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1/66. Cerebral angioplasty and stenting for intracranial vertebral atherosclerotic stenosis.

    A 72-year-old man underwent cerebral angioplasty and stenting for a high-grade eccentric atherosclerotic stenosis (93%) of the right intracranial vertebral artery. The lesion was sufficiently and smoothly dilated very easily with the use of a highly flexible, balloon-expandable coronary stent. No complications occurred during or after the procedure. This therapeutic option may prove to be a safe and useful means to resolve an intracranial atherosclerotic stenosis.
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2/66. Ischaemic complication following obliteration of unruptured cerebral aneurysms with atherosclerotic or calcified neck.

    We report three cases of ischaemic complications following direct surgery of unruptured cerebral aneurysms having necks with atherosclerotic or calcified walls. Among 30 patients we treated directly for unruptured aneurysm over the last 4 years, 6 had 8 such aneurysms. Atherosclerotic or calcified neck was a major contributor to postoperative ischaemic sequelae in our recent series of unruptured aneurysms treated surgically, and common technical problems during surgery seemed to have caused ischaemic complications in the 3 patients reported here. In this report, attention is given to ischaemic complications in the treatment of such aneurysms.
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ranking = 5
keywords = cerebral
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3/66. Elective stenting of symptomatic middle cerebral artery stenosis.

    Percutaneous balloon angioplasty has been found to be useful for the treatment of intracranial atherosclerotic arterial stenosis. Nonetheless, an ongoing risk of this procedure is arterial dissection, which increases the hazards of acute closure, stroke, and restenosis. Stenting of the intracranial vasculature recently has been shown to be feasible in a variety of circumstances. To our knowledge, however, stenting of the middle cerebral artery has not been possible until now primarily because of difficulty with tracking stents across the carotid siphon. We describe the successful treatment of a symptomatic middle cerebral artery stenosis achieved using a balloon-expandable flexible coronary stent.
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ranking = 6
keywords = cerebral
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4/66. Complicated stent supported cerebrovascular angioplasty: case analyses and review of literature.

    BACKGROUND: Hemodynamic lesions of the cervicocerebral vasculature are currently being treated with stent supported percutaneous transluminal angioplasty. These procedures have met with increasing success when compared to the risks and morbidity of more invasive surgical approaches. The versatility of stent-supported angioplasty as a primary therapeutic modality is examined in the following complex cases. CASE DESCRIPTION: We present four cases involving cervical angioplasty with emergent or adjunctive stent placement. Two cases involved the subclavian arteries, whereas the others involved the vertebral and internal carotid arteries. In our experience, complications of cervicocerebral artery angioplasty have been successfully managed by stent placement. CONCLUSION: Our cases demonstrate the emerging role of cervical angioplasty and stent implantation as a successful therapeutic modality, highlighted in these complex cases.
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ranking = 2
keywords = cerebral
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5/66. The organized subdural blood clot in forensic case work - a case report.

    The medico-legal assessment of a subdural haematoma (recent or organized) usually requires some information regarding its cause. Quite often, especially in the absence of a known history of trauma, minor head injuries, which are no longer verifiable, are simply assumed to be the most likely causes. Considering the fact that a subdural haematoma could also be non-traumatic, e.g. in haemorrhagic disorders, cardiac conditions with persistent passive hyperaemia, true inflammatory and degenerative processes of the dura, etc., the medico-legal implication of a possible head injury would require the exclusion of such non-traumatic conditions capable of causing subdural bleeding. In this respect, the case of a 92-year-old man, who suffered from cerebral sclerosis with occasional episodes of confusion and agitation, is briefly discussed. He was reported to have fallen from his bed, was hospitalized and died 2 days later. A head injury was suspected. At autopsy, no skull fractures and no obvious bruises were discovered. Fresh bilateral temporal subdural haematomas were found. These appeared consistent with a suspected head injury sustained as a result of a fall. Fairly large partly organized adherent subdural clots in the parieto-occipital region completely remote from and unconnected with the fresh bitemporal haematomas were also found. Based on the gross pathology and the histology, an attempt is made to assess the possible cause of the organized clots. Some of the findings indicated a possible non-traumatic origin, a consideration which is likely to affect the forensic implications.
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6/66. Rapidly progressive stroke in a young adult with very low high-density lipoprotein cholesterol.

    Ischemic strokes can affect young adults (15-45 years old). Most such strokes are caused by cardioembolic events, small vessel disease, or illicit drug use, and less frequently by large vessel atherosclerosis. Large vessel cerebral atherosclerosis is usually associated with high levels of low-density lipoprotein (LDL) cholesterol, but a low level of high-density lipoprotein (HDL) is also a risk factor for ischemic strokes. The magnitude of increased risk is unclear, particularly with extremely low HDL levels found only in various genetic and inherited disorders. Advanced atherosclerosis developed in the patient in this study, with HDL of 3 mg/dL, leading to rapidly progressive stroke with a fatal outcome. The disease primarily affected the posterior circulation. The course of this case illustrates that very low HDL may be associated with advanced cerebrovascular atherosclerosis and fatal stroke, and as such should be considered in young individuals with stroke.
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keywords = cerebral
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7/66. Progressive intracranial vascular disease with strokes and seizures in a boy with progeria.

    progeria, a rare genetic disorder, is characterized by severe growth failure, premature aging, and very early atherosclerosis with coronary artery and cerebrovascular disease. There has been no detailed description of progressive cerebrovascular changes in progeria or any attempted neurologic correlation of those changes. A 5-year-old boy developed signs of progeria at 4 months and hypertension at 4 years, treated with atenolol and dipyridamole. Left-sided seizures with a left hemiparesis occurred at 5 years. magnetic resonance imaging (MRI) showed bilateral acute, subacute, and chronic cerebral infarctions. magnetic resonance angiography disclosed severe stenosis of the left internal carotid artery. The child was also found to have an aortic valve vegetation and was anticoagulated. He subsequently developed right-sided seizures, and treatment with gabapentin was started. Later, severe stenosis also of the right internal carotid artery was found. MRI showed new left cerebral infarction. The child's neurologic symptoms almost certainly were caused by cerebral infarctions from progressive atherosclerosis of major intracranial vessels, but clinical-neuroradiologic correlations were imprecise. There were multiple cerebral infarctions of different ages, some asymptomatic, others ipsilateral to the child's neurologic findings. No therapy has halted progression of the child's cerebrovascular disease.
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ranking = 4
keywords = cerebral
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8/66. Hyperperfusion phenomenon after percutaneous transluminal angioplasty for atherosclerotic stenosis of the intracranial vertebral artery. Case report.

    The authors report on a patient who underwent percutaneous transluminal angioplasty (PTA) for stenosis of the intracranial vertebral artery (VA). This 67-year-old man's dizziness while walking was caused by infarction of the left cerebellar peduncle. On angiograms, his left VA manifested 90% stenosis at the intracranial portion and his right VA ended at the posterior inferior cerebellar artery. Because single-photon emission computerized tomography (SPECT) showed low perfusion and poor perfusion reserve in the posterior circulation, the authors performed PTA of the left VA, which was only 35% dilated due to stenosis. Although the patient's postoperative course was uneventful, postoperative hemodynamic studies (SPECT and transcranial Doppler [TCD] ultrasonography) revealed the hyperperfusion phenomenon. A 100% increase of regional cerebral blood flow in the posterior circulation was demonstrated on SPECT studies and TCD ultrasonography revealed a doubling of blood flow velocity in the VA compared with preoperative values. Careful control of the patient's blood pressure resulted in resolution of the hyperperfusion phenomenon within I week post-PTA. Although hyperperfusion syndrome following carotid endarterectomy is not rare, it is seldom seen after reconstruction of the posterior circulation, and the possibility of its occurrence must be kept in mind when the posterior circulation is reconstructed.
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ranking = 1
keywords = cerebral
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9/66. Cerebral aneurysms in the perforating artery manifesting intracerebral and subarachnoid haemorrhage--report of two cases.

    BACKGROUND: An arteriosclerotic aneurysm in the perforating artery has been focused on as a causative factor for hypertensive intracerebral haemorrhage. However, its pathogenesis remains unknown, and its existence is still a controversy. CASE DESCRIPTION: A 62-year-old female and a 70-year-old male with a history of hypertension suffered from intracerebral haemorrhage accompanied by subarachnoid haemorrhage. Cerebral angiograms demonstrated an aneurysm arising from the perforating artery at the central location of the haematoma in both cases. The aneurysms were confirmed as the cause of bleeding during microsurgery, and were resected. Histological examination of the surgical specimens revealed that the walls of the aneurysms lacked internal elastic lamina and consisted only of the adventitia. CONCLUSION: These findings demonstrate that the aneurysm in the perforating artery can be a causative factor for hypertensive intracerebral haemorrhage, and indicate that the loss of internal elastic lamina induced by hypertension may contribute to the formation of the aneurysm of the perforating artery.
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ranking = 7
keywords = cerebral
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10/66. Evaluation of progression and spread of atherothrombosis.

    Symptomatic atherothrombosis in one vascular bed is usually indicative of disseminated disease. Indeed, involvement of multiple beds is common in everyday clinical practice, and these patients are at much higher risk of ischaemic events. The prevention of manifestations following atherothrombosis is therefore an important therapeutic goal in these patients. Some causative risk factors demonstrate affinities to particular arterial domains. Cigarette smoking, for example, is particularly associated with atherothrombotic involvement of the pelvic and lower limb arteries, whereas arterial hypertension is associated with the intracranial cerebral arteries. The degree, spread and progression of atherosclerosis can be assessed using various non-invasive and invasive modalities: high-resolution Doppler ultrasound, ankle-brachial index (ABI) measurement, magnetic resonance (MR), computed tomography (CT) and intra-arterial angiography. Indicators of atherothrombotic risk include increased carotid artery intima-media thickness, microembolic signals on transcranial Doppler ultrasonography and low ABI. There is a strong rationale for the inclusion of the ABI measurement as part of the routine clinical examination to assess the cardiovascular risk in patients with identified risk factors. Furthermore, detection of a low ABI should serve as a trigger for patient management with aggressive antiplatelet therapy. The generalized nature of atherothrombosis and the methods for evaluating the spread of disease are illustrated through the case history of a patient with disseminated atherothrombotic disease.
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ranking = 1
keywords = cerebral
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