No abstract

Stroke is an infrequent yet well‐known complication of transcatheter aortic valve implantation (TAVI). While mechanical thrombectomy (MT) is a useful rescue procedure in patients with symptomatic post‐TAVI stroke, it should be reminded that embolic materials derived from degenerated aortic valve have heterogeneities. We describe a case of post‐TAVI stroke in which a calcified debris caused embolic occlusion of the left middle cerebral artery. The calcified embolus eluded detection on magnetic resonance imaging (MRI), which might have been responsible, at least in part, for unsuccessful MT. Formation of calcified debris may not be rare after TAVI, and therefore, brain CT may be given priority as an imaging modality in the initial evaluation of patients suspected of post‐TAVI stroke.

Objective In patients with acute ischemic stroke (AIS), prognosis strongly depends on the onset-to-recanalization time. The Ishinomaki protocol for rapid recanalization has been used since October 2017. This protocol determines the indication for reperfusion therapy based on computed tomography (CT)/three-dimensional CT angiography (3DCTA) findings and intends to reduce the onset-to-recanalization time. We aimed to compare the outcomes before and after protocol introduction. Methods Our hospital is the only thrombectomy-capable center in Ishinomaki, Tome, and Kesennuma medical area. Before protocol introduction (April 2014–June 2016), both CT and magnetic resonance imaging were performed to determine the indications for intravenous (IV) recombinant tissue-plasminogen activator (rt-PA) or mechanical thrombectomy within 6 hours of disease onset. However, after protocol introduction (from October 2017), plain CT and 3DCTA were used. We collected data on patients who underwent mechanical thrombectomy and/or IV rt-PA before (n = 13) and after (n = 34) the protocol introduction. The required time from onset to door (OTD), door to needle (DTN), needle to puncture (NTP), puncture to recanalization (PTR), and door to recanalization (DTR) were compared before and after protocol introduction. Furthermore, thrombolysis in cerebral infarction (TICI) grades and modified Rankin scale (mRS) scores at discharge were compared. Results The outcomes before and after protocol introduction were as follows: OTD: 105 ± 73.8 (mean ± standard deviation) vs. 120 ± 68.1 min ( p = 0.376, Mann–Whitney U test); DTN: 62.9 ± 15.9 vs. 41 ± 17 min ( p <0.01); NTP: 112 ± 69.8 vs. 39.9 ± 33.7 min ( p <0.01); PTR: 87.9 ± 45.4 vs. 52.5 ± 27.9 min ( p <0.01); and DTR, 230 ± 69.9 vs. 110 ± 40.3 min ( p <0.0001). Before and after protocol introduction, the proportion of patients with TICI grade 2b–3, mRS score of 0–2 at discharge, and mRS score of 5–6 were 54% vs. 50% ( p = 0.815, Fisher’s exact test), 23% vs. 21% ( p = 0.854), and 15% vs. 50% ( p = 0.046), respectively. Conclusion The Ishinomaki protocol reduced the mean DTR time by 120 min. The reduction in treatment time was due to the change in CT-based recanalization and collaboration with emergency physicians and paramedics. There was no increase in good outcomes, but there was a significant increase in poor outcomes at discharge. Patients who could not be salvaged were indicated for reperfusion therapy as CT and 3DCTA cannot detect the ischemic core.

市川 誉基 1) 稲桝 丈司 2) 木全 大 3) 要旨：68 歳女性．Roux-en-Y 法再建胃状態の進行期パーキンソン病にレボドパ/カルビドパ配合経腸用液 (levodopa-carbidopa intestinal gel，以下 LCIG と略記)療法を選択した．経鼻空腸チューブ下 LCIG 投与で off の 短縮と dyskinesia が軽快した．残胃に胃瘻造設が困難で，3DCT 併用で直接経皮内視鏡的空腸瘻(direct percutaneous endoscopic jejunostomy，以下 D-PEJ と略記)で LCIG 導入した．術後瘻孔トラブルなく良好な control が維持された．胃瘻が困難な進行期パーキンソン病に，3DCT 併用 D-PEJ による LCIG 療法は有用である．

Objective: We describe a rare case report of micro-arteriovenous malformation (micro-AVM) treated by the endovascular approach in addition with literature review.Case Presentation: A 12-year-old boy presenting with a spontaneous intracerebral hematoma in the left occipital lobe underwent conventional diagnostic workups. The results of initial catheter angiography were considered to be equivocal as the AVM. Superselective angiography (SA) demonstrated a micro or small AVM (single feeder and single drainer type) with an aneurysmal dilatation. Immediate transarterial embolization (TAE) might fail to occlude the whole of nidus area completely, and subsequently, we switched to the surgical exploration of AVM lesion. Intraoperative findings demonstrated that the whole of AVM lesion had already been occluded completely, indicating the complete occlusion by TAE only. Pathological findings of the surgical specimen showed an aneurysmal dilatation was a venous aneurysm with vulnerable vascular wall structure, which was certainly the source of bleeding. Based on the above results, the retrospective revaluation of superselective angiogram permitted us to understand that the nidus of AVM was micro nidus type and TAE had resulted in the complete nidus occlusion. Conclusion:SA is the most useful diagnostic modality to clarify the angioarchitecture of micro-AVM and AVM-related aneurysms. If SA is successfully performed and relatively safe TAE is expected to be possible, the subsequent attempt to do curative embolization as a first-line treatment may be worthy of consideration. However, the surgical procedure should be fully reserved for the possible incomplete obliteration and hemorrhagic complications.