We conducted overnight polysomnographic sleep studies of 16 patients (5 men and 11 women) with clinically well-controlled myasthenia gravis (MG). The subtypes of MG were IIA (3 patients), IIB (11 patients), IV (1 patient) and V (1 patient). Twelve patients were found on polysomnography to have obstructive and/or central types of the sleep apnoeas (SA). Their mean age was 42.4, SD 16.4 years, and the mean duration of MG was 7.4, SD 6.96 years. SA was not detected in 4 patients whose mean age was 30.8, SD 10.71 years and who had manifested MG for a mean duration of only 0.9, SD 0.65 years. Thus, patients with a longer duration of MG tended to have more SA. In 9 of the 12 SA patients, polysomnographic studies were repeated following thymectomy. SA had resolved in 6 patients, but persisted in 3. These findings suggest that SA is a possible clinical manifestiation of MG and that nocturnal dysfunction of both peripheral and central colinergic systems may be involved.

Intracranial hemorrhages can occur after carotid revascularization due to cerebral hyperperfusion syndrome (CHS). Subarachnoid hemorrhages associated with CHS after carotid artery stenting (CAS) have been reported in many cases; however, they are rare after carotid endarterectomy (CEA). We report a case of subarachnoid hemorrhage (SAH) associated with CHS after CEA performed in the acute phase of a cerebral infarction. A 50-year-old man was admitted to our hospital with transient right hemiparesis and dysarthria. Magnetic resonance imaging (MRI) demonstrated a cerebral infarction in the left cerebral hemisphere. Digital subtraction angiography revealed a severe stenosis in the right cervical internal carotid artery. Medical treatment was started; however, cerebral infarction progressed. CEA was performed on the 7th day after admission. On the first postoperative day, MRI demonstrated SAH in the sulcus of the frontal and parietal lobes. Xenon CT revealed an increased cerebral blood flow (CBF) in the left cerebral hemisphere. We diagnosed CHS after CEA. We continued sedation using Propofol and maintained the systolic blood pressure below 120 mmHg using nicardipine. Sedation was stopped on postoperative day 3. The patient was discharged with slight dysarthria on postoperative day 17. SAH due to CHS is rare but can occur early after CEA. Careful patient management is required after CEA in consideration of SAH due to CHS.

We describe the results of electron microscopic examination in two patients with ruptured intracranial aneurysms who were successfully treated by endovascular coil embolization. The aneurysms were seen completely occluded on the follow-up angiograms. Autopsies of these patients were performed five and 26 months after endovascular treatment when they died of pneumonia and thalamic hemorrhage, respectively. The aneurysms were densely filled with the coils, which were readily identified through the thin and transparent wall of the aneurysmal dome. The orifice of the aneurysm was completely occluded so that macroscopically the coils were not directly visualized through the orifice. To examine any evidence of endothelialization across the orifice of the aneurysms, scanning electron microscopic examination was performed. In both cases, evidence of well regenerative endothelialization was observed across the aneurysmal orifice, being contiguous with the endothelial layer of the adjacent parent vessels. These ultrastructural findings indicate that the aneurysms are completely isolated from the lumen of the parent artery by a continuous lining of the regenerated endothelial cells following the endovascular treatment with coils, and further suggest that aneurysms have a potential of being cured permanently by this treatment modality. This is, to the best of our knowledge, the first report in humans verifying a complete endothelialization of the luminal surface at the aneurysmal neck after coil embolization, as evidenced by scanning electron microscopy.

We report a case of internal carotid artery (ICA) occlusion caused by en bloc distal embolization of carotid free-floating thrombus (FFT) treated by mechanical thrombectomy.Case presentation: A 57-year-old woman was brought to our hospital with dysarthria, right hemiparesis, and motor aphasia. MRI and MRA revealed acute infarction due to middle cerebral artery occlusion. Carotid ultrasonography demonstrated a pedunculated mobile plaque in the left ICA. We diagnosed embolic infarction due to the carotid FFT and started medical treatment. However, on the second hospital day, the carotid FFT detached from the arterial wall en bloc, resulting in left ICA occlusion. The occluded ICA was successfully recanalized by mechanical thrombectomy. Conclusion:FFT is associated with a high risk of embolic ischemic stroke and the primary treatment strategy must be carefully considered.

Objective: Changes in the VerifyNow (Accumetrics, San Diego, CA, USA) assay results before and after neuroendovascular therapy and complications were evaluated. Methods:Of the 124 neuroendovascular procedures at our hospital between June 2014 and June 2015, 15 patients received elective treatment with dual-antiplatelet therapy (DAPT) consisting of aspirin at 100 mg/day and clopidogrel at 75 mg/day continued from at least 7 days before the procedure to the postprocedural period. Of these patients, those who underwent the VerifyNow assay before treatment and within 1 month after the procedure were included. Changes in the results of VerifyNow assay and complications were retrospectively evaluated. Results:Thirteen patients were included. The treatment was coil embolization of intracranial aneurysm in five patients (stent-assisted in four patients), carotid artery stenting in seven patients, and angioplasty and stenting for intracranial atherosclerosis in one patient. No significant change was observed in the aspirin reaction units (ARU) value after compared with before treatment. The P2Y12 reaction units (PRU) value decreased significantly after treatment (152 [interquartile range (IQR): 126-157] vs. 9 [IQR: 6-61], p = 0.001). Hemorrhagic events were observed in eight patients (61.5%) after treatment. Conclusion: Continuation of DAPT after neuroendovascular treatment may induce delayed clopidogrel hyper-response, which may lead to hemorrhagic complications.