating evidence exists regarding the efficacy of preoperative APT, there is no evidence regarding the optimal duration or discontinuation of APT.

Dural arteriovenous fistula (dAVF) of the foramen magnum (FM) region is rare. Moreover, the terminology of dAVF is very confusing in this region. In the narrow sense, the FM dAVF is the non-sinus-type dAVF with direct venous reflux to the medulla oblongata or spinal cord via the bridging veins (BVs) of the FM. Previous literature was systematically reviewed to investigate the clinical characteristics, angioarchitecture, and effective treatment of the FM dAVF. From the literature review, almost all the feeders of FM dAVF were dural branches. Spinal pial arteries were rarely involved as the feeder. All lesions had venous reflux to the medulla oblongata via medullary BVs. The FM dAVF is characterized by a significant male predominance and a high incidence of aggressive symptoms. The most common symptom is congestive myelopathy, followed by hemorrhage. The FM dAVF differs from the craniocervical junction (CCJ) arteriovenous fistula (AVF) and is similar to the thoracolumbar spinal dAVF. Direct surgery for the FM dAVF is effective and safe. Endovascular treatment for the FM dAVF may be more effective and has lower complication rates than that for the CCJ AVF.

Neuroendovascular therapy is a key treatment for cerebrovascular disorders, driven by advancements in devices and techniques. The Japanese Society for Neuroendovascular Therapy (JSNET) established a certification system in 1997 to ensure operator competence and minimize complications, with the first examination in 2002. JSNET offers 2 main certifications: specialist and instructor. Specialists perform basic procedures, while instructors lead in practice, education, and research. In 2020, the mechanical thrombectomy practitioner qualification was added to promote mechanical thrombectomy. Applicants must have a JSNET membership, relevant certifications, training, and documented experience. The certification process includes rigorous written and practical examinations that now employ non-fluoroscopic models. Certification renewal every 5 years requires conference participation and a continuing education program. Public awareness and integration into stroke center designations have grown. Over 2200 specialists, including more than 500 instructors, have been certified, significantly advancing neuroendovascular therapy in Japan. JSNET aims to continue improving certification and education to maintain high standards.

Mechanical thrombectomy (MT) for acute ischemic stroke usually requires blind procedures when endovascular devices are advanced into the occluded vessels. Therefore, the visualization of occluded vessels could potentially achieve safer procedures, shorter procedural time, and progression of the reperfusion rate. We report on the usefulness of a novel technique in which a 3D roadmap of occluded vessels was created from a rapid 3D proton density-weighted (PDW) variable refocusing flip angle and turbo spin echo (VRFA-TSE) method. 3D PDW VRFA-TSE imaging was performed in addition to routine MRI for 2 patients with middle cerebral artery occlusion. With the adjustments to the imaging parameters, we were able to perform 3D PDW imaging in less than 1 minute. Subsequently, a 3D image of the occluded vessels was constructed from these images. To create a 3D roadmap, the 3D PDW images were positioned with cone beam CT images obtained before MT using 3D-3D fusion. Because a neurological technician performed the imaging processing while doctors and nurses prepared for MT, practical loss time was approximately 2 minutes. MT was performed with reference to the 3D roadmap, and the occluded lesion was recanalized without complications in both patients. The 3D roadmap of the occluded vessels was well-matched with the recanalized vessels. A 3D roadmap created from rapid 3D PDW imaging is a useful assistance technique for MT that allows the visualization of occluded vessels.

The implantation of stents in the cerebral arteries for aneurism exclusions requires the administration of dual antiplatelet therapy. This medication increases the haemorrhage risk, while some patients develop a phenomenon called "high on-treatment platelet reactivity," exposing to the material thrombosis. The focus on the platelet function monitoring in this context is key to the success of this procedure, allowing for identification of the different population of patients for the adjustment of the prescription for which antiplatelet therapy to use, to get the best balance between the prevention of material thrombosis and haemorrhage risk. This study focuses on the use of platelet function monitoring with Multiplate (Roche, Boulogne-Billancourt, France), in the context of a prescription of clopidogrel and its possible replacement by ticagrelor for resistant patients. The study is an observational retrospective cohort monocentric study. Patients were sampled for a Multiplate analysis with no antiplatelets treatment, then the day before the procedure, a new Multiplate analysis is proceeded with after 5 days of clopidogrel and aspirin. If adenosine diphosphate (ADP) test was above 300 area under the curve on Multiplate, it was decided to introduce ticagrelor. The primary endpoint was the occurrence of thromboembolic or haemorrhagic events during the first 30 days postoperatively. 104 patients treated electively with a stent for an intracranial aneurysm were included from January 2016 to June 2020; 77 patients were classified as responder to clopidogrel and 27 had to be switched from clopidogrel to ticagrelor; 9 patients under clopidogrel (8.6%) had an ischaemic event and 1 under ticagrelor (1%). No patient had a haemorrhagic event under clopidogrel and 3 under ticagrelor (2.8%). Comparing clopidogrel and ticagrelor group regarding ischemic or haemorrhagic event endpoints, the difference was not statistically significant: (p = 0.37), but statistically significant regarding fatal event (p = 0.02) in disfavour of ticagrelor. The use of platelet function monitoring makes it possible to determine the therapeutic effectiveness of P2Y12 inhibitors, and thus to provide the most appropriate antiplatelets treatment for the patient when an intracranial stent is placed.

The sphenoid wing dural arteriovenous fistulas (DAVFs) are clinically rare. They often present as non-sinus-type arteriovenous fistulas (AVFs) and may be associated with focal neurological deficits, intracranial venous hypertension, and intracranial hemorrhage. These cases are classified as lesser or greater sphenoid wing lesions. We searched the PubMed databases for studies evaluating the clinical presentation, surgical treatment, and endovascular treatment of these lesions and analyzed 37 cases from 22 papers. A total of 17 cases had lesser sphenoid wing AVFs, and the localization of the shunts could be divided into the sinus of the lesser sphenoid wing (SLSW) or the superficial middle cerebral vein (SMCV). Most SLSW AVFs drained into the cavernous sinus, but two cases drained directly into the deep middle cerebral vein via a bridging vein. All cases with shunts directly into the SMCV had reflux into the SMCV with varices. A total of 20 cases had shunts in the greater sphenoid wing, and the localization of the shunts varied, with shunt localization, and venous return morphology dependent on variations in middle fossa venous return. Most cases had shunts in the sphenobasal vein near the foramen ovale. However, some cases had shunts in the superior ophthalmic vein, sphenopetrosal vein, and laterocavernous sinus. Many were associated with cortical venous reflux. These lesions have been treated by surgical ligation of the drainage vein and transarterial or transvenous embolization. Recently, embolization has become the standard treatment for DAVFs due to advances in endovascular techniques. This paper reviewed and discussed the angioarchitecture, clinical presentation, and treatment of these lesions to clarify the characteristics of sphenoid wing DAVFs.

Middle meningeal artery embolization (MMAE) has emerged as a promising treatment, both as an adjunct to surgery and as a primary treatment for chronic subdural hematoma (cSDH). Here, we evaluate the efficacy of MMAE following surgery in reducing the likelihood of reoperation in patients requiring early introduction of antithrombotics. From our prospectively collected registry of patients with cSDH, we identified patients treated with surgical evacuation, either in combination with or without MMAE. Patients were included if they had a clinical indication requiring early antithrombotics within 7 days of surgery. The primary outcome was the rate of reoperation. The secondary outcomes included recurrence in midline shift or changes in cSDH width based on imaging findings. Among 43 patients (53 total cSDHs) who met the inclusion criteria for the study, the median age was 71 years, 13% were female, the mean SDH thickness was 17.9 mm, and the most commonly used postoperative antithrombotic was aspirin. Sixteen cSDHs in 13 patients were treated with MMAE + surgery, while 37 cSDHs in 30 patients were treated with surgery alone. There was no difference in reoperation rates between the 2 groups (8.1% vs. 0%, surgery alone vs. surgery + MMAE, p = 0.55), nor in the rate of recurrence (24.3% vs. 12.5%, surgery alone vs. surgery + MMAE, p = 0.47). In this single-center cohort study, we found no clear benefit in reduced rates of reoperation or recurrence for adjunctive MMAE in patients with cSDH treated with surgical evaluation. Despite this, encouraging trends were observed in the MMAE + surgery group.