Extreme fenestration of the basilar artery associated with cleft palate, nasopharyngeal mature teratoma, and hypophyseal duplication

The authors present the case of a newborn girl with extreme fenestration of the basilar artery. This anomaly was found incidentally during MR imaging study for cleft palate and nasopharyngeal teratoma. Magnetic resonance angiography showed a totally duplicated basilar artery with connections at the proximal and distal ends of the artery, suggesting an extreme fenestration. Duplicated pituitary gland was also found on MR imaging.

Quantitative MRI findings and cognitive impairment among community dwelling elderly subjects

OBJECTIVES

To study the factors which influence cognitive impairment among elderly subjects living in a local community, based on both MRI and clinical findings, to further elucidate the causes of dementia, and also to help develop strategies for its prevention.

METHODS

Cranial MRI and other medical examinations were performed on non-demented elderly subjects who resided in one rural community. A total of 254 subjects aged from 60 to 91 years of age, with a mean age of 73.9 (SD 6.8) were examined. The mini mental state examination (MMSE) was used to identify cognitive impairment. White matter lesions and cerebral atrophy on MR images were measured quantitatively. A multivariate analysis was also performed with the existence of cognitive impairment as the dependent variable, and the MRI findings and clinical observations were used as the independent variables.

RESULTS

Cognitive impairment was present in 46 subjects (18.1%). They were older, had a lower educational level, and more frequent hypertension compared with those without cognitive impairment. The packed cell volume was lower in the impaired group. In addition, their MRI findings showed significantly larger quantities of white matter lesions and cerebral atrophy, as well as more infarcts. A logistic regression analysis demonstrated a significant relation among such factors as white matter lesions (odds ratio (OR) 1.575, 95% confidence interval (95% CI) 1.123-2.208), cerebral atrophy (OR 0.761, 95%CI 0.587-0.987), and lower education (OR 0.682, 95%CI 0.544-0.855) for subjects with a cognitive impairment.

CONCLUSIONS

White matter lesions and cerebral atrophy are factors which induce a cognitive impairment in community dwelling elderly subjects without dementia. It is important to carefully watch for any abnormalities in these factors, and to perform cohort studies to check for the above risk factors, to both prevent and make an early diagnosis of dementia.

Technetium-99m-ECD SPECT in antiphospholipid antibody syndrome: a drastic improvement in brain perfusion by antiplatelet therapy

We present a case of antiphospholipid antibody syndrome (APS) with repeated transient ischemic attacks (TIAs). Magnetic resonance imaging showed multiple cerebral infarcts and ischemic changes in the cerebral white matter. Cerebral angiographies showed no abnormalities. Technetium-99m-ethyl cysteinate dimer (Tc-99m-ECD) brain SPECT showed multiple decreased perfusion areas, which were more extensive than the lesions demonstrated on MRI. After treatment with an antiplatelet agent, the patient subsequently recovered from the TIAs. Although no interval changes were observed by MRI after therapy, follow-up Tc-99m-ECD SPECT revealed a marked improvement in brain perfusion. This is the first imaging report of remarkable post-therapy improvement in brain perfusion in APS cases.

Giant Aneurysm of the Cervical Internal Carotid Artery Treated by Proximal Coil Embolization under Temporary Balloon Occlusion

SUMMARY

We report a patient with a giant aneurysm on the left cervical internal carotid artery (ICA) treated successfully by proximal coil occlusion. Fibered platinum coils were delivered via a 5-F catheter under temporary balloon occlusion of the proximal ICA and without complications. MR imaging ten months after the procedure showed the aneurysm to be reduced in size and sub totally thrombosed. Retrograde partial filling of the aneurysmal lumen was present, however. We describe the case in detail and discuss the ideal treatment of the cervical ICA aneurysm.

Supraclinoid carotid dissection in a pediatric patient

The authors present the case of a 13-year-old boy with a left temporal lobe infarction that developed during a 400-m run. Magnetic resonance (MR) angiography showed segmental narrowing of the left supraclinoid internal carotid artery (ICA) and a duplicated left middle cerebral artery (MCA). MR angiographic source images revealed a crescent-shaped left carotid lumen, indicative of a supraclinoid carotid dissection.

[A case of Japanese encephalitis presenting with unilateral lesions in diffusion-weighted MRI]

We report the findings of diffusion-weighted MRI (DWI) taken serially in a patient with Japanese encephalitis (JE). The patient was a 43-year-old woman presenting with headache, high fever and consciousness disturbance. The diagnosis of JE was made based on more than fourfold elevation of serum complement fixation antibody titer for JE virus in the convalescent phase of illness. The DWI on the second day of illness (Day-2) disclosed high-signal intensity lesions in the left thalamus, substantia nigra and frontal lobe cortex. The signal intensity of these lesions on the DWI increased on Day-3 but gradually decreased thereafter and normalized on Day-28. The improvement of the DWI findings was paralleled with that of the consciousness level and the cell number and neuron specific enolase concentration in the CSF, suggesting that DWI is useful for evaluation of the disease activity in JE. The lesions in the brain suffering from Japanese encephalitis are usually bilateral and diffuse. To our knowledge, this is the first report of JE presenting with unilateral lesions on MRI, of which phathomechanism remains to be elucidated.

Association of cerebral arteriovenous malformation with cerebral arterial fenestration

Cerebral arteriovenous malformations (AVMs) are rarely associated with other vascular lesions. Our goal was to examine the incidence of the coexistence of cerebral AVMs and cerebral arterial fenestrations. During the past 18 years, 51 patients with a cerebral AVM were examined with selective cerebral angiography in our institution. We retrospectively reviewed these cerebral angiographies and noted associated cerebral arterial fenestrations. We found five fenestrations distributed among 3 patients. In each patient one fenestration was located in the vertebral artery (VA). In 1 patient there were additional basilar and left middle cerebral artery fenestrations. Vertebral artery angiography was performed in 43 of the 51 patients; thus, the frequency of coexistence of AVM and VA fenestration was 7% (3 of 43). Although the clinical significance may not be great, we found a noteworthy incidence of associated VA fenestrations in AVM cases.

Persistent primitive olfactory artery: diagnosis with MR angiography

We present a case of persistent primitive olfactory artery (PPOA) diagnosed with the aid of magnetic resonance (MR) angiography. The proximal right anterior cerebral artery (ACA) had an extremely long anteroinferomedial course along the ipsilateral olfactory tract, made a hairpin turn posterosuperiorly, and became a normal distal ACA. After reviewing the literature, we considered the proximal segment of this anomalous ACA to be a PPOA. To our knowledge, this is the first report of a patient with this anomalous ACA diagnosed with MR angiography.

Persistent trigeminal artery variants detected by MR angiography

Persistent trigeminal artery (PTA) variants are cerebellar arteries that originate directly from the precavernous portion of the internal carotid artery (ICA). The goal of our study was to determine the incidence and MR angiographic features of PTA variants. Between April 1996 and September 1999, 523 cranial MR angiographies were performed at our institution. Most of the patients examined had or were suspected of having cerebrovascular disease. We retrospectively reviewed these 523 MR angiograms. A 1.5-T scanner was used in all studies, and maximum intensity projection (MIP) images obtained using the three-dimensional time-of-flight (3D TOF) technique were displayed stereoscopically. Four PTA variants were detected on MR angiograms, at a rate of 0.76%. At least three of the four PTA variants were anterior inferior cerebellar arteries (AICAs), small tortuous arteries arising from the precavernous portions of the ICAs and taking a posterior course. Although the clinical significance is not great, we found a relatively high incidence of PTA variants on MR angiograms. We stress that knowledge and recognition of these anomalous cerebellar arteries are useful and important in the interpretation of cranial MR angiograms.

Basilar artery fenestrations detected by MR angiography

Basilar artery (BA) fenestrations are the most frequently observed fenestrations of the cerebral arteries. Our goal was to examine the magnetic resonance (MR) angiographic incidence, location, and characteristic configuration of BA fenestration. Between April 1996 and March 2000, 600 cranial MR angiographies were performed at our institution. The majority of the patients examined had or were suspected to have cerebrovascular disease. We retrospectively reviewed these 600 MR angiograms. A 1.5 Tesla scanner was used in all studies, and maximum intensity projection (MIP) images obtained using the three-dimensional time-of-flight (3D-TOF) technique were displayed stereoscopically. Ten BA fenestrations (1.7%) were detected on MR angiograms. In 87 cases from the early period, the vertebrobasilar (VB) junction was unfortunately not included in the imaging slices. Eight of the 10 fenestrations were located at the proximal BA: six of them were small with a slit-like shape, and two were relatively large with a convex-lens-like shape. A small fenestration was located at the distal BA, and the remaining one was a total duplication of the BA. We stress that knowledge and recognition of BA fenestration are useful and important in the interpretation of cranial MR angiography. Since saccular aneurysms are reported to arise frequently at BA fenestration, the VB junction should be included in the imaging slices of routine cranial MR angiography.

Cerebral hemiatrophy caused by multiple developmental venous anomalies involving nearly the entire cerebral hemisphere

The authors present a case of multiple developmental venous anomalies (DVAs) that involved nearly the entire cerebral hemisphere and that were diagnosed by magnetic resonance (MR) imaging and selective cerebral angiography. The ipsilateral cerebral hemisphere was mildly atrophic, and there were focal white matter lesions on the MR images. Angiography showed multiple DVAs involving nearly the entire right cerebral hemisphere. We suggest that longstanding venous congestion caused the atrophy and white matter lesions.

Cranial MR imaging of sequelae of prefrontal lobotomy

BACKGROUND AND PURPOSE

Although prefrontal lobotomy is an obsolete treatment for schizophrenia, we still encounter patients who have undergone this procedure. The purpose of this study was to describe the MR imaging findings of sequelae of prefrontal lobotomy.

METHODS

We retrospectively reviewed cranial MR images of eight patients with schizophrenia who underwent prefrontal lobotomy approximately 50 years previously.

RESULTS

In all patients, a bilateral cavitary lesion with a thick wall was found in the frontal white matter. The genu of the corpus callosum was mildly to markedly atrophic. The size and location of the cavity and the degree of callosal atrophy were correlated.

CONCLUSION

MR imaging is useful for the diagnosis of sequelae of prefrontal lobotomy, including cavitary lesions with dense walls of gliosis and secondary degeneration of the genu of the corpus callosum.

123I-IMP SPET in the diagnosis of primary central nervous system lymphoma

We reviewed N-isopropyl-p-[123I]iodoamphetamine (123I-IMP) single-photon emission tomography (SPET) images of brain tumours and assessed the usefulness of 123I-IMP SPET for the diagnosis of primary central nervous system (CNS) lymphoma. We analysed 52 tumours that showed enhancement on magnetic resonance imaging: 11 malignant lymphomas, 3 anaplastic astrocytomas, 17 glioblastomas, 12 meningiomas, 4 metastatic brain tumours and 5 other brain tumours. 123I-IMP uptake in the tumours on early (15-min) and delayed (4-h) scans was visually classified as high, moderate or low as compared with the contralateral brain cortex. Early and delayed 123I-IMP uptake ratios comparing tumours with contralateral brain cortex (T/N ratio) were also calculated. In malignant lymphomas, the visual uptake of 123I-IMP was moderate to high on the delayed scans. The delayed T/N ratios were significantly higher than the early ratios (P<0.05) and all lymphomas, with the exception of one small one, had delayed ratios greater than 0.9. In non-lymphomatous tumours, the visual uptake of 123I-IMP was low on the delayed scans. The delayed T/N ratios were significantly lower than the early ratios (P<0.01) and all non-lymphomatous tumours had delayed ratios of less than 0.8. The T/N ratios of lymphomas were significantly higher than those of non-lymphomatous tumours on both early and delayed scans (P<0.0001). These results suggest that 123I-IMP SPET may be a useful tool in the differential diagnosis of primary CNS lymphoma.

[Transsphenoidal surgery assisted by navigation system]

Microneurosurgical technique combined with precise localization of lesions, can minimize the invasiveness of neurosurgical procedures. This report describes the usefulness of the neuronavigation system in transsphenoidal surgery. Nineteen transsphenoidal operations for sellar lesions including pituitary adenoma, clival chordoma, Rathke's cleft cyst and suprasellar germinoma were assisted by the optical tracking system (OTS). Operations were performed either through the sublabial or the endonasal approach using an operative microscope and, to a certain extent, the endoscope. All five microadenomas were totally removed. The tumors could be precisely localized by the navigation system. Four out of seven macroadenomas were totally removed. The operations were assisted effectively by the excellent guidance to the lateral margin of the tumors and the internal carotid arteries provided by the navigation system. The endonasal approach, in which the surgeon looks through a nostril at the sellar floor obliquely, was especially facilitated by the three-dimensional view provided by the system. The navigation system, however, was not useful in estimating the amount of the suprasellar residual tumor because of the dislocation that occurred during the tumor removal.

Bronchial artery embolization for hemoptysis due to benign diseases: immediate and long-term results

PURPOSE

To clarify the immediate effect and long-term results of bronchial artery embolization (BAE) for hemoptysis due to benign diseases and the factors influencing the outcomes.

METHODS

One hundred and one patients (aged 34-89 years) received bronchial artery embolization with polyvinyl alcohol particles and gelatin sponge for massive or continuing moderate hemoptysis caused by benign pulmonary diseases and resistant to medical treatment.

RESULTS

After BAE, bleeding stopped in 94 patients (94%). The immediate effect was unfavorable in cases where feeder vessels were overlooked or the embolization of the intercostal arteries was insufficient. Long-term cumulative hemoptysis nonrecurrence rates after the initial embolization were 77.7% for 1 year and 62.5% for 5 years. In bronchitis (n = 9) and active tuberculosis (n = 4) groups, an excellent (100%) 5-year cumulative nonrecurrence rate was obtained. The rate was lower in groups with pneumonia/abscess/pyothorax (n = 8) or with pulmonary aspergillosis (n = 9) (53.3%, 1-year cumulative nonrecurrence). There were higher incidences of early recurrence among patients with massive hemorrhage or more marked vascularity and systemic artery-pulmonary artery shunt in angiography: however, these trends were not statistically significant

CONCLUSIONS

BAE can yield long-term benefit in patients with hemoptysis due to benign diseases. Technical problems in the procedure had an impact on the short-term effect. The degree of hemorrhage or the severity of angiographical findings were not significant factors affecting the outcome. The most significant factor affecting long-term results was whether the inflammation caused by the underlying disease was medically well controlled.

Middle cerebral artery variations detected by magnetic resonance angiography

Middle cerebral artery (MCA) variations are found incidentally on cranial magnetic resonance angiography (MRA). Our goal was to examine the incidence and types of MCA variations detected by MRA. Between April 1996 and March 1999, cranial MRA was performed in 432 cases at our institution. Most of the patients examined had or were suspected to have cerebrovascular disease. After excluding 7 patients with moyamoya disease, we retrospectively reviewed 425 MRA results. A 1.5-T scanner was used in all studies, and maximum-intensity projection images obtained using the three-dimensional time-of-flight technique were displayed stereoscopically. In the 425 patients MRA revealed 16 anomalous MCAs, including 9 duplicated MCAs, 5 accessory MCAs, and 2 fenestrated MCAs, which is a rate of 3.8%. Thus, although the clinical significance is not great, we found a relatively high incidence of anomalous MCAs on MRA. We stress that knowledge and recognition of these variations are useful and important during the interpretation of cranial MRA.

Uptake of orally administered polystyrene latex and poly(D,L-lactic/glycolic acid) microspheres into intestinal lymphoid tissues in chickens

Fluorescein-labeled microspheres were orally administered to chickens and their distribution in intestinal lymphoid tissues was investigated. Polystyrene latex microspheres were observed in Peyer's patches, and also in the Meckel's diverticulum and the jejunum. Their density, however, seemed to be lower than that in Peyer's patches. Microspheres were rarely observed in the other intestinal tissues examined, including the bursa of Fabricius. Of note is that, although microspheres were present in the lumen, few, if any, were observed in the lamina propria of the caecal tonsil and caecum. Polystyrene latex microspheres of diameter 2.0 microm or 4.5 microm were also observed in Peyer's patches, but their density seemed to be lower as compared with the 0.75 microm microspheres. Poly(D,L-lactic/glycolic acid) (PLGA) microspheres were prepared using PLGAs of various molecular weights (MW) and their uptake into Peyer's patches was compared. Microspheres prepared with PLGA of average MW of 20000 were not taken up into Peyer's patches, but those prepared with PLGA of average MW of 61000 or 99 800 were taken up into Peyer's patches.

Thallium-201 SPECT of adjacent intracranial tumours: a contrast in thallium kinetics

We report a case of adjacent intracranial tumours: malignant fibrous histiocytoma (MFH) and meningioma. Thallium-201 single-photon emission computed tomography demonstrated different thallium kinetics between the tumours (slow washout from the MFH and rapid clearance in the meningioma) and could be said to have been useful for preoperative histological estimation.

Decreased plasma tryptophan associated with deep white matter lesions in elderly subjects

The aim was to identify potentially treatable risk factors for cerebral white matter lesions often found on MRI in elderly persons. findings were assessed on 1.0 T MRI of 178 subjects living in the community and aged 60 years or older. Participants underwent standardised evaluations including standard questionnaires, a physical and neurological examination, cognitive function tests, electrocardiogram, a complete blood chemistry panel, and plasma amino acid measurements. Brain MRI infarcts, deep white matter lesions (DWMLs), and periventricular hyperintensities were found in 26%, 43%, and 29% of the 178 participants, respectively. Subjects with DWMLs were significantly older and had a higher frequency of hypertension, higher systolic blood pressure, and more brain infarcts, but lower plasma concentrations of tryptophan. In the multivariate model, greater age and lower plasma tryptophan concentrations were independently associated with DWMLs. Tryptophan concentrations were inversely related to DWML grading, whereas hypertension and brain infarction were more common in subjects with higher extents of DWMLs. The present study suggests that greater age and lower plasma tryptophan concentrations were important in producing DWMLs in elderly subjects.

Comparison of adjuvants with respect to serum IgG antibody response in orally immunized chickens

We have previously shown that oral immunization with non-replicating antigens hardly induced serum IgG antibody response in chickens and addition of sodium fluoride (NaF) to the immunogen markedly improved their immunological states. In the present study, taurine, lithium and Quillaja saponin (Q-SAP) were compared with NaF with respect to their enhancement of serum IgG antibody response in chickens after oral immunization. The antibody titer of chickens which received Q-SAP as the mucosal adjuvant tended to be higher than that of chickens which received antigen plus NaF. Simultaneous administration of antigen with lithium or taurine elicited a higher antibody titer in chickens compared to those of chickens orally immunized with antigen alone, but the effect of these two adjuvants was less efficient compared with that of NaF. These results suggested that Q-SAP as well as NaF is useful as an oral adjuvant for chickens.

Model-based surgical planning and simulation of cranial base surgery

Plastic skull models of seven individual patients were fabricated by stereolithography from three-dimensional data based on computed tomography bone images. Skull models were utilized for neurosurgical planning and simulation in the seven patients with cranial base lesions that were difficult to remove. Surgical approaches and areas of craniotomy were evaluated using the fabricated skull models. In preoperative simulations, hand-made models of the tumors, major vessels and nerves were placed in the skull models. Step-by-step simulation of surgical procedures was performed using actual surgical tools. The advantages of using skull models to plan and simulate cranial base surgery include a better understanding of anatomic relationships, preoperative evaluation of the proposed procedure, increased understanding by the patient and family, and improved educational experiences for residents and other medical staff. The disadvantages of using skull models include the time and cost of making the models. The skull models provide a more realistic tool that is easier to handle than computer-graphic images. Surgical simulation using models facilitates difficult cranial base surgery and may help reduce surgical complications.

Reversible symptomatic venous congestion after treatment of dural arteriovenous fistula using NBCA

We treated a 73-year-old man with a dural arteriovenous fistula (AVF) with cortical venous drainage of the left mastoid region using transarterial embolization of the middle meningeal and occipital arteries with n-butyl 2-cyanoacrylate (NBCA). The patient's clinical symptoms improved dramatically. Three months after the procedure, follow-up CT showed resolution of white matter edema and follow-up angiograms showed no evidence of a recurrent AVF. This report indicates that dural AVFs without sinus drainage can be cured solely with transarterial NBCA embolization.

Blood blisterlike aneurysms of the internal carotid artery

OBJECT

An aneurysm arising from the anterior wall of the internal carotid artery (ICA) is a poorly understood entity. A small hemispherical bulge from the anterior wall of the ICA, which is called a "blood blisterlike aneurysm" (BBA), may be confused with a tiny berry aneurysm although the clinical features are distinctly different. This paper summarizes the clinical course of patients with this lesion to clarify the nature of the BBA.

METHODS

Six patients with BBAs who presented with subarachnoid hemorrhage (SAH) are described. In all patients, the initial angiogram obtained soon after SAH showed only a small bulge from the anterior wall of the ICA. In three of the six patients this bulge had progressed to a saccular appearance within a few weeks. The wall of the lesion was so thin and fragile that the aneurysm ruptured at the base during clipping or within a few hours after clipping in two patients.

CONCLUSIONS

From the authors' experience, as well as a review of the literature, which includes an autopsy study of similar cases, it is inferred that these lesions are focal wall defects covered only with thin fibrous tissue and that they are therefore not true aneurysms. Direct clipping often causes laceration of the lesion, whereas complete wrapping or clipping after wrapping is effective, but may fail to prevent growth of the aneurysm. Endovascular occlusion of the cervical ICA with or without bypass surgery, which is less risky than direct surgery, is another option.

Cystic dilatation of ventriculus terminalis in adults: MRI

We report the MRI findings in two patients with cystic dilatation of the ventriculus terminalis. The latter is usually a tiny ependyma-lined cavity of the conus medullaris. In both cases the markedly dilated ventriculus terminalis was seen as a rounded cavity with regular margins, the content of which gave the same signal as cerebrospinal fluid with all MR pulse sequences. No contrast enhancement was seen.

Plain CT findings of brain death confirmed by hollow skull sign in brain perfusion SPECT

Computed tomographic (CT) findings of 13 patients manifesting brain death were reviewed. This diagnosis was confirmed by the so-called "hollow skull" pattern observed in brain perfusion single photon emission computed tomography (SPECT), which was performed between 4 hours before and 3 days after the CT scans, and by subsequent corporal death. The brain perfusion SPECT was performed with the intravenous administration of technetium (Tc)-99m-hexamethylpropyleneamine oxime (HMPAO) or iodine (I)-123-N-isopropyl-p-iodoamphetamine (IMP). CT scans showed diffuse cerebral edema and the loss of gray-white matter differentiation in all the cases, and transtentorial herniation in 12 patients. These CT findings were considered predictive of brain death.