Naoki Toma

Objective: Cerebral vasospasm (CVS) following subarachnoid hemorrhage (SAH) is sometimes difficult to treat with conventional balloon angioplasty due to limited device accessibility. We report catheter-based mechanical dilation using a spindle-shaped delivery assist catheter for CVS that is difficult to access with conventional balloon catheters.Case Presentation: A 70-year-old man presented with severe SAH due to a ruptured anterior communicating artery aneurysm and underwent coil embolization along with ventricular drainage. On day 7, CVS of the left M1 segment of the middle cerebral artery (MCA) was treated with balloon angioplasty. On day 9, severe CVS of the left A1 segment of the anterior cerebral artery and the left M2 segment of the MCA was identified. A spindle-shaped delivery assist catheter was advanced to the distal left A1 segment, and mechanical dilation was performed by passing its bulb segment through the stenotic lesion. Subsequent angiography demonstrated vessel dilation. For the CVS in the left M2 segment, balloon angioplasty and selective intra-arterial fasudil hydrochloride infusion were performed. On day 14, newly developed vasospasm in the distal left M2 segment, beyond the segment previously treated with balloon angioplasty, was successfully dilated using the same technique. No procedure-related complications were observed, and no cerebral infarction developed in the treated vascular territories.Conclusion: Catheter-based mechanical dilation using a spindle-shaped delivery assist catheter may be considered as a feasible option for treating CVS when conventional balloon angioplasty is technically difficult. Further experience is required to determine its safety, efficacy, and durability.

Saccular aneurysms (SAs) have been long studied in hemodynamics using computational fluid dynamics (CFD), while dissecting aneurysms (DAs) remain unclear. To estimate which side of the aneurysm ruptured, we evaluated the hemodynamics of the bilateral vertebral artery DAs (VADAs). A 44-year-old male was diagnosed with subarachnoid hemorrhage by the rupture of either side of bilateral VADAs. The rupture side could not be determined on admission (Day 0). CFD was performed using a patient-specific geometry model obtained from 3-demensional (3D) rotational angiography (RA) on day 1. We predicted that the right DA had ruptured based on the hemodynamics, associated with flow stagnation and complexity in the ruptured SAs by a transient analysis with the patient-specific blood flow velocity waveforms. After careful observation, gadolinium-enhanced MRI on day 16 showed a contrast effect in the right wall and a change in the right shape was confirmed on the second 3D RA on day 17. According to both imaging evaluations and CFD, the right was presumed to be ruptured, and a flow-diverter stent was placed at the right VA. The right VADA did not re-rupture for 12 months. Our results indicated that hemodynamics of ruptured DAs would be similar to that of ruptured SAs.

Aneurysmal subarachnoid hemorrhage (SAH) is a poor-outcome disease with a delayed neurological exacerbation. Fibulin-5 (FBLN5) is one of matricellular proteins, some of which have been involved in SAH pathologies. However, no study has investigated FBLN5’s roles in SAH. This study was aimed at examining the relationships between serially measured plasma FBLN5 levels and neurovascular events or outcomes in 204 consecutive aneurysmal SAH patients, including 77 patients (37.7%) with poor outcomes (90-day modified Rankin Scale 3–6). Plasma FBLN5 levels were not related to angiographic vasospasm, delayed cerebral ischemia, and delayed cerebral infarction, but elevated levels were associated with severe admission clinical grades, any neurological exacerbation and poor outcomes. Receiver-operating characteristic curves indicated that the most reasonable cut-off values of plasma FBLN5, in order to differentiate 90-day poor from good outcomes, were obtained from analyses at days 4–6 for all patients (487.2 ng/mL; specificity, 61.4%; and sensitivity, 62.3%) and from analyses at days 7–9 for only non-severe patient (476.8 ng/mL; specificity, 66.0%; and sensitivity, 77.8%). Multivariate analyses revealed that the plasma FBLN5 levels were independent determinants of the 90-day poor outcomes in both all patients’ and non-severe patients’ analyses. These findings suggest that the delayed elevation of plasma FBLN5 is related to poor outcomes, and that FBLN5 may be a new molecular target to reveal a post-SAH pathophysiology.

The relationships between repeated non-fasting triglyceride (TG) measurements and carotid stenosis progression during follow-ups have never been investigated. In 111 consecutive carotid arteries of 88 patients with ≥50% atherosclerotic stenosis on at least one side, who had ≥3 blood samples taken during ≥one-year follow-ups, clinical variables were compared between carotid arteries with and without subsequent stenosis progression. To evaluate non-fasting TG burden, a new parameter area [TG ≥ 175] was calculated by integrating non-fasting TG values ≥ 175 mg/dL (i.e., TG values minus 175) with the measurement intervals (year). Carotid stenosis progression occurred in 22 arteries (19.8%) during the mean follow-up period of 1185 days. Younger age, symptomatic stenosis, higher mean values of TG during follow-ups, the area [TG ≥ 175], mean TG values ≥ 175 mg/dL and maximum TG values ≥175 mg/dL were significant factors related to the progression on univariate analyses. The cut-off value of the area [TG ≥ 175] to discriminate carotid stenosis progression was 6.35 year-mg/dL. Multivariate analyses demonstrated that symptomatic stenosis and the area [TG ≥ 175] ≥ 6.35 year-mg/dL were independently related to carotid stenosis progression. In conclusion, the area [TG ≥ 175] was an independent risk factor for carotid stenosis progression, and this study suggests the importance to continuously control non-fasting TG levels < 175 mg/dL during follow-ups to prevent carotid stenosis progression.

We report a rare case of subarachnoid hemorrhage (SAH) caused by a ruptured vertebral artery (VA) dissecting aneurysm (DA) under severe COVID-19 treatment, and discuss the potential relationships. A 58-year-old woman with COVID-19 fell into severe pneumonia needing mechanical ventilation at 10 days post-onset (day 10). The patient had no risk factors for DA or stroke other than COVID-19 infection. At day 17 when weaning ventilatory management, her systolic blood pressure was transiently elevated, and her consciousness did not recover thereafter. Computed tomography (CT) at day 21 revealed SAH with modified Fisher grade 4, and CT angiography revealed a DA in the right VA just distal to the right posterior inferior cerebellar artery (PICA). The DA was treated emergently with internal trapping by endovascular coiling, while the right PICA was preserved. Postoperative course was uneventful, and 2-time negative SARS-CoV-2 PCR results were obtained at day 45. The patient recovered to 4-month modified Rankin Scale 2. Although it is not clear from the present case alone whether SARS-CoV-2 infection causes SAH by a ruptured VA DA, the accumulation of more cases and further studies are warranted to clarify the relationships between SARS-CoV-2 infection and ruptured intracranial DAs.