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Carotid cavernous fistula (CCF) is an abnormal communication between the carotid artery and the cavernous sinus, which is most commonly caused by trauma. Due to its high-flow nature and aggressive clinical course, spontaneous resolution of CCF is rare, making endovascular embolization necessary. This procedure aims to prevent potential vision loss, emphasizing the importance of timely intervention to preserve visual function. We report a case of Barrow type A carotid-cavernous fistula which resolved spontaneously. A 42-year-old male was referred to Emergency Room with a chief complaint of seizure 3 days before admission. The seizure was both arm stiff and jerking, the eyes gazing upward, bitten tongue, foamy mouth, no bed wetting. Meanwhile, the patient was unconscious during and after the seizure. Regarding the medical history, the patient experienced head trauma 8 months ago due to a traffic accident. Additionally, the patient reported symptoms of redness, swelling, double vision, and inability to look to the right eye. Initial cerebral angiography was performed, reporting a carotid-cavernous fistula of Barrow type A. Further endovascular treatment could not be carried out, but a second cerebral angiography was conducted after a year, demonstrating spontaneous thrombosis of the carotid-cavernous fistula of Barrow type A. CCF were classified by Barrow et al. into types A, B, C, and D. It has been proposed that spontaneous resolution of CCF Barrow type A may result from thrombosis of the cavernous sinus.

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The most common manifestation of brain arteriovenous malformations (BAVM) is intracranial hemorrhage. The incidence of ruptured BAVM is 3.5 per 100,000 people per year. The mortality rate of ruptured BAVM within 1 month after diagnosis was 12.7%. Spontaneous thrombosis occurs in less than 1.5% of ruptured BAVMs. This phenomenon was still elusive. Up until now, the gold standard of imaging examination has been cerebral digital subtraction angiography (DSA), whose sensitivity and specificity reach 100%. We reported the spontaneous thrombosis of a ruptured deep BAVM. An 18-year-old woman presented with severe headache and vomiting. The patient also complained of seizures. There was no body weakness, skewed face, or slurred speech. Cerebral computed tomography (CT) showed extensive hemorrhage in the ventricular system and subarachnoid space. Cerebral DSA showed a left subcortical BAVM and was found to have spontaneous thrombosis 3 weeks later when the patient was about to be embolized. Spontaneous thrombosis of ruptured BAVM may occur after intracranial hemorrhage. In this patient, spontaneous thrombosis occurred within 3 weeks.

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Locked-in syndrome (LiS) is a condition of motor paralysis involving all the voluntary muscles of 4 extremities with retained consciousness and alertness. Meanwhile, Takayasu arteritis (TA) is a systemic inflammatory disease affecting large arteries, including the aorta and the branches. This disease often affects the extracranial arteries but rarely occurs in the intracranial arteries. An 18-year-old male presented with a sudden onset of decreased consciousness and bilateral weakness. The patient exhibited normal horizontal and vertical eye movements but presented with impairment of the trigeminal nerve, peripheral-type facial palsy, absence of gag reflex and tongue movement, and neck weakness. Physiological reflexes were increased bilaterally, while pathological reflexes were present on both sides. Autonomic function was impaired, and communication was impossible due to paralysis. Additionally, the patient displayed varying blood pressure readings between the right and left arms. The antinuclear antibody (ANA) and antismooth muscle (ASMA) antibody tests yielded negative results, while the electroencephalogram (EEG) showed normal readings. The cerebral angiogram indicated multiple internal and external stenoses, with total stenosis evident in the basilar artery. The patient was diagnosed with multiple extracranial and intracranial stenoses due to TA. Total stenosis of the basilar artery resulted in brainstem infarction, which led to the development of LiS. Meanwhile, the disturbance of the motor tracts in the ventral brainstem was the underlying cause of the LiS. This case report demonstrated a variety of atypical presentations of TA. The involvement of multiple extracranial and intracranial arterial was attributed to LiS.

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Unruptured giant intracranial aneurysms (GIAs) are characterized by their size, which exceeds 25 mm, and these conditions account for approximately 5% of all aneurysm cases. Furthermore, it typically develops in women during the fifth to seventh decade of life. Compared to small aneurysms, which cause subarachnoid hemorrhage, GIAs can manifest as masses or ischemic effects caused by thromboembolism. An elderly female patient, aged 67, was admitted to the hospital with a primary complaint of sudden facial sensory loss on the left side and vomiting. There was also a history of double vision accompanied by left ocular movement disturbance and gradually developed localized headache on the left side. Furthermore, a contrast head magnetic resonance angiography (MRA) revealed the presence of a high-flow giant aneurysm, measuring 30.7 × 31.8 × 27.2 mm in the cavernous segment of the left internal carotid artery (ICA). Cerebral angiography showed the absence of flow on the left ICA due to total occlusion. After cerebral angiography, the patient remained conscious but exhibited some neurological deficits, which were identical to the initial symptoms observed during hospitalization. Cases of spontaneous thrombosis in GIA are extremely rare. However, radiological examination, particularly angiography, can be used to diagnose spontaneous thrombosis in unruptured GIAs to ensure that the patient receives the right treatment.

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Introduction: An arteriovenous malformation (AVM) consists of a tangled cluster of dilated blood vessels forming anomalous communication between arterial and venous systems without capillary bridging. The most likely manifestations of a ruptured AVM are intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), or intraventricular hemorrhage (IVH). Subdural hematoma (SDH) is exceptional in cases of ruptured brain arteriovenous malformation (BAVM). Case Report: A 30-year-old female was referred to the Emergency Room with a major complaint of sudden thunderclap headache 1 day before admission. The patient also complained of double vision and left ptosis that lasted for 1 day. There was no other complaint or history of hypertension, diabetes, or trauma. Non-contrast head computed tomography (CT) showed ICH-SAH-SDH on the left side of the brain which was not typical of a hypertensive pattern. The secondary ICH has a score of 6, indicating that 100% of the bleeding might be caused by underlying vascular malformation. Furthermore, cerebral angiography showed cortical plexiform BAVM on the left occipital lobe, and the patient underwent curative embolization. Discussion: Spontaneous SDH is very rare, and there are some hypotheses about the reasons for its occurrence. First, brain movement stretches the arachnoid layer that adheres to the AVM, resulting in direct bleeding into subdural space. Second, high-flow pia-arachnoid ruptured blood might extravasate into subdural space. Finally, the ruptured cortical artery that connects the cortex and dura layer (bridging artery) might also cause SDH. Some scoring systems are useful in BAVM, and this study selected endovascular embolization for the patient. Conclusion: Brain AVM rupture usually causes ICH, SAH, or IVH. Clinicians must be more aware of spontaneous SDH because it might be caused by a vascular malformation, although it is rare.

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Cerebral aneurysm is a known cause of spontaneous subarachnoid hemorrhage (SAH). Furthermore, this condition is often asymptomatic, but the occurrence of a rupture can lead to fatal complications. The incidence of spontaneous thrombosis in saccular aneurysm is rare, with an incidence rate of 1%-2%. The most common sites include the middle cerebral artery (MCA) (41%), posterior communicating artery (PCOMM) (15%), and posterior inferior cerebellar artery (PICA) (11%). A head computed tomography angiography (CTA) with contrast is a common diagnostic tool for detecting SAH in the temporoparietal area, hippocampal gyrus, and right fissure of Sylvie. In some cases, saccular aneurysm can be found in the segment bifurcation of the right middle cerebral artery. A cerebral angiography was carried out, specifically digital subtraction angiography, which revealed the presence of visible blister remnants of aneurysm in the form of spontaneous thrombosis. After 1 year, another angiography evaluation was performed to assess the condition of the patient. Furthermore, the results showed no evidence of recanalization and there were no new neurologic deficits. Although spontaneous thrombosis led to the healing of aneurysm in some cases, secondary recanalization remained a possibility. Therefore, it was essential to monitor any incidence of this complication. Precise knowledge of the mechanism of spontaneous thrombosis could lead to the development of new therapeutic approaches. Spontaneous thrombosis in cases of saccular aneurysm is a rare occurrence, which can provide temporary or permanent benefits to the patient. Therefore, periodic evaluation is required to assess the condition of the patient.

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Cortical blindness refers to the loss of vision caused by a lesion affecting the geniculate calcarine visual pathway. Bilateral occipital lobe infarctions in the vascular territory of the posterior cerebral arteries are the most common cause of cortical blindness. However, bilateral cortical blindness gradual is rarely reported. Gradual bilateral blindness usually occurs in lesions other than stroke, such as tumors. We report a case of a patient with gradual cortical blindness caused by a nonocclusive stroke caused by hemodynamic compromise. A 54-year-old man diagnosed with bilateral cerebral ischemia after complaining of bilateral gradual vision loss and headache for 1 month. Initially, he only complained of blurred vision with >2/60 vision. However, his visual acuity worsened until he could only see hand movements and only light perception later on (with visual acuity of 1/∼). A computed tomography scan of the head revealed a bilateral occipital infarction, and cerebral angiography revealed multiple stenoses and near-total occlusion of the left vertebral artery ostium, underwent angioplasty and stenting. He has received dual antiplatelet and antihypertensive treatment. He got visual improvement with visual acuity 2/300 after 3 months of the treatment and procedure. Gradual cortical blindness caused by hemodynamic stroke is rare. The most common cause of posterior cerebral arteries infarction is embolism from the heart or vertebrobasilar circulation. With proper management and focusing on treating the etiology of these patients, vision improvements can be obtained in these patients.

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Tinnitus and vertigo are classic symptoms of inner ear disease. Dural arteriovenous fistulas (DAVF) are a rare type of acquired intracranial vascular malformation whose symptoms mimic inner ear disease, but what distinguishes it from other tinnitus is the characteristic of DAVF is pulsatile and heartbeat-synchronous. We present a 58-year-old male with chronic left-sided pulsatile tinnitus (PT) for 30 years and continuous vertigo for 3 years that took numerous consultations to establish a diagnosis after the onset of symptoms. Delay in diagnosis is caused by normal magnetic resonance imaging and an unrecognized subtle mass in the left temporal region by time-of-flight magnetic resonance angiography (TOF-MRA) at the screening test. As we know, TOF-MRA could not provide a clear picture to establish a slow-flow DAVF. Cerebral angiography, a gold standard diagnostic, revealed a Borden/ Cognard Type I single slow-flow DAVF in the left temporal region. The patient was treated with superselective transarterial embolization. After 1 week of follow-up, the symptoms of vertigo and PT were completely resolved.

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Delayed cerebral ischemia (DCI) remains a devastating complication in subarachnoid hemorrhage (SAH), however, there were no present reports that is associated with a ruptured spinal arteriovenous fistula (sAVF). We would like to present a rare case of DCI following embolization of a ruptured perimedullary sAVF. Initially, the patient clinical symptoms mimic a SAH caused by a ruptured intracranial aneurysm. Further evaluation revealed that the SAH was caused by a ruptured perimedullary sAVF and the patient's condition improved following the embolization procedure. Three days later, the patient developed an acute left-sided facial and motor weakness, which persisted until the patient was discharged on the day-15 onset. A magnetic resonance imaging and angiography is performed 1.5 years after discharge and revealed no signs of cerebral infarction and hemorrhage. In this paper, we reported DCI after embolization in a ruptured sAVF with SAH, supported by evidence from the current literature. We would like to also stress the importance of complete spinal and cerebral vessel imaging to reveal the underlying abnormalities and determine the most appropriate intervention.

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Patients with an acute subdural hematoma (aSDH) usually have a history of head trauma, but some patients may present with spontaneous aSDH due to a ruptured aneurysm. Spontaneous aSDH is a rare manifestation of aneurysmal rupture. However, aneurysmal rupture remains a major cause of spontaneous aSDH. A 42-year-old man was brought to the emergency room because of a sudden loss of consciousness during sexual intercourse. The patient has seizures and weakness on the right side of his body. The patient has no history of trauma and has never taken anticoagulant or antiplatelet drugs, sexual aphrodisiacs, or other drugs. Physical examination revealed the Glasgow Coma Scale of E2V1M3, ptosis on the left eye, left pupil mydriasis, right central facial palsy, and right hemiparesis. Laboratory results showed hypercoagulopathy. Noncontrast head computed tomography scan revealed subdural hematoma with no subarachnoid or intraparenchymal hemorrhage. The patient underwent an emergency craniotomy, and the hematoma was evacuated. Cerebral angiography was performed 1 week later, revealing a saccular aneurysm in the left posterior communicating artery. The patient has successfully undergone endovascular coiling and was discharged from the hospital in good condition, fully conscious, with no weakness in half side of the body, but there is still third nerve palsy. Patients with pure aSDH without a history of trauma should consider the possibility of aneurysm rupture and perform an angiographic examination to rule out vascular malformations so that the patient can receive appropriate treatment.

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Background: Asymptomatic carotid artery stenosis has become more prevalent worldwide and is often associated with a poor prognosis. Numerous guidelines highlighted surgical interventions as treatment for carotid artery stenosis, but only a few recommendations were made regarding non-surgical interventions due to its limited data. Aims: This study aims to develop a mice model for research in non-surgical interventions of asymptomatic carotid artery stenosis. Methods: Adult male Rattus norvegicus, Wistar strain models with bilateral asymptomatic common carotid artery stenosis (BACAS) were created by ligating the common carotid artery with a 0.6 mm diameter needle and then removing the needle. The mice's body weight, clinical signs and symptoms, and post-mortem brain analysis were compared between the sham-operated group and the BACAS group. Results: The mortality rate among the BACAS group is 11.11%. There is no significant difference in mean body weight before surgery, after the observation period, and percentage of weight decrease between sham-operated and BACAS groups (p = 0.710, 0.632, and 0.806, respectively). None of the surviving mice in this study exhibit signs of motor paralysis. Gross examination of the brain reveals no signs of infarction or hemorrhage. Conclusion: We have established a novel BACAS mouse model which is cost-efficient, easy to produce, and with no significant alteration in body weight, clinical parameters, and brain morphology.

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Introduction: While the overall incidence of vertebrobasilar dolichoectasia (VBD) is less than 0.05%-0.06%, it is not uncommon in patients experiencing acute stroke. The influence of VBD on the outcome of intravenous (IV) thrombolysis therapy has not been widely studied. We present the following case of IV thrombolysis use in a patient experiencing acute stroke, who had an increased risk of bleeding due to prior antiplatelet use, and who had concomitant VBD. Case presentation: A 62-year-old man presented with weakness in the left extremities that had begun 1 hour prior to admission. The patient had a history of coronary artery disease and had been regularly taking antiplatelet medication. Upon arrival, the patient was in a decreased level of consciousness, with severe dysarthria, left central facial palsy, left lateralization, and a National Institute of Health Stroke Scale (NIHSS) score of 17. Computed tomography scan of the head showed no intracranial hemorrhage. The patient was administered IV thrombolysis at 2 hours and 45 minutes after symptom onset. Within the first 24 hours, the patient's NIHSS score decreased from 17 to 12, and the final NIHSS score prior to discharge was 7. The Head and neck angiography of this patient revealed VBD. Conclusion: This case demonstrated that IV thrombolysis is safe and effective for use in patients with acute ischemic stroke who have a history of antiplatelet usage and who experience concomitant VBD.

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Middle cerebral artery stenosis is the leading and the most frequent cause of stroke due to intracranial stenosis in Asia. Magnetic resonance imaging (MRI) is more sensitive than computed tomography of the head for detecting acute brain ischemia. We are reporting a case of a 28-year-old female with recurrent left hemiparesis. After the last attack, an improvement in motor function was seen in less than 24 hours. Though the restoration of motor functions is not complete yet, an MRI scan that was done two weeks later appeared normal. Ischemic stroke in middle cerebral artery stenosis is associated with hemodynamic stroke due to hypoperfusion or lack of blood flow to brain tissue. Recurrent strokes can be prevented by better medical management in patients through regulation and management of risk factors.

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Intracranial atherosclerotic stenosis (ICAS) can cause ischemic stroke, up to 30-50% stroke in Asian population. However, recurrent exercise-induced headache due to ICAS has not been reported. We present a case of a patient 60-year-old male suffering from recurrent headache during exercise due to severe ICAS. The headache occurred after 5 minutes of running, appeared shortly after every running, and resolved at rest. Head magnetic resonance angiography showed moderate bilateral stenosis at middle cerebral artery (MCA), and cerebral catheter angiography confirmed 70% stenosis of the left MCA and 20% stenosis of the right MCA, with robust antegrade flow and good collaterals which explained why there was no neurological deficit. After treated with best medical therapy, including dual antiplatelet, statin therapy, and risk factor modification, for 90 days, he was capable of running for 20 min without headache.

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BackgroundThere is a limited data in Indonesia regarding the stroke knowledge and medication adherence among stroke survivors.ObjectiveTo assess the level of stroke knowledge and medication adherence along with their relationship among stroke survivors.SettingTwo tertiary-care hospitals in Surabaya, East Java, Indonesia.MethodsA prospective, cross-sectional study was conducted among 215 stroke survivors. Stroke Knowledge Test and the Morisky Green Levine Adherence Scale questionnaires were used to evaluate stroke knowledge and medication adherence, respectively. Binary logistic regression was performed to assess the rela tionship between stroke knowledge and medication adherence. Main outcome measuresRelationship between stroke knowledge and medication adherence.ResultsA total of 215 patients with mean age of 56.34 ± 8.69 years were recruited into this study. Mean Stroke Knowledge Test score was 7.89 ± 3.38 with 76.7% had low level of stroke knowledge. Mean Morisky Green Levine Adherence Scale was 3.05 ± 1.11 with 52.1% had low to medium medication adherence. Education and duration of stroke correlated with stroke knowledge level (Spearman's correlation coefficient: 0.307, p = 0.001 and 0.128, p = 0.041, respectively). Age and disability correlated with medication adherence (Spearman's correlation coefficient: 0.169; p = 0.013 and 0.171; p = 0.012), respectively. After adjustment for covariates, stroke knowledge level was independently associated with medication adherence (adjusted OR: 4.37, 95% CI 2.00-9.53; p < 0.001).ConclusionStroke knowledge was low among Indonesian stroke survivors and independently related to medication adherence. Attempts should be made to increase stroke knowledge which may improve medication adherence among stroke survivors.

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