Two Cases of Idiopathic Middle Meningeal Arteriovenous Fistula Initially Diagnosed by Magnetic Resonance Angiography

Reports of middle meningeal arteriovenous fistula (MMAVF) are relatively rare, and reports of idiopathic MMAVF are extremely rare. In the past, diagnoses of MMAVF have been confirmed by cerebral angiography, but magnetic resonance angiography (MRA) resolution is improving. Here, we report two cases of idiopathic MMAVF that were diagnosed by unreconstructed time-of-flight MRA (MRA-TOF) and successfully treated by trans-arterial embolisation with endovascular treatment. Both patients suffered from pulsatile tinnitus, and MRI was performed. Two dilated vessels were revealed in the middle temporal fossa by unreconstructed MRA-TOF imaging. These dilated vessels were thought to be the middle meningeal artery and middle meningeal vein; therefore, we diagnosed both patients with MMAVF. Following angiography, both patients had coil embolisation with endovascular treatment, and their conditions improved. In cases of idiopathic MMAVF without a history of trauma, brain surgery, or endovascular surgery, unreconstructed MRA-TOF may be useful as a primary diagnostic tool, and endovascular treatment before bleeding may produce better outcomes.

A Case of Metastatic Choriocarcinoma With Intracerebral Hemorrhage Caused by a Ruptured Pseudoaneurysm

A rare cause of cerebral hemorrhage is the metastasis of choriocarcinoma from gynecology. Herein, we report a case of a patient with brain metastasis of choriocarcinoma with cerebral hemorrhage. A 14-year-old female who had undergone surgery for a hydatidiform molar pregnancy presented with a disturbance of consciousness due to cerebral hemorrhage. Imaging studies revealed the presence of a cerebral aneurysm and several mass lesions in the lung field, and high serum beta-human chorionic gonadotropin level was confirmed. Thus, we suspected cerebral hemorrhage caused by brain metastasis of choriocarcinoma. She went into a coma, and an emergency craniotomy was performed to remove the hematoma and aneurysm. The pathology of the aneurysm was pseudoaneurysm due to the rupture of the vascular wall caused by increasing metastatic cells from choriocarcinoma in the cerebrovascular wall. Therefore, multidrug chemotherapy was immediately initiated. The choriocarcinoma, including the metastatic lesions, is in remission. To improve the outcome of choriocarcinoma, it must be diagnosed early, and treatment should be immediately started. Moreover, neurosurgeons should be aware of such diseases and consider them as one of the differential diagnoses, particularly in females of reproductive age with cerebral hemorrhage.

A Patient Who Underwent Mechanical Thrombectomy for Acute Occlusion of the Vertebral and Radial Arteries

Objective

We report a case of acute occlusion of the vertebral artery and radial artery. We performed mechanical thrombectomy for the radial artery following mechanical thrombectomy for the vertebral artery.

Case Presentation

A 73-year-old woman developed sudden-onset dizziness and dysesthesia of the left finger, and was taken to our hospital. Atrial fibrillation was observed. Image inspection revealed acute cerebral infarction of the left lateral medulla and left cerebellar hemisphere, and occlusion of the vertebral and radial arteries. Mechanical thrombectomy for the left vertebral artery occlusion was performed after intravenous recombinant tissue plasminogen activator (rt-PA), and then mechanical thrombectomy was performed for the left radial artery occlusion.

Conclusion

This case suggests that it is possible to guide the system to the radial artery and to perform thrombectomy using existing intracranial endovascular treatment devices.

Clinical Outcome of Patients With Large Vessel Occlusion and Low National Institutes of Health Stroke Scale Scores

Background and Purpose—

The treatment and prognosis of acute large vessel occlusion with mild symptoms have not been sufficiently studied. The present study aimed to investigate the clinical or radiological predictors of clinical outcome in patients with stroke with mild symptoms due to acute large vessel occlusion.

Methods—

Of 2420 patients with acute large vessel occlusion in the RESCUE-Japan Registry 2 (Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism-Japan Registry 2), a multicenter prospective registry in Japan, patients with modified Rankin Scale scores of 0 to 2 before onset and initial National Institutes of Health Stroke Scale (NIHSS) scores of 0 to 5 were examined in post hoc analysis. We examined the clinical and radiological characteristics associated with a favorable outcome (modified Rankin Scale score, 0–2 at 90 days) using multivariate analysis, as well as the factors associated with a favorable outcome in patients treated with endovascular therapy.

Results—

We analyzed 272 patients (median age, 73 years; median NIHSS score on admission, 3). Eighty-six (31.6%) patients were treated with intravenous recombinant tissue-type plasminogen activator, 54 (19.9%) underwent endovascular therapy, and 208 (76.5%) showed a favorable outcome. In multivariate analysis, age <75 years (odds ratio [OR], 2.42 [95% CI, 1.30–4.50]), initial NIHSS score 0 to 3 (OR, 3.08 [95% CI, 1.59–5.98]), intravenous recombinant tissue-type plasminogen activator (OR, 2. 86 [95% CI, 1.32–6.21]), and blood glucose level ≤140 mg/dL (OR, 2.37 [95% CI, 1.22–4.60]) were independently associated with a favorable outcome. However, endovascular therapy was not associated with a favorable outcome (OR, 1.65 [95% CI, 0.71–3.88]). Among 54 patients treated with endovascular therapy, good reperfusion status was more common in the favorable outcome group (88.6% versus 60.0%; P <0.05).

Conclusions—

Younger age, lower initial NIHSS score, intravenous recombinant tissue-type plasminogen activator, and absence of hyperglycemia were independently associated with a favorable outcome in patients with acute large vessel occlusion with low NIHSS scores.

Registration—

URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02419794.

A Patient with Subarachnoid Hemorrhage Related to a Ruptured Aneurysm in Week 8 of Pregnancy: Usefulness of Coil Embolization of Intracranial Aneurysms as a Treatment Option before Delivery

Object

We report a case of endovascular surgery for subarachnoid hemorrhage (SAH) that developed in early pregnancy.

Case Presentations

An 8-week pregnant 35-year-old female was admitted to our hospital with severe headache and loss of consciousness. Cephalic computed tomography (CT) revealed SAH (Hunt and Hess grade II). Digital subtraction angiography (DSA) demonstrated a 2.7 mm aneurysm at the right internal carotid artery-posterior communicating artery (IC-PC) bifurcation. We prioritized maternal treatment. Cerebral aneurysm coil embolization was performed on the 1st day under general anesthesia. During the operation, we tried to avoid irradiating the fetus by limiting the irradiation range and time. She was discharged on the 36th day of illness and gave birth to a 2532-g baby at 36 weeks of gestation.

Conclusion

If SAH develops in early pregnancy, it is necessary to prioritize maternal treatment. Endovascular surgery should be considered as a treatment option.

[Congenital Dermal Sinus with Dermoid Cyst Complicated by Brain Abscess: A Case Report]

Congenital dermal sinus(CDS)is a rare entity of spinal dysraphism, caused by the focal failure of disjunction leading to adhesion between the cutaneous and neural ectoderm. Some reports found that tumors, such as dermoid and epidermoid cysts, meningitis and subdural abscess are often complicated by CDS. A 1-year-old girl was referred to our department for CDS with a dermoid cyst complicated by brain and subdural abscesses. Diffusion weighted imaging and gadolinium-diethylenetriamine penta-aceticacid administration revealed ring-enhancing lesions, suggesting brain abscess, in the left temporal lobe, and subdural abscesses on the bilateral middle cranial bases. T1-and T2-weighted lumbar magnetic resonance imaging revealed CDS. With a preoperative diagnosis of CDS with brain and subdural abscesses, resection of CDS was performed after draining the brain abscess twice. The CDS extended into the spinal canal and it was completely exercised. We then performed sub-total resection of the dermoid cyst in the subdural space. Recent reports showed that dermoid cysts are related to CDS infection and deterioration of the infection, as seen in this case. Complication of dermoid cysts is an important consideration during CDS treatment. While the mechanism of the development of brain abscess in CDS patients has been unclear, this rare but important case revealed the mechanism to be the direct spread of inflammation via CDS.

Effect of Endovascular Therapy on Subsequent Decompressive Hemicraniectomy in Cardioembolic Ischemic Stroke with Proximal Intracranial Occlusion in the Anterior Circulation: Sub-Analysis of the RESCUE-Japan Registry 2

Background: Cardioembolic stroke is associated with a higher rate of functional limitation, which may be related to the larger ischemic lesion size. Endovascular therapy (EVT) for acute stroke caused by large vessel occlusion reduces severe disabilities. Objectives: We aimed to investigate the relationship between EVT and decompressive hemicraniectomy (DH) in patients with cardioembolic proximal intracranial occlusion in the anterior circulation (CPIOAC) using the data from the Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism (RESCUE)-Japan Registry 2. Methods: Among 2,420 patients in the RESCUE-Japan Registry 2, 555 patients aged 20–80 years with acute cardioembolic occlusion of the internal carotid artery and/or the first segment of the middle cerebral artery were included. The primary outcome was DH. Secondary outcomes were any type of intracranial hemorrhage, symptomatic intracranial hemorrhage indicating neurological worsening of >4 points on the National Institutes of Health Stroke Scale within 72 h after the onset of stroke, and recurrence of stroke or transient ischemic attack (TIA) within 90 days. Results: The median age was 73 years (66–77 years), and 360 patients (65%) were male. DH was performed in 1 of 374 patients in the EVT group and 5 of 181 patients in the no-EVT group (p = 0.032). The incidence of any type of intracranial hemorrhage and symptomatic intracranial hemorrhage within 72 h and recurrence of stroke or TIA within 90 days were similar between both groups. Conclusions: EVT may reduce DH in patients with CPIOAC without increasing intracranial hemorrhage.

Impact of Endovascular Therapy in Patients With Large Ischemic Core

Background and Purpose—

Endovascular therapy (EVT) is strongly recommended for acute cerebral large vessel occlusion with the Alberta Stroke Program Early CT Score (ASPECTS) ≥6 due to occlusion of the internal carotid artery or M1 segment of the middle cerebral artery. However, the effect of EVT for patients who have ischemic core with ASPECTS ≤5 (0–5) was not established. The purpose of this study was to elucidate the outcomes of EVT for patients with large ischemic core.

Methods—

Based on the data of The Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2, patients with internal carotid artery or M1 segment of the middle cerebral artery occlusion and pretreatment ASPECTS 0 to 5 on noncontrast CT or diffusion-weighted image were extracted, and the outcomes by EVT were analyzed. Primary end point was defined as a good functional outcome (modified Rankin Scale score of ≤2) after 90 days.

Result—

Among 2420 registered patients, 504 patients were with internal carotid artery or M1 segment of the middle cerebral artery occlusion and ASPECTS 0 to 5. Among these 504 patients, 172 (34.1 %) were treated with EVT (EVT group) and 332 (65.9 %) without (no-EVT group). In the no-EVT group, elderly patients, females, poor prestroke modified Rankin Scale, high National Institutes of Health Stroke Scale, low ASPECTS, and late admission were significantly more observed. Good functional outcomes were significantly more observed in the EVT group than in the no-EVT group (19.8 % versus 4.2 %; P <0.0001; adjusted odds ratio, 2.33; 95% CI, 1.10–4.94). The incidences of symptomatic intracranial hemorrhage within 72 hours did not significantly different between the EVT group and the no-EVT group (3.7 % versus 4.9%; P =0.55; adjusted odds ratio, 0.50; 95% CI, 0.14–1.73).

Conclusions—

Although outcomes in this group of patients were usually poor, the data suggested EVT may increase the likelihood of a good functional outcome.

Predicting ischemic stroke after carotid artery stenting based on proximal calcification and the jellyfish sign

OBJECTIVE Carotid artery stenting (CAS) has been considered to prevent ischemic strokes caused by stenosis of the cervical carotid artery. The most common complication of CAS is new cerebral infarction. The authors have previously reported that the jellyfish sign-the rise and fall of the mobile component of the carotid plaque surface detected by carotid ultrasonography-suggests thinning and rupture of the fibrous cap over the unstable plaque content, such as the lipid-rich necrotic core or internal plaque hemorrhage. The authors' aim in the present study was to evaluate the risk of a new ischemic lesion after CAS by using many risk factors including calcification (size and location) and the jellyfish sign. METHODS Eighty-six lesions (77 patients) were treated with CAS. The presence of ischemic stroke was determined using diffusion-weighted imaging (DWI). Risk factors included calcification of the plaque (classified into 5 groups for size and 3 groups for location) and the jellyfish sign, among others. Multiple linear regression analysis (stepwise analysis and partial least squares [PLS] analysis) was conducted, followed by a machine learning analysis using an artificial neural network (ANN) based on the log-linearized gaussian mixture network (LLGMN). The additive effects of the jellyfish sign and calcification on ischemic stroke after CAS were examined using the Kruskal-Wallis test, followed by the Steel-Dwass test. RESULTS The stepwise analysis selected the jellyfish sign, proximal calcification (proximal Ca), low-density lipoprotein (LDL) cholesterol, and patient age for the prediction model to predict new DWI lesions. The PLS analysis revealed the same top 3 variables (jellyfish sign, proximal Ca, and LDL cholesterol) according to the variable importance in projection scores. The ANN was then used, showing that these 3 variables remained. The accuracy of the ANN improved; areas under the receiver operating characteristic curves of the stepwise analysis, the PLS analysis, and the ANN were 0.719, 0.727, and 0.768, respectively. The combination of the jellyfish sign and proximal Ca indicates a significantly increased risk for ischemic stroke after CAS. CONCLUSIONS The jellyfish sign, proximal Ca, and LDL cholesterol were considered to be important predictors for new DWI lesions after CAS. These 3 factors can be easily determined during a standard clinical visit. Thus, these 3 variables-especially the jellyfish sign and proximal Ca-may be useful for reducing the ischemic stroke risk in patients with stenosis of the cervical carotid artery.

Somatosensory evoked potentials in carotid artery stenting: Effectiveness in ascertaining cerebral ischemic events

Somatosensory evoked potentials (SSEP) have been used in various endovascular procedures and carotid endarterectomy, but to our knowledge no literature deals exclusively with the utility of SSEP in carotid artery stenting (CAS). The purpose of this study was to evaluate the efficacy of SSEP in detecting cerebral ischemic events during CAS. We conducted a prospective study in 35 CAS procedures in 31 patients during an 18month period. Thirty-three patients without near occlusion underwent stenting using dual protection (simultaneous flow reversal and distal filter) combined with blood aspiration, while two patients with near occlusion underwent stenting without dual protection. All 35 patients underwent SSEP monitoring. SSEP were generated by stimulating median and/or tibial nerves and recorded by scalp electrodes. During the aspiration phase post-dilation, seven patients (20%) exhibited SSEP changes with a mean duration of 11.3±8.5minutes (range: 3-25minutes), three of whom later developed minor stroke/transient ischemic attack. Diffusion-weighted imaging showed new lesions in 10 patients (28.6%). Change in SSEP exhibited mean sensitivity of 100% (95% confidence interval, 0.29-1.0) and specificity of 88% (95% confidence interval, 0.71-0.96) in predicting clinical stroke post-CAS. Intra-procedural SSEP change was predictive of post-procedural complications (p=0.005, Fisher's exact test). Longer span of SSEP change was positively correlated with complications (p=0.032, Mann-Whitney test). Intra-procedural SSEP changes are highly sensitive in predicting neurological outcome following CAS. Chances of complications are increased with prolongation of such changes. SSEP allows for prompt intra-procedural ischemia prevention measures and stratification to pursue an aggressive peri-procedural protocol for high risk patients to mitigate neurological deficits.

Carotid artery stenting for vulnerable plaques on MR angiography and ultrasonography: utility of dual protection and blood aspiration method

Background

Carotid artery stenting (CAS) for internal carotid artery (ICA) stenosis with vulnerable plaques is controversial. We analyzed the effect of a dual protection and blood aspiration method during CAS in patients with vulnerable plaques.

Methods

A total of 111 patients with ICA stenosis underwent CAS using the dual protection (simultaneous flow reversal and distal filter) and blood aspiration method. In 103 of 111 patients, preoperative carotid plaque was estimated by both 3 T MRI and ultrasonography (US). ICA plaques with a high intensity signal on time-of-flight-MR angiography (TOF-MRA) and/or mobile component on US were defined as vulnerable plaques. We assessed major adverse events (MAE) (ie, major stroke, myocardial infarction, and death) and hyperintense spots on diffusion-weighted images (DWI) after CAS. We then evaluated the visible debris captured by dual protection and blood aspiration during CAS.

Results

The preoperative ICA plaque on TOF-MRA and US was judged to be vulnerable in 48.5% (50/103 patients). The success rate of the CAS procedure was 100% with no MAE within 30 days. DWI showed small hyperintense spots in 18% (9/50 patients) and 18.9% (10/53 patients) in the vulnerable and non-vulnerable plaque groups, respectively. Visible debris was captured in 68% (34/50 patients) and 45.3% (24/53 patients) in the vulnerable and non-vulnerable plaque groups, respectively (p=0.0286).

Conclusions

The combination of dual protection and blood aspiration could provide effective distal embolic protection although vulnerable plaques on TOF-MRA and US had a high incidence of debris during CAS. Thus, CAS using dual protection and blood aspiration is safe in patients with vulnerable plaques.

Endovascular Stenting under Cardiac and Cerebral Protection for Subclavian Steal after Coronary Artery Bypass Grafting Due to Right Subclavian Artery Origin Stenosis

Coronary-subclavian steal (CSS) can occur after coronary artery bypass grafting (CABG) using the internal thoracic artery (ITA). Subclavian artery (SA) stenosis proximal to the ITA graft causes CSS. We describe a technique for cardiac and cerebral protection during endovascular stenting for CSS due to right SA origin stenosis after CABG. A 64-year-old man with a history of CABG using the right ITA presented with exertional right arm claudication. Angiogram showed a CSS and retrograde blood flow in the right vertebral artery (VA) due to severe stenosis of the right SA origin. Endovascular treatment of the right SA stenosis was planned. For cardiac and cerebral protection, distal balloon protection by inflating a 5.2-F occlusion balloon catheter in the SA proximal to the origin of the right VA and ITA through the right brachial artery approach and distal filter protection of the right internal carotid artery (ICA) through the left femoral artery (FA) approach were performed. Endovascular stenting for SA stenosis from the right FA approach was performed under cardiac and cerebral protection by filter-protection of the ICA and balloon-protection of the VA and ITA. Successful treatment of SA severe stenosis was achieved with no complications.

Usefulness of dual protection combined with blood aspiration for distal embolic protection during carotid artery stenting

BACKGROUND

We describe dual protection (simultaneous flow reversal and distal filter) combined with blood aspiration as a novel technique to provide distal embolic protection during carotid artery stenting (CAS).

METHODS

Between July 2011 and August 2014, 190 patients with internal carotid artery (ICA) stenosis underwent 190 CAS procedures as follows. After post-dilation of the stent using dual protection, the aspiration catheter was placed between the distal filter and the proximal end of the stent, and the blood was aspirated several times from the ICA. We assessed hyper-intensity spots in diffusion-weighted images (DWI), and major adverse events (MAE) defined as major stroke, myocardial infarction and death after CAS. We then assessed visible debris captured in aspirated blood, the distal filter and a blood filter during flow reversal.

RESULTS

The overall technical success rate was 100 %, and all stenoses were dilated. Hyper-intense spots were found in 33 (17.3 %) of 190 DWI. The rate of MAE within 30 days was 1.05 % (2/190). Visible debris in 175 of 190 CAS procedures was captured in 92 (52.5 %) of these 175. In 25 (27.2 %) of these 92, visible debris was captured in all of aspirated blood, the distal filter and the blood filter during flow reversal, only the blood filter during flow reversal (n = 19; 20.7 %), only the distal filter (n = 14; 15.2 %), only aspirated blood (n = 11; 12 %), aspirated blood and the blood filter during flow reversal (n = 10; 10.8 %), aspirated blood and the distal filter (n = 7; 7.6 %) and the distal filter and blood filter during flow reversal (n = 6; 6.5 %).

CONCLUSIONS

Adding a distal filter and blood aspiration to flow reversal during CAS could provide effective distal embolic protection.

[Selective coil embolization of a distal anterior choroidal artery aneurysm associated with moyamoya disease: a case report]

Intracranial hemorrhage in patients with moyamoya disease is often caused by rupture of the associated aneurysms. Of these aneurysms, distal anterior choroidal artery (AChoA) aneurysms are rare. In patients with moyamoya disease, the AChoA constitutes collateral vessels and the aneurysm requires careful treatment strategy. However, reported cases of distal AChoA aneurysms include various procedures including conservative therapy, direct surgery, and endovascular therapy. Herein, we report a case of coil embolization of a distal AChoA aneurysm associated with moyamoya disease and discuss the treatment strategy. A 39-year-old female presented with severe headache and subsequent deep coma. Computed tomography (CT) revealed thick intraventricular hemorrhage, and three-dimensional CT angiography revealed a right distal AChoA aneurysm. Bilateral ventricular drainage was performed and subsequent ventriculoperitoneal (VP)shunt was performed. The persisting distal AChoA aneurysm was coil embolized without any complication. Rebleeding did not occur during the 1-year follow-up period. Endovascular treatment is effective for distal AChoA aneurysms associated with moyamoya disease to preserve collateral circulation.

Electrocorticographic-histopathologic correlations implying epileptogenicity of dysembryoplastic neuroepithelial tumor

Based on intracranial-video electroencephalography (EEG), histopathological features, and postoperative seizure outcome, we elucidated the epileptogenicity in patients with dysembryoplastic neuroepithelial tumor (DNT). Five patients (P1–P5) pathologically diagnosed with DNT underwent intracranial-video EEG to identify the ictal onset zone and irritative zone. We evaluated the correlations of ictal onset zone and irritative zone with the magnetic resonance imaging-visible lesion (MRI-lesion) and their histopatho-logical features. Intracranial-video EEG located the ictal onset zone adjacent to the MRI-lesion margin in four patients with complex/simple forms of DNT subcategory, and on the MRI-lesion in P3 with a nonspecific DNT form. The irritative zone extended to surrounding regions of the ictal onset zone in all patients. Histopathologically, MRI-lesions were characterized by specific glioneuronal elements, whereas the ictal onset zone and irritative zone were represented with dysplastic cortex accompanying oligodendroglia-like cells in four (P1, P2, P4, and P5) of five patients. Cortical dysplasia was identified with typical histopathologic features in the irritative zone remote from the MRI-lesion in P5. P3, with a nonspecific form, indicated prominent component of dysplastic cortex with oligodendroglia-like cells scattered in the MRI-lesion. Lesionectomy of MRI-lesion with additional cortical resections (including the ictal onset zone and irritative zone) yielded postoperative seizure freedom (Engel Class I) in P3, P4, and P5, while P1 and P2 (with only lesionectomy) experienced postoperative residual seizure (Class II and III in each patient). Our results suggest the intrinsic epileptogenicity of DNT. The topographical correlation indicated that the dysplastic cortex accompanying oligodendroglia-like cells was more epileptogenic than the specific glioneuronal elements itself. Meticulous intracranial-video EEG analysis delineating the MRI nonvisible ictal onset zone and the irritative zone may yield better seizure outcome.

[A case of posterior reversible encephalopathy syndrome associated with coil embolization of a basilar apex aneurysm]

About three weeks after successful coil embolization of a basilar apex aneurysm, a 66-year-old woman developed occipital headaches. T2 and FLAIR MRI brain images demonstrated multiple new hyperintense lesions in the posterior circulation territory including cerebellum, right superior cerebellar peduncle, left thalamus and bilateral temporo-occipital lobes and she was subsequently hospitalized. Findings suggestive of other underlying disease were not observed, although an increased protein level was noted in cerebrospinal fluid (69 mg/dl). Headache and clinical findings improved approximately 12 weeks after coil embolization. MRI findings also showed improvement. These clinical and radiological findings made this patient a distinctive case of posterior reversible encephalopathy syndrome (PRES) associated with coil embolization suggesting that clinicians should be aware that PRES can present as comparatively mild symptoms several weeks after coil embolization.

Carotid artery stenting using the proximal or dual protection method for near occlusion of the cervical internal carotid artery

The treatment for patients with near occlusion of the cervical internal carotid artery (ICA) is controversial. The aim of this study was to examine the results of carotid artery stenting (CAS) as a surgical treatment for ICA near occlusion. Between April 2008 and September 2012, 14 patients (all men; mean age, 75.4 years) with ICA near occlusion were treated with CAS. This represents 5.2% of a total of 267 patients treated with CAS during the study period. All patients were treated with CAS using an embolic protection device. The proximal balloon protection method was performed in five patients, and the dual protection method using a proximal balloon and distal filter protection was used in nine patients. We examined the change of stenotic lesion, hyperintensity spot in diffusion-weighted imaging (DWI), and perioperative complications after CAS. All near occlusions were successfully dilated. Among 2 of 14 patients, DWI showed 1 and 4 hyperintensity spots. Transient and persistent complications, including neurological deficits, did not occur in any patients. In this small number of cases, CAS using the proximal or dual embolic protection method seems to be a safe and beneficial treatment for ICA near occlusion.

Endovascular stenting of symptomatic innominate artery stenosis under distal balloon protection of the internal carotid and vertebral artery for cerebral protection: a technical case report

The use of cerebral protection devices in endovascular treatment for innominate artery (IA) stenosis is not well established. We describe a novel technique for cerebral protection during endovascular stenting of symptomatic IA stenosis. An 82-year-old man presented with acutely scattered brain infarction by artery-to-artery embolism due to IA stenosis. Endovascular treatment for symptomatic IA stenosis was planned to prevent recurrent attacks. Endovascular stenting for IA stenosis via the right femoral artery approach was performed under simultaneous distal balloon protection of the right internal carotid artery (ICA) and vertebral artery (VA) via the right brachial artery approach. Successful treatment of symptomatic IA stenosis was achieved with no complications. The technique with simultaneous distal balloon protection of the ICA and VA provided excellent cerebral protection in stenting of IA stenosis.

Multiple antiplatelet therapy contributes to the reversible high signal spots on diffusion-weighted imaging in elective coiling of unruptured cerebral aneurysm

INTRODUCTION

Our aim was to systematically investigate radiographic characteristics and outcome of diffusion-weighted imaging (DWI) changes in the elective coiling of unruptured cerebral aneurysm with analyzing the correlation of antiplatelet therapy (APT).

METHODS

In a total of 34 consecutive patients with unruptured cerebral aneurysms initially treated by coiling without stent assist, 26 (76.5%) had DWI changes with 91 high signal spots within 24-48 h after the procedure. We recorded DWI parameters (location, volume, mean, and minimum values of the apparent diffusion coefficient: expressed as ADCAVE and ADCMIN) for each lesion, and evaluated its radiographic outcome on conventional MRI at follow-up (interval, 58.4 ± 37.2 days) in the modes of APT.

RESULTS

All patients with DWI high spots had no clinical symptoms. There was a strong correlation between ADCAVE and ADCMIN (r = 0.82, p < 0.0001). The mean ADCAVE and rADCAVE were 0.74 ± 0.14 × 10(-3) mm(2)/s and 87 ± 10 %. DWI high spots were small with a mean volume of 0.13 ± 0.12 cm(3), ranging from 0.04 to 0.86 cm(3). A negative correlation was observed between the volume and values of ADCAVE (r = -0.48, p < 0.0001). The DWI volume was significantly larger in single APT than in multiple (0.15 ± 0.14 versus 0.10 ± 0.07 cm(3), p = 0.0091). The permanent signal change was more observed in single APT than in multiple (24.5% versus 5.2%, p = 0.02).

CONCLUSION

DWI high spots after elective coiling were small without significant decrease of ADC, and do not correspond to brain infarction. Periprocedural use of multiple antiplatelet agents is expected to reduce the volume of thromboembolism and permanent tissue damages.

Arterial spin-labeling imaging at 3-T in dural arteriovenous fistulas of cavernous sinus before and after endovascular treatment

A 72-year-old man presented with chemosis and ophthalmoplegia due to dural arteriovenous fistulas (DAVF) of the cavernous sinus (CS). Preoperative arterial spin-labeling (ASL) image showed visible vein in the bilateral superior ophthalmic vein (SOV). Endovascular transvenous embolization of the shunting points of the CS-DAVF was performed, and the postoperative angiogram showed complete obliteration of the CS-DAVF. Postoperative ASL showed no visible vein in the bilateral SOV. ASL in CS-DAVF was proved to have shown retrograde venous drainage from the CS-DAVF by comparing ASL before and after treatment.

Y-configured double stent-assisted coil embolization with double microcatheter technique for complex basilar bifurcation aneurysm

Y-configured double stent technique is useful for coil embolization of a bifurcation wide neck aneurysm while preserving the patency of the two important vessels. However, if the important vessels emanating directly from the aneurysm comprised four vessels, two vessels not deployed, Y-stents might not be preserved with the Y-stent technique by itself. We report a case treated with Y-configured double stent-assisted coil embolization with a double microcatheter technique for complex basilar bifurcation aneurysm. A 78-year-old woman presented with a subarachnoid hemorrhage (SAH) of poor grade. CT-angiography showed a wide neck and shallow aneurysm of complex basilar bifurcation involving both posterior cerebral arteries (PCAs) and superior cerebellar arteries (SCAs). In the chronic stage of SAH, Y-configured double stent-assisted coil embolization with a double microcatheter technique was performed. After Y-stent (two Enterprise) deployment from both the PCAs to the basilar artery, coil embolization of a basilar bifurcation aneurysm was performed using a double microcatheter technique to preserve both SCAs.

Successful treatment of mesial temporal lobe epilepsy with bilateral hippocampal atrophy and false temporal scalp ictal onset: a case report

Patients with bilateral hippocampal atrophy (BHA) in a subgroup suffering from mesial temporal lobe epilepsy represent a therapeutic challenge. We achieved successful surgical treatment in a case with BHA and false lateralized ictal onset on video-scalp electroencephalogram (EEG). A 27-year-old male patient with seizures since the age of 15 years showed current seizures consisting of an epigastric aura, a feeling of difficulty in breathing and oroalimentary automatism, which were frequently followed by secondary generalization with right-arm tonic extension. MRI showed BHA with hyperintensity on FLAIR and a slightly smaller volume in the left hippocampus on volumetry. Ictal EEG started from the left anterior temporal and subtemporal regions, spreading to the right anterior to middle temporal region. Interictal EEG was not lateralized, and showed independent spikes in the bilateral anterior temporal and subtemporal regions. The patient underwent chronic intracranial EEG-monitoring, revealing that the seizure onset originated from the right hippocampus with a rapid spread to the hippocampus and lateral temporal cortex on the left side. We performed a right anterior temporal lobectomy with amygdalohippocampectomy. Histological diagnosis was classic hippocampal sclerosis. The patient has since been seizure-free for 4 years. In this case, false lateralization may have been caused by an atypical seizure-propagating route to the contralateral temporal region via the dorsal hippocampal commissure instead of the usual pathway to the ipsilateral temporal neocortex. The technique of bilateral intracranial EEG-monitoring is advantageous to lateralize the actual side, particularly in BHA patients even with clearly and falsely lateralized ictal onset on scalp-EEG.

Modulation of abnormal synaptic transmission in hippocampal CA3 neurons of spontaneously epileptic rats (SERs) by levetiracetam

Levetiracetam (LEV) inhibits partial refractory epilepsy in human, and both convulsive and absence-like seizures in the spontaneously epileptic rat (SER). Two-thirds of hippocampal CA3 neurons in SER show a long-lasting depolarization shift, with accompanying repetitive firing upon mossy fiber stimulation. This abnormal excitability is probably attributable to abnormalities in the L-type Ca(2+) channels. We performed electrophysiological studies to elucidate the mechanism underlying the antiepileptic effects of LEV via intracellular recording from the hippocampal CA3 neurons in slice preparations of SER and non-epileptic Wistar rats. LEV (100 μM) inhibited the depolarization shift with repetitive firing by mossy fiber stimulation (MFS), without affecting the first spike in SER CA3 neurons. At a higher dose (1mM), LEV suppressed the first spike in all SER neurons (including the CA3 neurons which showed only a single action potential by MFS), while the single action potential of Wistar rat CA3 neurons remained unaffected. SER CA3 neurons with MFS-induced abnormal firing exhibited a higher number of repetitive spikes when a depolarization pulse was applied in the SER CA3 neurons. LEV (100 μM, 1mM) reduced the repetitive firing induced by a depolarization pulse applied without affecting Ca(2+) spike in SER neurons. LEV is known not to bind glutamate and gamma-aminobutyric acid (GABA) receptors. These findings suggest that the therapeutic concentration of LEV inhibits abnormal firing of the CA3 neurons by modulating abnormal synaptic transmission and abnormal Na(+) channels in SER.

Endovascular coil embolization for ruptured kissing aneurysms associated with A1 fenestration

Background:

Fenestration of intracranial arteries is a rare anomaly, and is frequently associated with cerebral aneurysms. In this paper, we report rare kissing aneurysms associated with A1 fenestration.

Case Description:

A 71-year-old woman presented with subarachnoid hemorrhage. Diagnostic digital subtraction angiography revealed two saccular aneurysms at the proximal junction of a fenestration and posterior aspect of the fenestration that appeared to be ‘kissing’ each other. Emergent endovascular coil embolization was performed.

Conclusion:

Kissing aneurysms associated with fenestration of the horizontal segment in the anterior cerebral artery are rare, and have not been reported. During treatment of such specific types of aneurysms by endovascular treatment, three-dimensional rotational digital subtraction angiography was very useful for deciding the appropriate working angles.

Late recurrence of intractable epilepsy associated with MRI-occult pilocytic astrocytoma in the temporal lobe nine years after initial removal: a case report with surgical and late-seizure recurrence observations

A 28-year-old male who presented a relapse of intractable epilepsy consisting of complex partial seizures with occasional secondary generalizations at the age of 26, had undergone removal of a left mesial temporal lobe tumor at another hospital at 18 years old. Pathological examination at that time revealed a low-grade astrocytoma, and the tumor was further treated by complementary adjuvant irradiation therapy. Magnetic resonance imaging (MRI) findings on admission portrayed a post-operative cavity anterior to the atrophied hippocampus on the left side with hyperintense in fluid-attenuated inversion recovery (FLAIR) images. There were no enhanced lesions in T1-weighted gadolinium images. As it was diagnosed as left mesial temporal lobe epilepsy with preoperative evaluations, the patient underwent left anterior temporal lobe resection (TLR). Intraoperative findings revealed that a small lump of grey tissue was attached to the anteromesial side of the sclerotic hippocampus. We surgically removed this and the tissue was a pilocytic astrocytoma. The patient has since remained seizure-free for 2.5 years. Seizure outcomes at postoperative 1-2 years are highly predictive of long-term outcomes after TLR for temporal lobe epilepsy (TLE). Late-seizure recurrence (> postoperative 2 years) with an initially successful outcome rarely occurs in TLR patients. This case report suggests that recurrence of even benign pilocytic astrocytomas may occur when seizure recurs in long-term follow-up.

Endovascular coil embolization for ruptured aneurysm associated with persistent primitive anterior choroidal artery--case report

An 18-year-old man presented with a rare case of a ruptured internal carotid artery (ICA)-persistent primitive anterior choroidal artery (PPAchA) manifesting as sudden onset of headache. Computed tomography (CT) showed subarachnoid hemorrhage. Three-dimensional CT angiography showed a saccular aneurysm at the right ICA-AchA region. Right internal carotid angiography showed a PPAchA and saccular aneurysm. Endovascular treatment of the aneurysm achieved complete aneurysm occlusion.

Feasibility of extended-coverage perfusion and dynamic computer tomography (CT) angiography using toggling-table technique on 64-slice CT

PURPOSE

The major drawbacks of brain computed tomography (CT) perfusion are limited coverage in the z-axis, radiation exposure and the use of contrast medium, all of which increase when CT angiography (CTA) is performed with double acquisitions. The purpose of this study was to investigate the feasibility of the 'toggling-table' technique using a 40-mm detector.

MATERIALS AND METHODS

The clinical usefulness of CT perfusion and 4D-CTA (time-resolved 3D-CTA), as well as the time taken and radiation exposure, were assessed in 14 non-ischemic patients clinically indicated for CT perfusion and CTA.

RESULTS

A perfusion map and 4D-CTA was successfully achieved in all patients. The total time needed for scanning and processing was approximately 30 min per examination. The 80-mm CT perfusion coverage and 4D-CTA images were advantageous for analyses of the anatomy and widely distributed lesions. The estimated effective radiation dose was 2.22 mSv, and the amount of contrast media was 40 mL.

CONCLUSION

The 'toggling-table' technique acts as a 'one-stop-shop' protocol for perfusion mapping and 4D-CTA over a wide area, following a single contrast injection and scan.

Intracranial Aneurysm with Systemic Lupus Erythematosus Treated by Endovascular Intervention

Systemic lupus erythematosus (SLE) is a chronic disease with multiple pathologies that can affect every organ system of the body including central nervous system. Intracerebral aneurysms and subarachnoid hemorrhage (SAH) are one of comparatively rarer manifestations of central nervous system SLE. Here we present a case of known SLE complicated by the rupture of intra cerebral aneurysm at basilar artery tip which was successfully treated with endovascular coiling. Keywords: cerebral aneurysm, endovascular surgery, SAH, SLE

Cerebral angiography using gadolinium as an alternative contrast medium in a patient with severe allergy to iodinated contrast medium

We report cerebral digital subtraction angiography (DSA) using Gadolinium in a patient allergic to iodinated contrast media. A 77-year-old woman was admitted to our hospital for surgical resection of a brain tumor. Although a DSA was requested as a preoperative examination, the patient had a history of allergic reaction to non-ionic iodinated contrast medium. Therefore, DSA was performed using Gadolinium. The DSA showed no tumor stain and normal venous drainage. The patient underwent surgical resection of the tumor and was discharged with no new neurological deficit. DSA using Gadolinium was useful in a patient with an anaphylactic reaction to iodinated contrast media.

Intracranial aneurysm with systemic lupus erythematosus treated by endovascular intervention

Systemic lupus erythematosus (SLE) is a chronic disease with multiple pathologies that can affect every organ system of the body including central nervous system. Intracerebral aneurysms and subarachnoid hemorrhage (SAH) are one of comparatively rarer manifestations of central nervous system SLE. Here we present a case of known SLE complicated by the rupture of intra cerebral aneurysm at basilar artery tip which was successfully treated with endovascular coiling.

Traumatic anterior communicating artery pseudoaneurysm with cavernous sinus fistula

A traumatic carotid-cavernous fistula and an intracranial pseudoaneurysm are uncommon but well-known complications of head trauma. A rare subtype of arteriovenous fistula may occur from a pseudoaneurysm of the anterior communicating artery (AcoA) instead of the internal carotid artery. We describe a patient with a traumatic pseudoaneurysm of the AcoA with a cavernous sinus fistula treated with endovascular treatment. A 68-year-old man presented with a severe head injury after a fall. Coronal view multiplanar reformatted images with contrast medium showed gradual expansion of the pseudoaneurysm of the AcoA and the enhanced area of the cavernous sinus. Five weeks after the injury, the patient had a subarachnoid hemorrhage. A cerebral angiogram showed a fistula between the pseudoaneurysm of the AcoA and the cavernous sinus. The AcoA, left anterior cerebral artery and part of the pseudoaneurysm were obliterated by coil embolization. A postoperative angiogram showed no flow through the pseudoaneurysm and the cavernous sinus fistula. A traumatic AcoA pseudoaneurysm with a cavernous sinus fistula may occur as an extremely rare complication of head injury.

Ruptured vertebral artery dissecting aneurysms treated with endovascular treatment

Intracranial vertebral artery (VA) dissecting aneurysms often present with severe subarachnoid hemorrhage (SAH) and a subsequent high rate of mortality. We retrospectively studied the treatment efficacy and outcomes of 26 patients with ruptured VA dissecting aneurysms treated with endovascular surgery. Twenty-six patients with ruptured VA dissecting aneurysms were enrolled. Fifteen patients presented with poor-grade SAH and eleven with good-grade SAH. All patients were treated with endovascular treatment. We reviewed modes of therapy, complications and clinical outcomes. Coil occlusion of the artery at the dissecting aneurysm was performed in 24 patients. Proximal parent artery occlusion was performed in 2 patients. Obliteration of the dissecting aneurysm on postoperative angiogram was found in all patients. No patient sustained permanent complications associated with endovascular treatment. Regarding clinical outcome, although five patients died due to severe SAH, 19 patients had a good recovery or moderate disability. Ruptured VA dissecting aneurysms can be managed safely with coil occlusion of the lesion and/or parent artery.

Ruptured subclavian artery pseudo-aneurysm associated with Neurofibromatosis type 1

OBJECTIVE

A subclavian artery aneurysm associated with Neurofibromatosis type 1 (NF 1) is extremely rare. We report a ruptured pseudo-aneurysm of the subclavian artery in a patient with NF 1 treated with endovascular surgery.

CLINICAL DESCRIPTION

A 51 year old man with NF 1 presented with initially sudden left neck pain and continuous dysphagia. Radiological examination showed a pseudo-aneurysm of the left subclavian artery. Endovascular stenting and coil embolisation was performed to prevent rebleeding and the lesion was completely obliterated. Follow-up angiography at 3 months revealed good flow through the stent without flow into the pseudo-aneurysm.

CONCLUSION

Our patient is the first reported example of successful endovascular treatment for a ruptured subclavian artery pseudo-aneurysm associated with NF 1. Endovascular stenting and coil embolisation for the ruptured subclavian artery pseudo-aneurysm was very effective.

Posterolateral protrusion of the vertebral artery over the posterior arch of the atlas: quantitative anatomical study using three-dimensional computed tomography angiography

Object

The vertebral artery (VA) often takes a protrusive course posterolaterally over the posterior arch of the atlas. In this study, the authors attempted to quantify this posterolateral protrusion of the VA.

Methods

Three-dimensional CT angiography images obtained for various cranial or cervical diseases in 140 patients were reviewed and evaluated. Seven patients were excluded for various reasons. To quantify the protrusive course of the VA, the diameter of the VA and 4 parameters were measured in images of the C1–VA complex obtained in the remaining 133 patients. The authors also checked for anomalies and anatomical variations.

Results

When there was no dominant side, mean distances from the most protrusive part of the VA to the posterior arch of the atlas were 6.73 ± 2.35 mm (right) and 6.8 ± 2.15 mm (left). When the left side of the VA was dominant, the distance on the left side (8.46 ± 2.00 mm) was significantly larger than that of the right side (6.64 ± 2.0 mm). When compared by age group (≤ 30 years, 31–60 years, and ≥ 61 years), there were no significant differences in the extent of the protrusion. When there was no dominant side, the mean distances from the most protrusive part of the VA to the midline were 30.73 ± 2.51 mm (right side) and 30.79 ± 2.47 mm (left side). When the left side of the VA was dominant, the distance on the left side (32.68 ± 2.03 mm) was significantly larger than that on the right side (29.87 ± 2.53 mm). The distance from the midline to the intersection of the VA and inner cortex of the posterior arch of the atlas was ~ 12 mm, irrespective of the side of VA dominance. The distance from the midline to the intersection of the VA and outer cortex of the posterior arch was ~ 20 mm on both sides. Anatomical variations and anomalies were found as follows: bony bridge formation over the groove for the VA on the posterior arch of C-1 (9.3%), an extracranial origin of the posterior inferior cerebellar artery (8.2%), and a VA passing beneath the posterior arch of the atlas (1.8%).

Conclusions

There may be significant variation in the location and branches of the VA that may place the vessel at risk during surgical intervention. If concern is noted about the vulnerability of the VA or its branches during surgery, preoperative evaluation by CT angiography should be considered.

Multiple concurrent anastomotic procedures in the management of moyamoya disease: a case report with review of literature

It has already been proved by many studies that surgical revascularization definitely helps in curing the symptoms of moyamoya vasculopathy. In this regard, we present a case of moyamoya disease which was cured by concurrent multiple anastomotic procedures, namely superficial temporal artery (STA), middle cerebral artery (MCA) anastomosis, encephalomyosynangiosis (EMS) and encephalogaleosynangiosis (EGS). A 24-year-old woman presented with symptoms of cerebral ischemia. Thorough investigation with MRA and MRI revealed moyamoya vasculopathy and was confirmed by cerebral angiogram. Multiple concurrent combined anastomotic procedures on both sides relieved the symptoms, which was also confirmed angiographically. A Combination of multiple direct and indirect procedures covers the whole ischemic cortical area and provides effective neovascularization.

Transient headache related to enlargement of the contralateral vertebral artery after vertebral artery occlusion

BACKGROUND

Endovascular proximal parent artery occlusion has been performed for VA dissection. We describe a case that presented with headache associated with transient enlargement of contralateral VA after VA occlusion.

CASE DESCRIPTION

A 54-year-old man presented with constant occipital headache on the left due to left VA dissection. Proximal parent artery occlusion of the left VA with detachable coils was performed, and the headache disappeared after coil occlusion. However, the patient presented with occipital headache on the right 1 week later. The MRI showed enlargement of the right VA compared with before the procedure. Four weeks later, the right occipital headache disappeared, and MRI showed improvement of enlargement of the right VA.

CONCLUSION

The patient might present with right occipital headache related to transient enlargement of contralateral VA after VA occlusion. Careful postoperative neuroradiological examination of the contralateral VA is required because contralateral VA enlargement may be caused by hemodynamic stress after VA occlusion.

Angiographic neovascularization after bypass surgery in moyamoya disease: our experience at Hiroshima University Hospital

In this study, we investigated the effect of different bypass procedures on postoperative neovascularization in patients with moyamoya disease at Hiroshima University Hospital. Fourteen cerebral hemispheres of seven patients with moyamoya disease were investigated. Five of the 14 hemispheres underwent direct bypass surgery and the remaining 9 underwent indirect bypass. The neovascularization after bypass surgery was evaluated by cerebral angiography. The extent of angiographic neovascularization after direct or indirect bypass surgery was graded as good, fair or poor. Postoperative neovascularization status (good, fair or poor) was compared with the bypass procedure (direct and indirect bypass). Good neovascularization was observed in 8 hemispheres and the remaining 6 had poor neovascularization. Direct bypass surgery was significantly more effective for angiographic neovascularization than the indirect procedure in moyamoya patients (chi2-test, p<0.05). Therefore, we concluded that the direct bypass procedure is a better choice for moyamoya disease as evidenced by angiographic neovascularization.

Expression of vascular endothelial growth factor in dura mater of patients with moyamoya disease

Vascular endothelial growth factor (VEGF) has been found to be involved in vasculogenesis in different intracranial lesions. We investigated meningeal cellularity and VEGF expression in dura mater of patients with and without moyamoya disease. Nine dural specimens from nine cerebral hemispheres of seven patients with moyamoya disease and four control dural specimens from four non-moyamoya patients were collected during surgery and investigated. Dural specimens were immunohistochemically stained with VEGF antibody, and then meningeal cellularity and VEGF expression in dural tissue were analyzed. The mean+/-standard error (SE) of total number of meningeal cells (meningeal cellularity) in dural tissue was 21.5+/-3.0 in the moyamoya disease patients, whereas it was 2.7+/-0.7 in control patients. The mean+/-SE of VEGF expression was 51.1+/-4.9% in the moyamoya disease patients, whereas it was 13.8+/-5.9% in control patients. The meningeal cellularity and VEGF expression were statistically significantly higher in the moyamoya group in comparison to control group (p<0.0001). Meningeal cellularity and VEGF expression are significantly increased in dura mater of the patients with moyamoya disease.

Multi-detector-row CT angiography as a preoperative evaluation for spinal arteriovenous fistulae

The role of multi-detector-row computed tomographic angiography (MDCTA) in spinal vascular malformations has not yet been determined. We present a report on a short series of spinal arteriovenous fistulae (AVF) evaluated by MDCTA. With 4-row and 16-row MDCTA, three cases of spinal dural AVF and one case of perimedullary AVF were examined. Each case was also examined by magnetic resonance (MR) imaging and spinal catheter angiography. In two patients with spinal dural AVF, including one patient with angiographically occult AVF, MDCTA successfully located the site of the AVF in a multi-planar reformation image. MDCTA failed to locate the remaining case of spinal dural AVF, probably due to the small amount of shunting blood volume at the fistula. In a patient with perimedullary AVF, MDCTA visualized the broad range of the lesion, including the anterior spinal artery as a single feeder, the fistulous point, and the single perimedullary draining vein. In conclusion, although conventional spinal angiography might be still essential, MDCTA provides useful information for the surgeon in treatment of the spinal dural AVF. Further accumulation of clinical cases is required to determine the potential of MDCTA for perimedullary AVF. MDCTA should be considered as a choice of investigation in the evaluation of spinal AVFs.

Transfemoral transvenous embolization of dural arteriovenous fistulas involving the isolated transverse-sigmoid sinus

SUMMARY

Dural arteriovenous fistulas involving the transverse-sigmoid sinus (T-S dAVFs) are sometimes isolated because this affected sinus is often thrombosed. It is difficult to perform to microcatheter cannulation to the isolated sinus through the thrombosed portion. We are now treating these T-S dAVFs by transfemoral transvenous embolization via the ipsilateral side even if the affected sinus is thrombosed and isolated or not. We use a triaxial system (6Fr. guiding catheter / 4Fr. diagnostic catheter / microcatheter) to emphasize the pushability and handling of the microcatheter. And we insert 4Fr. Catheter into the affected sinus. So we can perform microcatheter cannulation into the isolated and affected sinus for treatment by coil embolization with various detachable coils.

Gradient magnetic-field topography for dynamic changes of epileptic discharges

We developed gradient magnetic-field topography (GMFT) for magnetoencephalography (MEG). We plotted the Euclidean norms of gradient magnetic fields occurring at the centers of 102 sensors onto 49-point grids and projected these norms onto the MRI brain surface of a 12-year-old boy who presented with neocortical epilepsy secondary to a left temporal tumor. The peak gradient magnetic field located posterior to the tumor and correlated to MEG dipoles. The gradient magnetic field propagated to the temporo-parietal region and corresponded with spike locations on electrocorticography. GMFT revealed the location and distribution of spikes while avoiding the inverse problem.

CT perfusion imaging in the syndrome of the sinking skin flap before and after cranioplasty

The syndrome of the sinking skin flap (SSSF) has been described as one of the causes of neurological deficits after decompressive craniectomy We report a case of a 57-year-old woman with SSSF. Two years earlier, this patient, with no neurological deficits, underwent removal of the bone flap during treatment of an epidural abscess due to wound infection after a clipping operation for a ruptured aneurysm. The patient, who subsequently developed a sinking skin flap, gradually presented with gait disturbance and poor activity around 1 year before she came to our facility. On admission, neurological examination showed left hemiparesis and mild confusion. Cranioplasty with titanium mesh plate was performed. The cerebral blood flow (CBF) value in CT perfusion imaging in the symptomatic hemisphere increased from 23 to 31 cm3/100 g/min, and the value in the contralateral side increased from 37 to 41 cm3/100 g/min after cranioplasty. CT perfusion imaging after cranioplasty revealed the improvement of cerebral blood flow not only on the symptomatic side but also on the contralateral side. The patient recovered well and was discharged without hemiparesis and confusion 2 weeks after cranioplasty. As far as we know, this is the first reported case of SSSF examined with CT perfusion imaging before and after cranioplasty.

Subtracted 3D CT angiography for evaluation of internal carotid artery aneurysms: comparison with conventional digital subtraction angiography

BACKGROUND AND PURPOSE

3D computed tomographic angiography (3DCTA) has been used recently for the evaluation of intracerebral aneurysms, but it is difficult to use this technique to visualize aneurysms near the base of the skull because of the presence of bone. Subtracted 3DCTA could replace digital subtraction angiography (DSA) for evaluation of aneurysms near the base of the skull if the 2 methods were to give similar results. The aim of this study was to compare the evaluation of aneurysms of the internal carotid artery (ICA) near the base of the skull by subtracted 3DCTA and DSA.

METHODS

CTA and DSA were obtained in 25 patients with unruptured aneurysms of the ICA. To create subtracted 3DCTA images, we used a volume subtraction (VS) method, wherein nonenhanced volume data are subtracted from enhanced volume data. CTA and DSA were reviewed by 2 neuroradiologists who performed the detection and characterization of aneurysms of the ICA by using 2D multiplanar reformatted (MPR) and VS- and nonsubtracted (NS)-3DCTA images with volume rendering techniques.

RESULTS

DSA detected 29 aneurysms in the 25 patients. VS-3DCTA detected all 29 aneurysms in the 25 patients and was equivalent to DSA for evaluating their characteristics (location, size, and direction). NS-3DCTA detected 19 (1 cavernous, 4 ophthalmic, 1 superior hypophyseal, 7 posterior communicating, and 6 anterior choroidal artery) of these 29 aneurysms, but it could not characterize ophthalmic and superior hypophyseal artery aneurysms because they were only partly visible on NS-3DCTA because of bony structures. 2D-MPR images detected all but the small aneurysms (24 of 29 detected). VS-3DCTA and 2D-MPR could visualize all branching arteries (ophthalmic, posterior communicating, and anterior choroidal) detected by DSA, but NS-3DCTA could not visualize ophthalmic arteries because of the presence of bony structures.

CONCLUSION

VS-3DCTA can be used as an alternative to DSA for preoperative examination of aneurysms near the skull base, where it provides equivalent identification and characterization.

Zygomatic osteotomy for resection of medial temporal cavernous angioma in dominant hemisphere after subdural grid electroencephalographic study

We report the treatment of a patient suffering from intractable epilepsy caused by a large cavernous angioma in the hippocampus of his dominant hemisphere. Surgical removal of a lesion and epileptic focus located in the surrounding brain tissue significantly improves seizure conditions. However, total removal of a large cavernous angioma in the medial temporal structure of dominant hemisphere is occasionally difficult because of the depth of the lesion and its contiguity with eloquent brain structures. Furthermore, when an intracranial electrocorticogram with grid electrodes is adopted, swelling of soft tissue caused by the initial operation for the installation of the grid electrodes narrows the operative view obtained by conventional frontotemporal craniotomy. We added a zygomatic osteotomy to the operative procedure for the present patient, and this enabled us to push soft tissue down and away from the operative field to provide a wider operative corridor through which total removal of the lesion and epileptic focus was accomplished. The patient has had a favorable postoperative course without suffering any seizure for 4 years.