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Objective: CASPER Rx stent (Terumo, Tokyo, Japan) is one of the dual-layer micromesh stents for carotid artery stenosis. Although it is expected to be safe and efficacious even for vulnerable plaque, we report a case of in-stent occlusion 2 weeks after stenting with CASPER Rx stent. Case Presentation: The patient was a 78-year-old man with a symptomatic, severely stenosed lesion of the cervical internal carotid artery (ICA). He had an unstable plaque and underwent carotid artery stenting with the CASPER Rx stent. There were no problems with the procedure or the patient's subsequent course, and he was discharged home 1 week after the procedure. However, on postoperative day 14, the patient had a transit ischemic attack and imaging showed acute occlusion due to thrombus in the stent and in the distal part of the ICA. Mechanical thrombectomy was performed and good recanalization was achieved, but postoperative cerebral infarction was observed and the patient was transferred to other hospital with modified Rankin Scale 2. Conclusion: We experienced a case of in-stent occlusion 2 weeks after stenting with the CASPER Rx stent.
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We present a case of autoimmune-acquired factor XIII deficiency associated with systemic lupus erythematosus, which was diagnosed as a cause of repeated intracerebral hemorrhage. An intracerebral hemorrhage occurred in a 24-year-old female patient. Craniotomy was performed to remove the hematoma, but rebleeding occurred at the same site on days 2 and 11, respectively. Detailed blood tests revealed that factor XIII activity decreased. Although autoimmune-acquired factor XIII deficiency is a very rare disease, it can sometimes be fatal when intracerebral hemorrhage occurs. If there is repeated intracerebral hemorrhage, factor XIII activity should be confirmed.
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Nonocclusive mesenteric ischemia (NOMI) is a rare but life-threatening post-stroke complication. This is the first case series report of NOMI after stroke, describing its characteristics and the difficulty of diagnosis. We retrospectively reviewed 367 stroke patients from April 2018 to May 2019 in our hospital. We identified six patients (1.6%) with NOMI after stroke and described their clinical presentation, including characteristics, vital signs, laboratory parameters, treatment, and outcomes. The mean interval between stroke onset and diagnosis of NOMI was 4.6 days (range, 3-10 days). Five patients had disturbance of consciousness caused by stroke, and therefore the major complaints and symptoms associated with NOMI were nonspecific, possibly resulting in delayed diagnosis and treatment. All patients had a high respiratory rate (≥22 breaths/min). C-reactive protein and lactate levels were high (mean, 21.6 mg/L and 2.4 mmol/L, respectively). All patients underwent emergent abdominal operations. Four patients were discharged with modified Rankin Scale scores ≥4, and two patients died. NOMI can be a fatal post-stroke complication and is challenging to diagnose. Further investigations should be conducted to determine the most efficient way to diagnose NOMI after stroke.
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Thrombectomy has demonstrated clinical efficacy against acute ischemic stroke caused by intracranial occlusion of the internal carotid artery (ICA), even if performed 6-24 h after onset. This study investigated the outcomes of thrombectomy performed 6-24 h after stroke onset caused by extracranial ICA occlusion. Of 586 stroke patients receiving thrombectomy during the past 3 years and registered in the Tama Registry of Acute Endovascular Thrombectomy database, 24 were identified with ICA occlusion (14 extracranial and 10 intracranial), known to be well 6-24 h before presentation, and with pre-stroke modified Rankin Scale (mRS) score of 0 or 1. Clinical outcomes measured were the rate of functional independence at 90 days according to mRS score of 0-2 and 90 day mortality rate. Of patients with extracranial ICA occlusion, two received additional carotid stenting with thrombectomy. The median interval between the last time the patient was known to be well and hospital arrival was 601 (interquartile range, 476-729 min). Both the rate of functional independence at 90 days and 90 day mortality were comparable between patients with extracranial or intracranial ICA occlusion (36% vs. 40% and 7% vs. 10%, respectively). No symptomatic intracranial hemorrhages occurred within 24 h following treatment of extracranial ICA occlusion. Thrombectomy performed 6-24 h after extracranial ICA results in acceptable functional outcome. Further clinical study is warranted to better define the temporal window of thrombectomy for acceptable functional outcome in patients with extracranial ICA occlusion.
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Trombosis de las Arterias Carótidas/terapia , Procedimientos Endovasculares/métodos , Accidente Cerebrovascular/terapia , Trombectomía/métodos , Tiempo de Tratamiento , Trombosis de las Arterias Carótidas/diagnóstico , Bases de Datos Factuales , Sistema de Registros , Resultado del TratamientoRESUMEN
Acute infectious endocarditis (IE) is a complex disease that presents as a serious clinical condition associated with a high mortality rate, especially due to intracranial hemorrhaging (ICH). The most common causative organism is Staphylococcus aureus. We herein report a patient with ICH following subacute IE with a positive blood culture for Cardiobacterium hominis. A review of the existing literature revealed that acute IE associated with Cardiobacterium has been reported to cause ICH in only seven previous cases. Prolonged culture-specific antibiotic therapy along with extended surveillance of blood culture is therefore essential for timely intervention.
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Cardiobacterium , Endocarditis Bacteriana/complicaciones , Infecciones por Bacterias Gramnegativas/complicaciones , Hemorragias Intracraneales/microbiología , Adulto , Antibacterianos/uso terapéutico , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Although, thrombectomy for stroke more than 6 hours after onset supported by automated perfusion computed tomography (CT) software (RAPID, iSchemaView) is effective, this software is not available in Japan. This study aimed to elucidate the efficacy of thrombectomy 6-24 hours after onset in our patient cohort using conventional imaging mismatch. METHODS: Of 586 ischemic stroke patients who underwent thrombectomy registered from January 2015 to December 2017, patients with occlusion of the intracranial internal carotid artery or middle cerebral artery, who had last been known to be well 6-24 hours earlier and who had a prestroke modified Rankin scale (mRS) score 0 or 1 were enrolled. Clinical outcomes were the scores of the utility-weighted (UW) mRS, which ranges from 0 (death) to 10 (no symptom or disability), and the rate of functional independence (mRS score of 0-2) at 90 days. RESULTS: This study sample included 31 patients. The median baseline National Institutes of Health Stroke Scale score was 17 (interquartile range [IQR], 13-20), and the median Diffusion-Weighted Imaging-Alberta Stroke Program Early CT Score was 7 (IQR, 5-8). The median interval between the time that the patient was last known well and revascularization was 741 (IQR, 641-818) minutes. The mean UW mRS score at 90 days was 5.3, the rate of functional independence was 32%, and the 90-day mortality rate was 13%. CONCLUSIONS: Thrombectomy 6-24 hours after onset which can be performed with conventional imaging mismatch might be secured for improving functional independence in stroke patients.
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Estenosis Carotídea/cirugía , Toma de Decisiones Clínicas , Imagen de Difusión por Resonancia Magnética , Procedimientos Endovasculares , Infarto de la Arteria Cerebral Media/cirugía , Selección de Paciente , Trombectomía/métodos , Tiempo de Tratamiento , Anciano , Anciano de 80 o más Años , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/fisiopatología , Bases de Datos Factuales , Evaluación de la Discapacidad , Procedimientos Endovasculares/efectos adversos , Femenino , Humanos , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Infarto de la Arteria Cerebral Media/fisiopatología , Japón , Masculino , Persona de Mediana Edad , Imagen de Perfusión/métodos , Valor Predictivo de las Pruebas , Recuperación de la Función , Sistema de Registros , Estudios Retrospectivos , Programas Informáticos , Trombectomía/efectos adversos , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
Trauma patients with uncontrolled hemorrhage encountering coagulopathy are often associated with poor outcome. Recently, the concept of damage control interventional radiology, which focuses on "speedy stoppage of bleeding" by interventional radiology among trauma patients with hemodynamic instability and acute traumatic coagulopathy, was proposed as an alternative to damage control surgery. N-butyl cyanoacrylate (NBCA) has been used as a liquid embolic agent in various non-traumatic situations, where it has been shown to have a high technical success rate and low recurrent bleeding rate, especially in patients with coagulopathy. In this case, we treated a young patient with hemodynamic instability caused by a high-grade hepatic injury, who underwent arterial embolization (AE) using NBCA assisted with resuscitative endovascular balloon occlusion of the aorta and achieved successful hemostasis. A review of published works using PUBMED was carried out, and 10 published reports involving 23 trauma patients who underwent AE using NBCA were identified. Among them, only four reports involving five trauma patients with torso visceral injuries were identified. Three of five patients who were hemodynamically unstable underwent AE using NBCA, resulting in the stabilization of hemodynamics. We concluded that AE with resuscitative endovascular balloon occlusion of the aorta as a damage control interventional radiology procedure might be acceptable for the hemodynamically unstable hepatic injury, and NBCA could be one of the effective hemostatic agents for this purpose, in cases of trauma-induced coagulopathy.
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The formation of external carotid artery (ECA) pseudoaneurysms caused by stab wounds is a rare vascular anomaly. Although the surgical exploration of the ECA segment is the standard treatment, endovascular treatment (EVT) can be considered if there is difficulty in identifying the source of bleeding in the injured regions that are difficult to operatively access. Here we treated a young patient who had hemorrhagic instability with hemorrhage-induced coagulopathy caused by a zone III cervical stab wound with a pseudoaneurysm from the main trunk of the ECA; the patient underwent EVT and successful hemostasis. A literature review based on the data available on PubMed was conducted, and 15 published reports of 82 penetrating ECA injuries treated by EVT were identified. We concluded that EVT appears to be an effective surgical alternative for patients with hemorrhage-induced coagulopathy caused by a ruptured ECA pseudoaneurysm after a cervical stab wound.
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Aneurisma Falso/cirugía , Traumatismos de las Arterias Carótidas/cirugía , Arteria Carótida Externa/cirugía , Procedimientos Endovasculares , Heridas Punzantes/cirugía , Adulto , Humanos , MasculinoRESUMEN
INTRODUCTION: Comprehensive treatment of a patient in acute medicine and surgery requires the use of both surgical techniques and other treatment methods. Recently, acute vascular interventional radiology techniques (AVIRTs) have become increasingly popular, enabling adequately trained in-house experts to improve the quality of on-site care. METHODS: After obtaining approval from our institutional ethics committee, we conducted a retrospective study of AVIRT procedures performed by acute care specialists trained in acute medicine and surgery over a 1-year period, including those conducted out of hours. Trained acute care specialists were required to be certified by the Japanese Association of Acute Medicine and to have completed at least 1 year of training as a member of the endovascular team in the radiology department of another university hospital. The study was designed to ensure that at least one of the physicians was available to perform AVIRT within 1 h of a request at any time. Femoral sheath insertion was usually performed by the resident physicians under the guidance of trained acute care specialists. RESULTS: The study sample comprised 77 endovascular procedures for therapeutic AVIRT (trauma, n = 29, and nontrauma, n = 48) among 62 patients (mean age, 64 years; range, 9-88 years), of which 55% were male. Of the procedures, 47% were performed out of hours (trauma, 52%; and nontrauma, 44%). Three patients underwent resuscitative endovascular balloon occlusion of the aorta in the emergency room. No major device-related complications were encountered, and the overall mortality rate within 60 days was 8%. The recorded causes of death included exsanguination (n = 2), pneumonia (n = 2), sepsis (n = 1), and brain death (n = 1). CONCLUSION: When performed by trained acute care specialists, AVIRT seems to be advantageous for acute on-site care and provides good technical success. Therefore, a standard training program should be established for acute care specialists or trauma surgeons to make these techniques a part of the standard regimen. LEVEL OF EVIDENCE: Therapy/care management study, level V.
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Procedimientos Endovasculares , Radiología Intervencionista , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/terapia , Enfermedad Aguda , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Oclusión con Balón , Niño , Competencia Clínica , Femenino , Humanos , Japón , Masculino , Persona de Mediana Edad , Estudios RetrospectivosAsunto(s)
Aorta , Oclusión con Balón/métodos , Complicaciones Cardiovasculares del Embarazo/terapia , Embarazo Tubario/cirugía , Choque Hemorrágico/terapia , Adulto , Femenino , Humanos , Embarazo , Complicaciones Cardiovasculares del Embarazo/diagnóstico por imagen , Complicaciones Cardiovasculares del Embarazo/etiología , Embarazo Tubario/diagnóstico por imagen , Resucitación , Choque Hemorrágico/diagnóstico por imagen , Choque Hemorrágico/etiología , Tomografía Computarizada por Rayos X , UltrasonografíaRESUMEN
BACKGROUND: Haemorrhagic shock is a major cause of death in the acute care setting. Since 2009, our emergency department has used intra-aortic balloon occlusion (IABO) catheters for resuscitative endovascular balloon occlusion of the aorta (REBOA). METHODS: REBOA procedures were performed by one or two trained acute care physicians in the emergency room (ER) and intensive care unit (ICU). IABO catheters were positioned using ultrasonography. Collected data included clinical characteristics, haemorrhagic severity, blood cultures, metabolic values, blood transfusions, REBOA-related complications and mortality. RESULTS: Subjects comprised 25 patients (trauma, n = 16; non-trauma, n = 9) with a median age of 69 years and a median shock index of 1.4. REBOA was achieved in 22 patients, but failed in three elderly trauma patients. Systolic blood pressure significantly increased after REBOA (107 vs. 71 mmHg, p < 0.01). Five trauma patients (20 %) died in ER, and mortality rates within 24 h and 60 days were 20 % and 12 %, respectively. No REBOA-related complications were encountered. The total occlusion time of REBOA was significantly lesser in survivors than that in non-survivors (52 vs. 97 min, p < 0.01). Significantly positive correlations were found between total occlusion time of REBOA and shock index (Spearman's r = 0.6) and lactate concentration (Spearman's r = 0.7) in survivors. CONCLUSION: REBOA can be performed in ER and ICU with a high degree of technical success. Furthermore, correlations between occlusion time and initial high lactate levels and shock index may be important because prolonged occlusion is associated with a poorer outcome.