We report a patient with acute-phase cerebral embolism related to Trousseau's syndrome (TS) in whom thrombectomy was performed, and white thrombi were captured. Case Presentation: The patient was a 65-year-old female. Sudden-onset dizziness and progressive consciousness disorder were noted. Diagnostic imaging led to a diagnosis of occlusion of the basilar artery (BA). In the acute phase, thrombectomy was performed, and white thrombi were captured, differing from standard-type embolism. After surgery, the symptoms rapidly reduced, but systemic investigation suggested advanced gastric cancer as an etiologic factor for embolism. Subsequently, embolism recurred, and the patient died of hemorrhagic cerebral infarction 31 days after onset. Conclusion: If a white thrombus is captured during thrombectomy, TS should be differentiated as an etiologic factor.

Fenestration of the middle cerebral artery detected after thrombectomy: case report

Deep Sylvian meningiomas are rare, accounting for 0.3–0.4% of all meningiomas, and mostly present in young adults and children. We report on a 32-year-old man who presented with headache but had no neurological deficits. Computed tomography of brain revealed a 24 × 19 × 21 mm 3 mass lesion in the right Sylvian fissure with calcification. Magnetic resonance imaging showed that the lesion was isointense on T 1 - and T 2 -weighted images (WI), with homogenous enhancement on post-gadolinium T 1 WI. The lesion was surgically removed via right fronto-temporal craniotomy. The tumor was located in deep Sylvian fissure and had no dural attachment. Histopathological examination of the lesion revealed both meningothelial and fibroblastic features, thereby suggesting the diagnosis of transitional meningioma (WHO grade I), with Ki-67 labeling index of 6.9%. Thus, meningioma should be considered as a differential diagnosis of enhancing mass lesions in the Sylvian fissure even in the absence of dural tail sign, especially in young adults and children.

Among middle cerebral artery aneurysms, those at the M1 portion of the middle cerebral artery have a lower incidence of occurrence. We retrospectively analyzed and reported the clinical features and management of 12 M1 aneurysms in 12 patients treated with direct clipping. Aneurysms arising at the M1 portion were mostly smaller in size and prevalent in older women, on the left side, with more intracerebral hematoma and less accompanied than those at the bifurcation. Ruptured aneurysms comprised 80% of the aneurysms and were larger than 5 mm in size, while 14.3% of those smaller than 5 mm in size were unruptured. Aneurysms were located in the upper (n=5), downward (n=5), anterior (n=1), and posterior (n=1) directions. Of the five aneurysms in the upper direction, three were in the early frontal branch, one was in the early temporal branch, and one was in the lenticulostriate artery. Two of the aneurysms in the upper direction had an intracerebral hematoma (ICH) in the frontal and temporal lobes, while one aneurysm in the downward direction had an ICH in the temporal lobe. The preoperative clinical grade of M1 aneurysms with ICH was worse than that of bifurcation aneurysms; however, the outcome was equal to that of bifurcation aneurysms.Aneurysms arising at the M1 portion should be treated with a preoperative meticulous investigation for their anatomical complexity, not only with direct clipping but also with endovascular techniques.

Background: Early recognition of stroke symptoms, pre-notification to the hospital, and rapid transport of the patients has been associated with faster intervention and better outcomes. We studied the impact of continuous monthly educational intervention to the emergency medical services (EMS) members on the therapeutic time till mechanical thrombectomy in acute ischemic stroke. Methods:Our hospital manages Doctor Heli (DH) and Doctor Car (DC). Since April 2017, continuous monthly educational sessions on stroke care have been conducted involving the EMS doctors and paramedics, using the modalities like lectures and focus group discussions. We evaluated the change in performance time indicators prior to and after the initiation of this educational intervention. Results:In all, 10 patients underwent mechanical thrombectomy for acute ischemic stroke before and 36 patients underwent the procedure after the initiation of educational intervention program. The number of EMS-transported patients (by DH and DC) out of the total patients who underwent mechanical thrombectomy increased from 20% to 42% after the initiation of the educational intervention. The median time interval of onset to door (O2D) decreased from 109.5 to 71 minutes and that of door to recanalization (D2R) decreased from 164 to 88 minutes following the educational intervention.Other performance time indicators were also notably reduced. This improvement of time indicators was observed gradually and annually. Conclusion:This study showed that the continuous monthly education on stroke care to EMS members notably increased the number of EMS-transported patients as well as improved the performance time indicators till treatment in acute ischemic stroke.