Objective: Intravenous tissue plasminogen activator (IV t-PA) is commonly used as bridging therapy before mechanical thrombectomy (MT) in acute ischemic stroke. However, in practice, some patients undergo MT only after IV t-PA has been fully administered. This study aimed to compare clinical and radiological outcomes of MT only versus IV t-PA followed by MT within 4.5 hours of symptom onset. Methods: We retrospectively reviewed 190 patients with acute large artery occlusion treated with MT between January 2018 and December 2020. After excluding 53 patients ineligible for IV t-PA. A total of 137 patients were enrolled and categorized into two groups: MT only (n=82, 59.8%) and post-IV t-PA MT (n=55, 40.2%). The primary outcome was successful recanalization; the secondary outcome was a good clinical outcome at 90 days (3-month modified Rankin Scale (mRS) score of 0–2). Results: The successful recanalization rates did not significantly differ between the MT-only and post-IV t-PA MT groups (92.7% vs. 89.1%, p=0.466). Good outcomes at 90 days were not statistically different between both groups (58.5% vs. 61.8%, p=0.701). Multivariable analysis identified baseline National Institutes of Health Stroke Scale (NIHSS) score (adjusted odds ratio (OR) 0.873; 95% confidence intervals (CI), 0.806–0.946; p<0.001) and door-to-puncture time (adjusted OR 0.987; 95% CI, 0.978–0.997; p=0.009) as independent predictors of outcome. Conclusions In our study, MT alone yielded comparable outcomes to IV t-PA followed by MT in patients treated within 4.5 hours. Direct MT may be a reasonable treatment strategy.

Objective: : With the recent increase in mechanical thrombectomy (MT) for acute ischemic stroke (AIS), the role of neurosurgeons in AIS treatment has become increasingly important. This study aimed to assess the outcomes of patients with AIS treated by neurosurgeons and neurologists in the emergency room (ER) of a tertiary hospital in South Korea. Methods: : From January 2020 to June 2021, 536 patients with AIS within 24 hours of symptom onset were admitted to our hospital via the ER. Based on the type of doctors who provided initial care for AIS in the ER, patients were divided into two groups : (a) neurosurgeon group (n=119, 22.2%) and (b) neurologist group (n=417, 77.8%). Results: : Intravenous tissue plasminogen activator (tPA) was administered in 82 (15.3%) of 536 patients (n=17 [14.3%] in the neurosurgeon group and n=65 [15.6%] in the neurologist group). The door-to-tPA time was not significantly different between both groups (median, 53 minutes; interquartile range [IQR], 45–58 vs. median, 54 minutes; IQR, 46–74; p=0.372). MT was performed in 69 patients (12.9%) (n=25, 36.2% in the neurosurgeon group and n=44, 63.8% in the neurologist group). The neurosurgeon group achieved a shorter door-to-puncture time than the neurologist group (median, 115 minutes; IQR, 107–151 vs. median, 162 minutes; IQR, 117–189; p=0.049). Good clinical outcomes (3-month modified Rankin Scale 0–2) did not differ significantly between the two groups (96/119 [80.7%] vs. 322/417 [77.2%], p=0.454). Conclusion : The neurosurgeon group showed similar door-to-treatment time and clinical outcomes to the neurologist group in patients with AIS in the ER. This study suggests that neurosurgeons have comparable abilities to care for patients with AIS in the ER.

Forehead flaps are widely used to reconstruct nasal defects. The authors report a case wherein a folded forehead flap was used to reconstruct a large nasal defect after wide excision of squamous cell carcinoma. A 65-year-old man was diagnosed with squamous cell carcinoma by a punch biopsy conducted at the dermatology department, and the mass was located in the left nasal vestibule. A forehead flap was planned to cover the full-thickness defect that occurred after wide excision. A flap with an extended transverse skin paddle was designed; thereafter, the distant part of the flap was folded up to the nasal lining inside the nose. The interpolation flap was properly maintained for 3 weeks, and flap division was performed. The reconstructed nose exhibited symmetry during a 5-month observation period. A folded forehead flap is a surgical option when considerable nasal restoration, including soft tissue and the internal lining, is necessary.

Objective: Simultaneous anterior cerebral artery (ACA) and middle cerebral artery (MCA) occlusion is rare. We investigated the clinical and radiological outcomes of patients with simultaneous ACA and MCA occlusion treated with mechanical thrombectomy. Methods: We analyzed the clinical and radiological outcomes of 12 patients with simultaneous ACA and MCA occlusion treated with mechanical thrombectomy from January 2018 to December 2020. The clinical outcome was assessed using the modified Rankin Score (mRS) after 3 months of thrombectomy. The radiological outcome was assessed using the thrombolysis in cerebral infarction (TICI) score. Results: The median National Institutes of Health Stroke Scale score at hospital arrival was 18 (interquartile range, 16–20). M1 was the most common occlusion lesion (n=8), and A3 was the most common lesion in the ACA (n=6). Six patients were first treated for MCA occlusion and later for ACA occlusion (MCA group). Other patients were first treated for ACA occlusion and later for MCA occlusion (ACA group). There was no difference in clinical outcomes between the MCA and ACA groups (p=0.180). Successful recanalization (TICI ≥2b) of MCA was achieved in 10 patients (83.3%). Successful recanalization of ACA was achieved in 10 patients (83.3%). Successful recanalization of both ACA and MCA occlusion was observed in eight patients (66.7%). Three patients (25%) had good clinical outcomes (mRS ≤2). Conclusions In our series, simultaneous ACA and MCA occlusion showed relatively poor successful recanalization rates and poor clinical outcomes despite treatment with mechanical thrombectomy.

Procedure-related subarachnoid hemorrhage (SAH) after mechanical thrombectomy is known to be a clinically benign presentation. However, the treatment in the presence of definite contrast leakage without vessel rupture is controversial. Here, we report a case in which a salvage technique was performed for procedure-related SAH after mechanical thrombectomy for a proximal M3 occlusion.
A 56-year-old female patient presented with global aphasia and right hemiparesis within 2 hours after symptom onset. The initial National Institute of Health Stroke Scale score of the patient was 18 points, and Computed tomography (CT) angiography showed that the superior division of the left middle cerebral artery (MCA) was occluded. We decided to treat the patient with mechanical thrombectomy. Control angiography showed a left proximal M3 occlusion. We performed mechanical thrombectomy with a partially deployed technique using a Trevo 3 mm stent (Stryker). Control angiography showed recanalization of the occluded vessel but contrast leakage after stent retrieval. We decided to treat the lesion presenting with contrast leakage with stenting using a Neuroform Atlas 3 mm stent (Stryker). Serial control angiography continued to show contrast leakage of the recanalized artery. We decided to treat the lesion with temporary balloon occlusion using a Scepter C balloon catheter (MicroVention). The patient recovered and had a modified Rankin scale score at discharge of 0.
Given the results of our case, stenting and subsequent repeat temporary balloon occlusion should be considered for SAH with contrast leakage after mechanical thrombectomy, as spontaneous cessation of the arterial bleeding is unlikely.

Naso-orbito-ethmoidal (NOE) fractures are complicated fractures of the mid-face. The treatment of NOE fractures is challenging and a comprehensive treatment strategy is required. We introduce a case of NOE fracture treated with open reduction and suspension sutures. A 28-year-old woman presented with a unilateral NOE fracture. To reduce the frontal process of the maxilla, a suspension suture was made by pulling the fragment using a double arm suture via a transcaruncular incision. The suture thread was placed in the horizontal plane. Another suspension suture on the inferior orbital rim assisted reduction procedure, and they passed through the overlying skin. The reduction alignment could be finely adjusted by tightening the transcutaneous suture threads while checking the degree of bone alignment through the subciliary incision. The two suture threads were suspended using a thermoplastic nasal splint. An additional skin incision on the medial canthal area, which would have resulted in a scar, could be avoided. Four months postoperatively, computed tomography showed an accurate and stable reduction. The patient was satisfied with her aesthetic appearance, and functional deficits were not present.

The scalp is the thickest skin in the body and protects the intracranial structures. The coverage of a large scalp defect is a difficult surgical procedure, the full details of which must be considered prior to the procedure, such as defect size and depth, and various factors related to the patient’s general condition. Although a free flap is the recommended surgical procedure to cover large scalp defects, it is a high-risk operation that is not appropriate for all patients. As such, other surgical options must be explored. We present the case of a patient with an ulcer on the scalp after wide excision and split-thickness skin graft for squamous cell cancer. We successfully performed a reverse temporalis muscle flap for this patient.

Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder is a rare disease characterized by a single mass on the face or upper part of the trunk. It usually presents an asymptomatic and favorable progression, and its histopathologic findings include small and medium-sized lymphoid cells. The authors report a case of primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder on the forehead. A 51-year-old man presented with a protruding mass on his forehead that the patient had noted 1 month previously. Surgical excision and a permanent biopsy were performed under local anesthesia. Based on the biopsy results, the mass was diagnosed as a primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder. There was no evidence of recurrence at a 15-month follow-up visit.

A checkrein deformity can occur after a distal tibiofibular fracture. Usually, a checkrein deformity due to a dysfunction of the extensor hallucis longus muscle is rarer than that of the flexor hallucis longus. Only a few related studies have been reported. The authors encountered an extensor hallucis longus checkrein deformity due to extensor retinaculum syndrome while managing a triplane fracture. In magnetic resonance imaging, an increase in the heterogeneous signal was observed on the T2-weighted images suggesting muscle necrosis or ischemic changes in a part of the extensor hallucis muscle. Postoperative great toe motor weakness, unintentional movement, sensory changes, and weakness improved spontaneously during the follow-up.

Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder is a rare disease characterized by a single mass on the face or upper part of the trunk. It usually presents an asymptomatic and favorable progression, and its histopathologic findings include small and medium-sized lymphoid cells. The authors report a case of primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder on the forehead. A 51-year-old man presented with a protruding mass on his forehead that the patient had noted 1 month previously. Surgical excision and a permanent biopsy were performed under local anesthesia. Based on the biopsy results, the mass was diagnosed as a primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder. There was no evidence of recurrence at a 15-month follow-up visit.