??Carotid endarterectomy can effectively prevent the occurrence of stroke in patients with severe symptomatic carotid artery stenosis, and carotid artery stenting has been widely used as an alternative treatment.
??However, the current decision-making factors related to carotid artery stenosis are based on outdated clinical trials. Medical therapy has improved considerably in the past two decades, and this has reduced the incidence of stroke in both symptomatic and asymptomatic carotid stenosis cases. Clinicians should consider the various clinical and pathophysiological variables to determine the appropriate treatment for patients with carotid stenosis.
??This study aimed to clarify the current evidential status pertaining to acute endovascular thrombectomy and its treatment indications and limitations. Mechanical thrombectomy is being widely performed due to the results presented by five large-scale randomized trials. Recently, both Japanese and international guidelines for mechanical thrombectomy have been updated to extend its indications in unresolved fields. Obvious effectiveness was observed in patients treated within 6-16 hours of onset, as well as in patients with occlusion of the distal middle cerebral artery. However, the indications for patients with occlusion of the posterior circulation and extensive areas of infarction remain controversial. The indications for mechanical thrombectomy are expected to become more widespread, depending on the results of the ongoing clinical trials.
??To prevent recurrent ischemic stroke in patients with non-valvular atrial fibrillation, it is recommended to start the administration of oral anticoagulants within 14 days of onset. In recurrent non-cardioembolic stroke cases, administration of dual antiplatelet therapy (clopidogrel plus aspirin for the first 21 days, followed by single antiplatelet therapy) can effectively reduce the risk of stroke recurrence and the risk of hemorrhage. The combination of cilostazol with aspirin or clopidogrel reduced the ischemic stroke recurrence and did not increase severe or life-threatening bleeding complications when compared with using aspirin or clopidogrel alone. For the treatment of patients with embolic stroke of undetermined sources (ESUS), direct oral anticoagulants were not superior to aspirin. ESUS may include underlying covert atrial fibrillation, patent foramen ovale, and aortogenic embolism. In emergencies, idarucizumab can rapidly reverse the anticoagulant effect of dabigatran. The four-factor prothrombin complex concentrate is not only effective, but also superior to plasma in the rapid reversal of the prothrombin time-international normalized ratio induced by vitamin K antagonists. After an ischemic stroke or transient ischemic attack in patients with atherosclerosis, the low target level of low-density lipoprotein of ＜70mg/dl is superior to the high target range of 90-110mg/dl in preventing subsequent cardiovascular events. For patients with active cancer, anticoagulant therapy, including subcutaneous heparin injections, may be recommended.
??The recurrence rate of stroke due to intracranial atherosclerotic disease (ICAD) is known to be high. Surgical treatment against ICAD including intravascular surgery doesn't have enough evidence to prevent from recurrence of stroke. In Asian population, ICAD is more common than in European and American population. In this manuscript, recent knowledge about the pathophysiology and the treatment for ICAD are summarized. Especially, different diagnosis and MRI findings of arteriosclerotic ICAD and other ones are shown. In addition, surgical treatment for ICAD in our institute is described.
??We report two cases of ruptured dissecting cerebral aneurysms presenting with subarachnoid hemorrhage (SAH) that were successfully treated with surgical craniotomy. In case 1, there was a ruptured dissecting aneurysm in the A1 portion of the anterior cerebral artery. Although the cause of the hemorrhage could not be confirmed by preoperative imaging examination, the rupture point was confirmed under direct vision, and the parent artery was trapped after preserving the perforating artery. In case 2, there was a ruptured dissecting aneurysm in the V4 portion of the vertebral artery (VA). The VA of the contralateral side was of the posterior inferior cerebellar artery end type ; therefore, we performed angioplastic partial clipping of the rupture point while preserving the blood flow in the parent artery. By performing direct surgery, we were able to preserve the blood flow in the perforating artery and the parent artery, as well as confirm the rupture point, which is considered difficult in endovascular treatment.
??Peripheral arterial occlusive disease is one of the adverse events associated with the use of tyrosine kinase inhibitors (TKIs) for treating chronic myelogenous leukemia. Here, we report a case of multiple arterial stenoses due to long-term treatment with nilotinib, a second-generation TKI. The patient was diagnosed with chronic myelogenous leukemia at 31 years of age. The patient was taking TKIs for over 15 years since the age of 35. Cerebral angiography revealed multiple stenotic lesions in the thoracic and cervical regions ; hence, TKI was discontinued, and percutaneous balloon dilation was performed for severe stenosis at the origin of the left vertebral artery. Awareness among clinicians regarding the possibility of multiple arterial stenoses caused by nilotinib when treating stroke is necessary.